Corrective Action Plans

Finding 2023-002 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority claimed expenses that were previously claimed and reported on the Period 1 report to te Department of Health and Human Services Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Rebecca Sharp, Interim Chief Financial Officer Anticipated Completion Date: June 2024

Finding No: 2023-001 Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.498 Program: COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Compliance Requirement: Activities allowed or unallowed/allowable costs Award Year: January 1, 2020 through December 31, 2022 (a) Criteria or Requirement 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. (b) Condition Found The System did not have adequate controls related to determining allowability of expenditures for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Grant. Our testing identified one charge within the population that had been charged incorrectly to the federal program. This charge was for government contract labor totaling $126,313 that was determined to be an unallowable expenditure that should have been removed prior to submission to the federal agency. In addition, during our testwork over expenses, we selected for testing a sample of 40 expenses charged to the program. One of our samples related to COVID lab tests was identified with a cost that should have been zero as the tests were voided and the vendor invoice reflected a zero balance; however, a standard test was inappropriately charged to the federal program in excess of the vendor invoice. Further, one sample was identified as having the incorrect price applied to the cost due to the drug being purchased from a different vendor, which had a lower price. This resulted in a higher price being charged to the federal program.The resulting impact of the above two items was $508 inappropriately charged to the federal program. In addition, the System was unable to provide evidence of management review and approval for three of the 40 expenses sampled. These three disbursements were for allowable costs under the terms and conditions of the program. (c) Cause The System’s review process in place over the recording of these costs did not operate effectively to prevent unallowable charges and inaccurate amounts from being submitted for reimbursement by the federal agency. The System was unable to provide evidence of certain management reviews and approvals due to system limitations that only maintain electronic approvals (via email) for 365 days. (d) Effect Federal funds were expended for unallowable purposes or for inaccurate amounts and evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (e) Questioned Cost Expenditures related to contract labor and other costs of $126,821. (f) Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding (h) Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs. (i) View of Responsible Officials The Monthly Cost Capture detail for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (ALN No. 93.498) reporting was developed to appropriately track expenditures that qualified under the grant. A wide variety of costs from across the company were charged to a COVID cost department. These costs originated in a variety of ways. While the overall amounts were tracked and reviewed, a comprehensive 100% review was not conducted. As a result, the government labor expenditure and the cost for a COVID lab specimen that spilled in transit were inappropriately included. Additionally, a higher cost per unit was used to allocate for a specific drug used by COVID inpatients. Furthermore, there were three Morris and Dickson invoices that were submitted to AP electronically approving payment via email, but the emails automatically delete after 365 days. (j) Corrective Action Plan The expenditures for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (ALN No. 93.498) were reported through the PRF Reporting Portal using quarterly financial data. The portal restricted the entry of expenses up to the awarded amount plus interest earned. Consequently, we have sufficient expenses to cover any ineligible expenditures identified in this audit. As the program has concluded, no further actions are required for COVID drug and COVID lab test findings, as these were already accounted for in system reports that are now obsolete due to surpassing the Period of Availability dates. A new process will be implemented for manager sign-off on Morris and Dickson invoices submitted to AP electronically to ensure proper approval evidence is captured and documented correctly. Anticipated Completion Date: 6/30/2024 Name of Contact Person for Corrective Action: Sharon Nobles, Chief Financial Officer

• Finding 2023-002 – In June 2024, Management provided re-education to grant personnel preparing and reviewing calculations to ensure an adequate understanding of the key calculation elements are identified and validated for the grant year. o Responsible Party: Peggy Wisher

• Finding 2023-001 – The FEMA submission request was submitted by management in 2021, which occurred prior to management’s implementation of its corrective action plan to address Finding 2022-004. Management performed an independent review of the expenditure for FEMA eligibility as part of an iterative review process with its FEMA consultants and FEMA representatives. This review was also documented in management’s representation on the FEMA online portal when the submission was made. However, management’s process did not include internal documentation to evidence an independent review had occurred prior to submission. The process has been corrected for any future FEMA submissions in October 2022. o Responsible Party: Amanda Zentefis

Sanford Corrective Action Plan December 31, 2023 Finding 2023-001 – Suspension and Debarment/Procurement Information on the federal program: Federal Agency: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.155 Award Year: 2021 Planned corrective actions: As it relates to the reliance on the third-party vendor that conducts suspension and debarment -party vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) Report and therefore did not provide this level of report to Sanford. To provide context on scale of vendors subject to suspension and debarment, Sanford paid a total of 23,754 vendors in 2023. There were three vendors identified through the vendor setup and monitoring process to be suspended or debarred. None of those vendors were associated with the programs funded with federal funds. Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendor is effectively mitigated through existing preventive and detective internal controls. In August 2023, Sanford began documenting a periodic validation of the suspension and debarment search results performed by the third-party vendor for vendor searches that yield no suspension and debarment match. In addition, Sanford enhanced its procedural documentation regarding retention of evidence related to reconciliation of vendor list when discrepancies are identified and the suspension and debarment results generated through the vendor setup process. Responsible official: Tracy Sattler, Director of Compliance and Melanie Paape, Vice President of Supply Chain Operations As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of procurement under the program $2,298,733 in expenditures exceeded the micro purchase threshold and $307,249 were found to have inadequate documents for sole source. Sanford will provide education to applicable departments related to the compliance requirements subject to procurement. Sanford will document the procurement process from the initial approval to potential sale/disposition items. Responsible official: Kristi Crawford, Director of Office of Grants Anticipated completion date: June 30, 2024

2023-002 – Internal Control over Compliance and Compliance with Period of Performance Contact Name – Jeff Kaufman Position – Global Controller Contact – jkaufman@corusinternational.org Estimated date of completion: September 30, 2024 Corrective Action Plan – Corus management concurs with this finding and reaffirms its commitment to responsible stewardship of funding awarded to Corus by the United States Government and other donors. There are occasions when Corus may anticipate successfully negotiating a program extension with the USG or other donors. In the event there are immediate needs of the program’s potential beneficiaries, Corus may decide to utilize its own unrestricted funds in expectation that if the extension is obtained, these funds will be reimbursable under the terms of the extension. Corus recognizes that there is no guarantee that the program will be extended; thus, it understands that it incurs the expenses at its own risk. As a point of emphasis, while the expenses referenced in this finding were incorrectly coded such that this spending was erroneously included on the SEFA, Corus did not draw on USG funding to recover these expenses, the expenses were funded by Corus’ own unrestricted resources. Action steps to be implemented during the Corus 2024 fiscal year include: • The steps outlined in response to 2023-01 should also ensure proper account coding of expenses and timely monitoring of program spending against available obligated funds as well as program expiration dates.

Kid Power, Inc. agrees with the finding. The Organization will implement effective and written procedures for the review of cost allocation journal entries, allowable costs and activities, period of performance, matching, and reporting. The written procedures will explicitly lay out the processes for review and approval of each of these compliance components per each federal Assistance Listing that the Organization receives. Curtis Leitch, Deputy Director, will use the most up to date 2 CFR Part 200, Appendix XI - Compliance Supplement to identify the specific compliance requirements for each of the Assistance Listings and create the written procedures. Procedures for internal controls include monthly expense reports completed through Brex by the Operations Manager, Charles Thomas, and stored in Kid Power, Inc.’s Google Drive; allowability and expense allocations will be reported in Google Drive on monthly basis and completed by the Deputy Director, Curtis Leitch; cost allocation journal entries will be inputted into QuickBooks on monthly basis by the Deputy Director, Curtis Leitch. Federal allocation and reimbursement reporting will be prepared by the Deputy Director, Curtis Leitch; reviewed by the Executive Director, Andria Tobin; and submitted by the Deputy Director, Curtis Leitch, on a quarterly basis.All reviews and approvals will be documented henceforth in Kid Power, Inc.’s Google Drive. Curtis Leitch, Deputy Director, will oversee the implementation of this corrective action.

2023-003 – Internal Control over Compliance and Compliance with Reporting Contact Name: Charlie Feeney Position: Chief Financial Officer Telephone Number: (202) 796 2496 Corrective Action Plan – Management will continue to work with Federal agencies to resolve any grants that a FAIN was not issued. Estimated Completion – September 30, 2024

May 31, 2024 Finding 2023-001: Allowable Costs/Cost Principles, Reporting, and Special Tests and Provisions Industrial Development Authority Corrective Action Plan: To ensure financial statements, Federal tax returns, Personal Financial Statements, and insurance renewals are received annually the invoice for December will include a reminder, with appropriate due dates, to the borrower. Additionally, in January a separate letter will be sent to each borrower requesting the updated information. Finally, a member of the Business Development staff will be responsible for calling any borrower that fails to comply and request the information. A member of the Business Development staff will perform an annual site visit to each borrower. The individual responsible for filing the ED-209 reports is no longer employed at Allegheny County Economic Development. To ensure the reports are prepared in a correct manner and submitted in a timely manner a member of the Business Development staff will be trained on how to complete and submit the report. In 2024 a reviewing routing procedure was initiated where the reports were circulated for review by the Assistant Director, Operations, Sr. Finance Manager, and Deputy Director review the reports prior to submission. To ensure the reports are submitted timely staff will be required to circulate the report for review at least two weeks prior to the deadline. Additionally, a member of the Fiscal staff will be responsible for reconciling the ED-209 reports with the Authority's financial records and balances. Finally, a checklist for each loan will be provided to each staff member to ensure that all documents are received and kept in the appropriate file. For all new loans a Manager will be responsible for reviewing each file prior to and at closing to ensure that all documents have been reviewed.

Planned Corrective Action: To address a gap identified internally by the Health Board, a new, comprehensive reconciliation and reporting process has been established. This gap was recognized when new finance department leadership assumed their positions prior to audit fieldwork, leading to the development and implementation of immediate corrective actions. Management at the Health Board has implemented a robust internal control process that includes reconciliation in two phases, which was developed in collaboration with our grants team. This documented process ensures thorough reconciliation and robust internal controls. It enhances the accuracy and timeliness of our financial reporting, particularly for FFR SF-425 submissions, thereby strengthening our overall financial management practices. The following outlines the detailed steps of this process, divided into two critical phases: Phase I: Revenue, Expenses, and Cash Reconciliation 1. Reconciliation by FP&A Analyst: Ensures that the figures and documents entered in Sage Intacct align with the Payment Management System (PMS) regarding authorized grant amounts and drawdown amounts at each month-end close. 2. Grant Receivable Invoices: Recorded in Sage Intacct as part of the month-end close process. A billing or AR accountant collects the expenses and enters corresponding revenue amounts, which the system uses to generate invoices. 3. Notification of Drawdown: The FP&A Analyst notifies the Director of FP&A and the Account Manager via email about the drawdown and the corresponding invoice amount. 4. Verification and Processing: The Director of FP&A verifies the amount and processes the drawdown from PMS to the bank. 5. Monthly CFO Report: The CFO receives a monthly status report. Phase II: FFR Reporting 1. Weekly PMS Review: Every Monday, the PMS is reviewed to identify any projects pending or expired for quarterly, annual, and final report periods. 2. Preparation of Revenue Reports: The billing or AR accountant prepares the direct and indirect revenue based on expense amounts. 3. Submission for Approval: The prepared revenue reports are submitted in the PMS for approval by the Director of FP&A. 4. Final Submission: After the DFPA's approval and final submission in the PMS, the information appears in the Grant Solution system for further approval by the program and grants team. 5. PMS Report: Receive an approval or rejection report from the PMS. Name of Responsible Party: Zecharias Mesgane, CMA, Director of FP&A Anticipated Completion Date: September 30, 2024

Finding 2023-002 – Preparation and Maintenance of Equipment Population The single audit report included the following recommendation: To address the Condition identified above, we recommend Amtrak to continue integration of the systems in such a way that appropriate funding source would be tagged to each asset automatically and that required property records would automatically be consolidated into one system of record and updated in that system. Ensure that adequate IT interface and business process application controls over the completeness, accuracy, validity, confidentiality, and availability of transactions and data during application processing (input, processing, output, etc.) are in place. Additionally, management should consider breaking out large purchase orders containing multiple items of equipment and tools under one purchase request, by creating separate level 2 WBSE codes in order to distinguish between different types of items being acquired, in order to be able to provide more appropriate classification. Identification as a repeat finding: Not a repeat finding Management Response/Status of Action Plans: Amtrak will implement the following to mitigate the finding related to the equipment population. 1. To prevent errors regarding the mapping of grant funding to equipment, the Capital Accounting Department will be implementing additional procedures and validations in the preparation and approval of the equipment review population file. This will include additional cross checks to validate mappings from fund sources to equipment and an additional review by EAMDT. The additional review and approval steps will be formalized with documented steps before September 2024. 2. To prevent errors related to missing asset numbers, the Capital Accounting Department, in coordination with EAMDT, has implemented an additional review of the single audit eligible indicator and inclusion of an asset unit number at the time the equipment asset is recorded in the fixed asset ledger. Additionally, EAMDT and Capital Accounting are now utilizing automated reporting that allows real time review of single audit equipment additions and data fields from the Company’s systems. This reporting allows for a timely view of key data fields from the related systems including Asset Equipment Description, Asset Unit Number, Single Audit Flag, Last Audit Date and Conditions. All equipment with missing asset unit numbers will be investigated and corrected. If any equipment marked as single audit eligible appears as not being eligible, Capital Accounting will investigate and resolve. The contacts for this item are Carol Hanna, VP Controller and Michele Millsaps, Assistant Controller, Capital and Inventory Accounting. Amtrak anticipates that changes above will remediate this finding in the fiscal year ending September 30, 2024 and beyond.

Finding 2023-001 – Equipment and Real Property Management The single audit report included the following recommendation: We recommend that Amtrak continue to work toward a full integration or reconciliation between Amtrak’s fixed asset system of record and the different equipment-tracking systems. We recommend that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs. For example, Amtrak should consider an automated system report that would flag an asset proactively when a 2-year inventory deadline is approaching. During the observation process, management should ensure there is a review control within the process to validate that the asset is accurately tagged and such identifying information matches the equipment-tracking system. Additionally, this review control should also be performed when the asset is first logged into the equipment-tracking system. In the interim, until such processes are fully implemented, Amtrak should enhance the current control procedures surrounding the asset documentation and ensure that field personnel are aware of and are consistently and carefully updating the asset records such that clerical/human errors are minimized and that the asset records contain the necessary asset details in order to properly track equipment by federal requirements. This would include enhancing the asset chain of custody recordkeeping so that such changes are identified and reported timely. Additionally, management should consider requiring the serial number and model number to be documented in the system of record at set up in addition to the asset tag number. This will help ensure that the equipment has a unique ID number that can help it be identified and matched to the system record should an asset number not get added timely. Finally, as it relates to condition #4 above, management should investigate the root cause of the asset that could not be located and determine if additional control changes or modifications need to be made in order to prevent reoccurrence. Identification as a repeat finding: This finding was identified as a repeat finding in the immediate prior year as Finding 2022-001. This finding was reported in prior years as well, beginning in at least FY2012. Management Response/Status of Action Plans: Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Amtrak continues to progress on a multi-year effort to remediate this finding. Amtrak created the EAMDT which has been tasked to improve equipment record keeping which will resolve this finding. 1. In April 2024, Amtrak completed an engagement with an outside consulting firm that delivered three items: an updated Equipment Control Policy (ECP), standard operating procedures (SOPs) for equipment management based on the accountable property system of record, and a one-hour eLearning course that reinforces the importance of good equipment management practices and the need to follow the equipment tracking requirements of 2 CFR Part 200. These deliverables will improve policies and corporate governance over assets by providing training to the employees and improving the processes needed for oversight of equipment management, as well as to help ensure that assets are not capitalized without a complete record, which would include a unique asset identifier and the condition and location of the asset. The ECP was approved and published in the Amtrak Policy and Instruction Manual in May 2024. Amtrak will communicate the updated policy to all relevant personnel by the end of June 2024. The EAMDT is working with the Learning and Development team to identify the employees who will need to take the eLearning course, and these employees will be required to take the eLearning material beginning in the first quarter of FY25. 2. The EAMDT is implementing controls throughout the equipment lifecycle as it identifies improvement opportunities. For example, EAMDT has been added as an approver to the purchase requisition workflow for equipment purchases, and EAMDT is working with Capital Accounting to ensure that assets are recorded completely before being capitalized, which would include a unique asset identifier, condition, and location of the asset. EAMDT is reviewing assets currently in the system that do not have assigned asset IDs. EAMDT’s goal is to resolve and update existing records that are missing IDs and other information by the end of April 2025. Additionally, in August 2023, the Asset Disposition group began reporting into EAMDT which enables centralization of a more complete oversight of Amtrak’s assets. EAMDT is working to improve the record keeping for asset dispositions. 3. EAMDT is working with Amtrak’s Digital Technology (DT) Department to find ways to track equipment electronically. This includes installing location tracking technology on yard and Engineering Maintenance of Way equipment to better track and locate Amtrak assets. As of the end of April 2024, location tracking technology has been installed on over 1,500 pieces of equipment with the goal of having location tracking technology installed on approximately 2,400 assets by the end of June 2024. EAMDT is also coordinating with DT on an application accessible via a mobile device (e.g., cell phone, tablet) used by field personnel to perform audits and update equipment records. 4. EAMDT has developed trend reporting and operational reporting to help EAMDT and the departments track their compliance progress and identify assets that are out of compliance or soon-to-be out of compliance to both bring assets back into compliance, as well as to ensure an inventory is done and recorded within the two-year period. As of September 2023, two primary dashboards have been developed and can be used by all departments to help identify assets that are out of compliance and/or need to be audited. 5. EAMDT performs site visits to assist the equipment managers in performing equipment and vehicle audits. During these visits, equipment managers are educated on their responsibilities and tools available for performing audits. The contacts for this item are Ian Hinke, AVP Supply Chain Management and Robert Hoban, Director Asset Management. Amtrak anticipates the implementation of the above procedures, along with continual process monitoring and refinement, will fully remediate this finding by June 2026.

Finding: Certain timecards were not properly approved prior to payment of the payroll expenditure within Assistance Listing #10.555 and #10.553 in regards to the Child Nutrition Program. Response: This took place during a period of transition in management personnel within the Child Nutrition Program. The Chief School Finance Officer (CSFO) has implemented the following procedure: If a timesheet has not been approved by a supervisor, the timesheet will be deleted from the payroll run that month and payment will be delayed until the supervisor approval is obtained or approval is granted by the CSFO. Completion date: April 1, 2024.

2023-002 Approval of Living Allowance Payments: Management Response: Management will include others on correspondence regarding approval of payroll, which will help detect when an approval of payroll is not made timely. If payroll is not approved before paid, then Management will perform a documented review to ensure payroll payments are proper. Management will also develop a policy to stop living allowance payments timely when a member will not meet their service hour obligation. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

2023-001 Segregation of Duties: Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. However, during the 2023 fiscal year, LDSC created a financial policies handbook that outlines controls and responsibilities in the financial reporting cycle. We will ensure the areas recommended above are added to our current policy to the extent it is economically feasible. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

It is the policy that either Marlon Mitchell or James Kilgore approves expenditures of the programs. FirstFollowers is not in the habit of initialing the invoices, so we will purchase a stamp to provide physical evidence that the invoice requests and/or receipts have completed the review steps. Either Marlon or James will date/initial with the approval stamp. All the contractors and employees have a yearly review of their salary and/or hourly rates. Those contracts are written and kept in the files of FirstFollowers and were provided to CliftonLarsonAllen upon request. We will continue to update these contracts each fiscal year and ensure that the contracts are reviewed by the Board of Directors and noted in the minutes.

Finding No. Name of Responsible Official Management’s Response to Findings Description of Corrective Action 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding for CFDA 93.498 where Period 5 Provider Relief Funds (PRF) were excluded on the original SEFA and an adjustment of $9,234,533 was required. 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding and the corrected amount on the federal SEFA. On the original draft of the SEFA, for CFDA 93.914 expenses were included from February 2024 dates of service. An adjustment of $152,329 was required Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Anticipated Completion Date Completion of SEFA for Fiscal Year 2024 will be completed in first quarter 2025.

2023-001Activities Allowed or Unallowed, Allowable Costs/ Cost Principles – Indirect Costs 1. When posting each month-end numbers in the accounting worksheet, the Controller or Chief Financial Officer will verify that the formulas are accurate and display the correct information. This check will be completed on all the formulas used to determine not only the indirect but also the direct costs in the grant. 2. After this review and verification step has been completed, the Accounting I AR and Grants Admin will create the invoice and journal entries into the accounting system, QuickBooks. 3. The grant workbook will be locked at that time to ensure that the information is not mistakenly adjusted. 4. Before requesting the funds from the federal entity (ex. National Science Foundation) or the Subaward institution, the Accounting I AR and Grants Admin will review the worksheet and verify once more that the formulas are correct and the total requested matches the invoice in QuickBooks. Steps to correct an error(s) 1. Identification of the error and correct the formula. Example, if an error is found in the indirect cost calculation, the formula will be corrected to determine the actual costs that should have been collected. 2. A new column will be created in the accounting worksheet to track changes that are made to the original invoice. a. A new invoice will be created if funds need to be requested from the entity. b. A credit memo will be created if funds are owed. This will be applied to the following months request. c. If the invoice has not been paid by the Federal entity, a revised invoice can be created and submitted for payment.

Finding 2023‐003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve funds for the federal program. Responsible Individuals: Marcus Lewis, CEO, and Nina Hollingsworth, CFO Status: We will implement additional control processes to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2024

Finding 2023-002, Significant Deficiency – Allowable Costs Corrective Action Plan: Goal: To ensure that duplicative expenses are not drawn down in state funding. Plan: The County identified the duplicate transaction of $20,740 reported for drawdown for Project AA 362 was due to an issue with the reporting mechanism. Specifically, the report used to extract project costing details included a commitment number column, which inadvertently resulted in the creation of duplicate records for each commitment associated with a single invoice. Performance Improvement Strategies: To address this issue and prevent its recurrence in the future, immediate steps have already been taken. County Finance has amended the report to exclude the commitment number parameter, thereby eliminating the possibility of duplicate records being generated. Responsible Parties: Nursing Supervisor Brooke Hamby and Assistant Health Directors Nicole Priddy & Marie Stephens Timeframes: Brooke Hamby will reach out to the Division of Public Health, Women & Children’s Health/Children & Youth section, no later than June 15, 2024, to inform them of the Audit finding of this duplicate expense and request what the process is for returning the funds.

Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Minnesota Assistance Listing Number: 93.558 Program Name: Minnesota Family Investment Program (MFIP) Finding Summary: For one employee tested, documentation was not maintained to support all hours charged to the TANF program. Responsible Individuals: Lisa Gochanour, Accounting Manager – Stephanie Kilian, CFO Corrective Action Plan: For the employee tested the effective date of an employee status change was not clear and was subject to interpretation. We have made changes to ensure that any future documentation has clear beginning and ending dates. This will eliminate confusion of allocable hours in the future. Anticipated Completion Date: Completed. 5/1/2024

2023-004 FFATA Reporting Recommendation: We recommend the City establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Explanation of disagreement with audit finding: NO Action taken in response to finding: Review City’s policy and Establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS n later than the end of the month following the month of issuance of each subaward. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Crimer, Doug Weller, Kyera Pope. Planned completion date for corrective action plan: 06/30/2024. Moving forward: No later than the end of the month following the month of issuance of each subaward.

2023-003 – Period of Performance Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that expenditures are not charged to federal awards during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and Related services and the Portsmouth Finance department will monitor expenditures on an ongoing basis to ensure the funds are spent in accordance with the period of performance of the grant. The Finance department will review all purchases and notify the Office of Special Education if purchases are unallowable and do not follow the period of performance and have alternate suggestions on how the purchase can be made. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

2023-002 – Allowable Costs/Cost Principles Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that it retains documentation supporting time and effort on federal grants and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and related services, in collaboration with Portsmouth Schools Finance department will monitor that the certification of pay certifications are completed on a semi-annual basis. Finance will communicate via email, the list of personnel required to have the certification and also review once they are completed by the Office of Special Education. Finance will review all dates and signatures. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

2023-001 Reporting- IDIS Recommendation: We recommend that the City review its policies and procedures to ensure that compliance with federal reporting requirements are evident. Explanation of disagreement with audit finding: NO Action taken in response to finding: Review grant policy and procedures to ensure that City’s policy and procedure is in compliance with federal reporting requirements. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Crimer, Doug Weller, Kyera Pope. Planned completion date for corrective action plan: 06/30/2024.