Corrective Action Plans

East Stroudsburg University: The University Records’ Office will implement policy and procedures to ensure the enrollment effective date, and program enrollment effective date are in alignment between the University system, the National Student Clearinghouse and NSLDS. In the situation where a student is withdrawing from the University or being administratively withdrawn due to an unofficial withdrawal, the University Records” Office will monitor student accounts to ensure that adjustments made to student records are not overridden by automated procedures. All reporting will be completed through the National Student Clearinghouse. Kutztown University: We re-evaluated policies and procedures to ensure compliance in reporting. We worked with the Registrar’s Office to rectify any errors in a timely fashion, as well as to detail and update our processes moving forward. A new resource was identified for this responsibility, who is continuously monitoring our submissions to ensure they are accepted in a timely manner. A financial aid resource works in conjunction with the Registrar’s Office to ensure errors are addressed timely to certify the accuracy of our reporting. Cheyney University: Cheyney University of Pennsylvania currently utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to National Student Clearinghouse. The National Student Clearinghouse only includes enrollment data for students on the enrollment roster they receive from the National Student Loan Data System (NSLDS). Students did not appear on the rosters, so the National Student Clearinghouse did not provide the enrollment data to NSLDS. Cheyney University learned that NSLDS did not receive students' enrollment status changes from NSC. As of Spring 2023, Cheyney University has implemented procedures to report enrollment status changes and last date of attendance for all Title IV recipients to NSLDS. Beginning August 2024, Cheyney University will begin utilizing BANNER to create the required enrollment file and transmit the information directly to NSLDS vis EdConnect or TDClient. Commonwealth University (Lock Haven): Controls have been put in place across multiple offices to ensure that program enrollment effective date and program enrollment status is reported correctly to NSLDS. Actions will include, but are not limited to, timely review of changes and checking data files prior to upload. West Chester University: Initial action has been taken to update the student's record with NSLDS. WCU will also add an additional check to our transmission process to review the file for this specific scenario. We will develop a report from our student information system to assist us in this review.

West Chester University: We have recently modified our submission schedule to ensure we have adequate time to prepare our files, conduct our pre-submission checks, and resolve errors prior to the monthly exchange of data between the National Student Clearinghouse and NSLDS. We will continue to monitor the time it takes to complete these tasks and make any necessary modifications to support timely reporting to NSLDS. East Stroudsburg University: The University Records’ Office will implement policy and procedures to ensure students’ enrollment statuses are being reported to NSLDS through the National Student Clearinghouse. Reporting will occur on a monthly basis by means of the University Records’ Office transmitting a file to the National Student Clearinghouse. The University Records’s Office will monitor student statuses in NSLDS by randomly sampling students reported through the National Student Clearinghouse to ensure the accuracy of data being reported to NSLDS. Kutztown University: We re-evaluated our reporting procedures and worked with the Registrar’s Office to further redefine our process(es). The Registrar’s Office submits monthly transmissions to NSC (National Student Clearinghouse), who in turn updates our information to NSLDS. A new resource was identified for this responsibility, who is continuously monitoring our submissions to ensure they are accepted in a timely manner. A financial aid resource works in conjunction with the Registrar’s Office to ensure errors are addressed timely to certify the accuracy of our reporting. Cheyney University: Cheyney University of Pennsylvania currently utilizes the National Student Clearinghouse as a third-party service provider for enrollment reporting and provides all enrollment data to NSC, believing that enrollment would be reported to NSLDS in compliance with federal regulations; unfortunately, NSC only includes enrollment data for students on the enrollment roster they receive from the National Student Loan Data System (NSLDS). Cheyney University is a Heightened Cash Monitoring 2 (HCM2) institution, and students' Title IV aid/disbursements are reported differently than advance pay institutions. Students did not appear on the rosters, so NSC did not provide the enrollment data to NSLDS. While investigating the issues with enrollment reporting for our HCM2 students, Cheyney University learned that NSLDS did not receive students' enrollment from NSC. As of Spring 2023, Cheyney University has implemented procedures to report enrollment for all Title IV recipients to NSLDS. Beginning August 2024, Cheyney University will begin utilizing BANNER to create the required enrollment file and transmit the information directly to NSLDS vis EdConnect or TDClient.

Cheyney University: The discrepancy in the SEFA is primarily due to a timing issue with the approval of the HCM2 Claims. However, the Federal Title IV grant and loan funds should be properly reflected in the upcoming SEFA because the University will be current in its processing of 2023-2024 Federal Student Aid and request for reimbursement. Hence, the University should not have this issue in the FY24 fiscal year. In addition to timely processing, relevant staff in the Financial Aid, Bursar, and Business Office have participated in Federal Student Aid (FSA) Cash Management Training. Furthermore, effective July 2023, reconciliation has been outsourced to FAS. Therefore, monthly reconciliations will inform the SEFA development process. Meaning, adjustments that required for the SEFA will be made more timely than in the recent past.

Pennsylvania Western University: This finding resulted from reporting issues caused by the complexity of integration. These reporting issues have been corrected and now accurately identify students who need to be reviewed for official and unofficial withdrawals. Cheyney University: In July 2023, Cheyney University signed an agreement with Financial Aid Services, LLC (FAS) to outsource many of the financial aid related functions. Return to Title IV (R2T4) was one of the functions outsourced. The process to begin outsourcing was started in December 2023. In addition to outsourcing R2T4, the Office of the Registrar will provide the Office of Student Financial Services (SFS) with a list of students who are not registered for each semester. This distribution will culminate with census reporting to PASSHE and allow SFS to notify about repayment and Return to Title IV processes. For students who apply for graduation for a particular semester, a distribution of names, identification numbers, and anticipated graduation semester, will be provided to SFS so that they can complete their exit counseling procedures.

Recommendation: We recommend that the Department develop internal controls and procedures to ensure that all required subawards are reported timely to FSRS no later than the end of the month following the month of issuance in accordance with FFATA reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: HCD has made it part of a dedicated staff member to input the data into the FSRS system on a timely basis. HCD will also update their process so that all applicants must provide their UEI number. Name(s) of the contact person(s) responsible for corrective action: Sherrill Hampton Planned completion date for corrective action plan: 7/31/24

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

FINDING 2023-005 Information on the federal program: Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (Or Other Identifying Number): 19611-067-PN01, 20611-070-PN01, 21611-070-PN01, 22611-02-CEIS, 22611-070-PN01, 22611-070-ARP, 23611-067-PN01, 21619-070-PN01, 22619-070-ARP, 22619-070-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness, Qualified Opinion Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreements and Procurement and Suspension and Debarment compliance requirements. Context: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $250,000 unless a lower, more restrictive threshold is set by a non-Federal entity. As Indiana Code has set a more restrictive threshold of $150,000, informal procurement methods are permitted when the value of the procurement does not exceed $150,000. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $50,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. For fiscal year 2022, the School Corporation had one vendor, with disbursements totaling $199,713 for the fiscal year, which exceeds the simplified acquisition threshold of $150,000. The School Corporation did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. For fiscal year 2022, three vendors, totaling $228,079, were identified as being less than the simplified acquisition threshold of $150,000, but exceeding the $50,000 micro-purchase threshold. One of the three vendors was selected for testing. The School Corporation did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. For fiscal year 2023, one vendor, totaling $65,861, was identified as being less than the simplified acquisition threshold of $150,000, but exceeding the $50,000 micro-purchase threshold and was selected for testing. The School Corporation did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Suspension and Debarment Prior to entering into subawards and covered transactions with federal award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. “Covered transactions” include but are not limited to contracts for goods and services awarded under a non-procurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the SAMs exclusions, collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. During the audit period, there were six vendors identified which exceeded $25,000 in disbursements on an annual basis. Two vendors were selected for testing. In both instances, the School Corporation’s contract with the vendor did not include any suspension and debarment clause and the School Corporation did not verify the vendor’s suspension and debarment status prior to payment. The lack of internal controls and noncompliance was systemic issues throughout the audit period. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Specifically, regarding Suspension and Debarment, for contracts over $25,000, MSD of Pike Township will obtain a Certification or include a Suspension and Debarment clause in the contract. Absent Certification, the Director of Grants will review for “Suspension and debarment” and maintain documentation. The Special Education Department will work with the Grant Manager and will review contracts over $50,000 to follow the appropriate procurement policy to obtain quotes. Where specialized services are being solicited, we will maintain a procurement file memo documenting the process and the reasons for vendor selection. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan. Plan will be implemented by June 30, 2024.

FINDING 2023-004 Information on the federal program: Subject: Child and Adult Care Food Program – Suspension and Debarment Federal Agency: Department of Agriculture Federal Program: Child and Adult Care Food Program Assistance Listing Number: 10.558 Federal Award Numbers and Years (Or Other Identifying Number): FY2022, FY2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child and Adult Care Food Program and Procurement and Suspension and Debarment compliance requirements. Context: During the audit period, the School Corporation had purchases over $25,000 from three vendors charged to Fund 0800 – School Lunch Fund which requires suspension and debarment procedures. For one of two vendors selected for testing, there was no evidence provided to verify that the vendor was checked for suspension and debarment prior to entering into the transaction. The total amount disbursed to the vendor during the audit period was $141,128. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Specifically, regarding Suspension and Debarment, for contracts over $25,000, MSD of Pike Township will obtain a Certification or include a Suspension and Debarment clause in the contract. Absent Certification, the Director of Grants will review for “Suspension and debarment” and maintain documentation. This review will continue annually. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan.

FINDING 2023-003 Information on the federal program: Subject: Child Nutrition Cluster – Suspension and Debarment Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (Or Other Identifying Number): FY2022, FY2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child Nutrition Program and Procurement and Suspension and Debarment compliance requirements. Context: During the audit period, the School Corporation had purchases over $25,000 from three vendors charged to Fund 0800 – School Lunch Fund which requires suspension and debarment procedures. For one of two vendors selected for testing, there was no evidence provided to verify that the vendor was checked for suspension and debarment prior to entering into the transaction. The total amount disbursed to the vendor during the audit period was $141,128. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Specifically, regarding Suspension and Debarment, for contracts over $25,000, MSD of Pike Township will obtain a Certification or include a Suspension and Debarment clause in the contract. Absent Certification, the Director of Grants will review for “Suspension and debarment” and maintain documentation. This review will continue annually. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan.

Student Financial Aid Cluster: Federal Pell Grant Program – Assistance Listing No. 84.068 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend that the College work with their third-party servicer and implement procedures to ensure that enrollment data, changes in status and effective dates within NSLDS are reported accurately and timely. And we recommend that the College implement formal review procedures to document the review process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Registrar and Financial Aid departments have established a set schedule for enrollment reporting to the National Student Clearinghouse (NSC) and National Student Loan Database System (NSLDS) to ensure accurate and timely reporting happens each month and graduate reporting at the end of semester, within the 60-day window. To ensure CMC meets requirements to report all changes to enrollment and continuing enrollment within the 60-days, the monthly enrollment will follow best practice to submit every 30 days to allow time for correction of any errors prior to submission to NSLDS. The Student Affairs Systems Specialist will pull the enrollment report from CMC’s Student Information System (SIS) on the 19th for submission to NSC on the 20th of each month. If the 20th falls on the weekend it will be the Friday before. The Student Affairs Systems Specialist will correct any enrollment errors with NSC within 3 business days from the time of submission. The enrollment submission from NSC to NSLDS is scheduled for the 3rd of each month, and the Assistant Director of Financial Aid will pull a list from CMC’s SIS to match with NSLDS on the 15th of each month. If the 15th falls on the weekend it will be the Friday before. If there are any enrollment errors or missing students in NSLDS the Assistant Director of Financial Aid will notify the Student Affairs Systems Specialist to update student enrollment data within NSLDS. If there are no errors or missing enrollments in NSLDS, the Assistant Director of Financial Aid will send an email to the Student Affairs Systems Specialist to confirm the report is accurate and submitted. The graduate report will be submitted to NSC by the Student Affairs Systems Specialist on the second Friday after the end of the semester to allow for grade and graduation processing. The Assistant Director of Financial Aid will verify the graduate report within NSLDS two weeks after submission to NSC and email confirmation or request corrections with the Student Affairs Systems Specialist. Name(s) of the contact person(s) responsible for corrective action: Natalie Torres and Janelle Cook Planned completion date for corrective action plan: May 2024

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: CLA recommends that the College review the requirement and implement a monitoring control to monitor the checks throughout the year. In addition, for the checks outstanding greater than 240 days, the College should return the funding to the U.S. Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To enhance the 240 Day Outstanding refund check processing efficiency and compliance, a streamlined procedure was developed and implemented to monitor all uncashed refund checks, including those from federal aid sources. This process will involve utilizing an Informer report every two weeks to compile a comprehensive list of uncashed refund checks for current and prior terms. Upon identification, a system-generated communication will be promptly dispatched to students, notifying them of the outstanding refund check and providing clear instructions to contact the Business Office. Calculations will be performed to ascertain if the refund originates from a federal aid source. For students with federal aid-related outstanding refunds, outreach efforts will be undertaken. Additionally, a progressive maintained cumulative report will serve as a real-time monitoring mechanism to track the status of refunds and ensure timely compliance. Continuous open communication will be maintained with the Financial Aid and Compliance team, facilitating the provision of student refunds requiring action and fostering collaboration across departments to address any outstanding issues effectively. The above-detailed process has already proven effective and noticeably successful in addressing the challenges associated with uncashed refund checks, particularly those originating from federal aid sources. Moving forward, this process will be continuously optimized and refined as system enhancements allow. Regular evaluations will be conducted to identify areas for improvement and implement necessary adjustments, ensuring that the refund processing workflow remains efficient, compliant, and responsive to the evolving needs of both students and regulatory requirements. This commitment to ongoing optimization underscores our dedication to providing timely and accurate refunds while upholding the highest standards of financial stewardship and accountability. Name(s) of the contact person(s) responsible for corrective action: Renee McBride Planned completion date for corrective action plan: January 2024

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the college reevaluate their procedures regarding the return of Title IV funds including the implementation of secondary review of calculations. This would prevent future errors, and provide a greater level of internal control. Additionally, we recommend they review policies regarding the timeliness and accuracy of student enrollment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CMC established a new secondary review procedure to help prevent future errors and provide a greater level of internal control regarding the return of Title IV funds (R2T4). Going forward, after an R2T4 is completed, the Quality Assurance (QA) review will be processed. As part of this review, the Financial Aid and Scholarship Coordinator will be notified that all R2T4’s have been completed for the current week. They will then pull up the spreadsheet of students who had an R2T4 completed and select at random at least 10% of the students on that list to review. In this review they will examine the following data for each of the selected students:  Each class for that semester including the name of the class, the dates the class took place, the credit load of the class, the last date of attendance (LDA) for each class, if the class counts towards the program, if the class was marked as never attended, and if the class should be used in the R2T4.  The Institutional charges to ensure the correct charges were used.  The Days attended vs Total days to ensure that any break of 5 or more days was removed. To document the review, the Financial Aid and Scholarship Coordinator will initial next to each class that they check as they review. The Financial Aid and Scholarship Coordinator will also review that the awards were updated in the Colleague AIDE screen correctly based on the calculation and ensure that any Post-Withdrawal Disbursement (PWD) or return is processed accurately. They will also verify that the Exit counseling request was sent to the student (this is indicated in the CRI screen). Once the review is completed, the Financial Aid and Scholarship Coordinator will initial and date the spreadsheet for the student that they performed the review on. They will then change the color on the spreadsheet tab to indicate that it was reviewed. Name(s) of the contact person(s) responsible for corrective action: Reilly Watanabe, JoAnna Hulett and Janelle Cook Planned completion date for corrective action plan: July 2023

Assistance Listings number and program name: 97.067 Homeland Security Grant Program Contact Person(s): Augustin Huerta Jr., Commander Anticipated completion date: April 30, 2024 Due to unexpected staff turnover, including the retirement of the office manager responsible for submitting Homeland Security Grant Program quarterly reports, the Sheriff’s Office ultimately relied on staff that was not properly trained nor have sufficient time to prepare the reports. The Sheriff’s Office has since improved the understanding of grant administration and submission process. The Sheriff's Office is working collaboratively to ensure accurate and timely submission of required documents to the grantor. Subsequent to June 30, 2023, the Sheriff's Office implemented calendar reminders of deadlines, statistic and financial reports are generated one week in advance of the due date, and quarterly reports are completed by the 13th day of each month. The Sheriff's Office will work with County finance staff to develop and implement written policies and procedures.

Assistance Listings number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person(s): Mauricio A. Chavez, Deputy County Manager/CFO Anticipated completion date: April 30, 2024 The County’s finance department reported the entirety of the allocation based on County’s interpretation of the final rule and multiple subsequent reporting guidelines. The County will revise and resubmit reports to the Treasury Department and will work with staff to correct any deficiencies for future reports. The County will meet with staff to assess all present and future grant reporting guidelines.

Assistance Listings number and program name: 17.259 WIOA Youth Activities Contact Person(s): Irasema Olvera, WIOA Director Anticipated completion date: June 30, 2025 To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County continues to develop written policies and procedures for its WIOA Youth Activities program. The County continues to provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. Through the pass-thru grantor, the County requested a waiver of the of the 75% out-of-school youth program earmark ultimately seeking a more balanced 50% for the out-of-school youth program and 50% for the in-school youth program distribution. The County will continue to monitor the out-of-school services spending throughout the fiscal year and award period.

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Acute Communicable Disease Controls (ACDC) agrees with the finding and recommendation. ACDC staff will monitor subawards and submit the required FFATA reports in the FFATA system upon execution date of the amendment, but no later than the following month it was executed. This includes keeping monitoring logs of all contract amendments and modifications that are subject to FFATA reporting requirements. 3. Anticipated implementation date: March 1, 2024

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Emergency Preparedness Response Program (EPRD) agrees with the finding and recommendation. EPRD staff will send the subrecipient/contractor the FFATA reporting notice, which includes a request for the five most highly compensated officers at the same time the contract is sent to the subrecipient/contractor for signature. This will assist EPRD with tracking the reporting notice because once the subrecipient/contractor returns the signed contract, they will also return the FFATA reporting notice. Once staff receives the executed contract from DPH’s Contracts and Grants, the FFATA reporting system will be updated accordingly and a screenshot showing the date/time the report was submitted will be kept on file. 3. Anticipated implementation date: July 1, 2024

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH, Division of HIV and STD Programs (DHSP) agrees with the finding and recommendation. DHSP will institute a new procedure that 1) notifies subaward recipients within 30 days of the effective date of the subaward execution or modification of relevant federal award information and 2) uploads federal subaward information to FFATA within 30 days of the effective date of the subaward execution or modification of relevant federal award information. These notifications will happen for all subawards that meet the threshold for FFATA reporting. DHSP understands that these notifications may precede the full execution of a new contract or subaward. 3. Anticipated implementation date: July 1, 2024

Reporting – Cash Management During the testing of the Department’s cash management procedures, it was determined that two out of sixty payments tested were not distributed within 21 days of the draw down of funds. For the items tested, the time elapsed between draw down and payment ranged to 28 to 57 days. Corrective Action Plan The Accountant draws cash from ASAP. After drawing federal funds, the Accountant sends the TDR to Budget and Finance (B&F) Treasury Management Section. B&F verifies the deposit and validates the TDR. Accountant will check Datamart daily to ensure funds are correctly posted in DataMart one day after B&F validates the TDR. The Accountant will also check DataMart daily to ensure adequate funds are available when invoice payment checks are processed. For payroll and indirect expenses, and DHO invoice expenditures and Pcard transactions the Accountant draws an estimated amount two days before the payroll cycle ends to be sure funds are available in Datamart. The Accountant checks the balance in DataMart daily. Implementation Date: April 1, 2024 Responding Official: Paul Uchima, WIC Administrative Officer

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for two of the testing selections. An additional selection contained a keying error. Responsible Individuals: Amy Spieker, Director Community Health and Analysis, and Erika Novick, Operations Manager Corrective Action Plan: The Program Director and Operations Manager will ensure all invoices are properly submitted and approved prior to including the expenses in the reimbursement requests. Program Director/Director of Community Health and Analysis will review draws/invoices to ensure amounts on supporting documents agree to the amounts submitted in the reimbursement requests. Finance will also revise Corporate Card Policy by June 30, 2024, to include expense reports being submitted in a timely manner. Finance will review open expense reports with card holder and their supervisor monthly. Anticipated Completion Date: April 1, 2024

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: There was no evidence retained that the Medical Center’s compliance reports submitted to Equal Justice and Wyoming Department of Family Services (WDFS) were reviewed and approved prior to submission. Responsible Individuals: Amy Spieker, Director Community Health and Analysis Corrective Action Plan: The Program Director will review and approve the data input into the monthly and quarterly reports. If red flags are identified, adjustments will be made. Once the reports are deemed satisfactory, the Program Director will electronically sign off on the report to denote review and approval for submission to awarding agency. Anticipated Completion Date: April 1, 2024

Action taken in response to finding: The District continues to enlist the assistance of Huron and other vendors to assess our internal controls over financial aid federal awards. The district collaborates with external entities to engage in comprehensive training to district-wide staff involved in student financial aid processing. College FA staff are sent regular reminders to reconcile and perform R2T4 calculations. Management is actively recruiting to fill vacant positions in this area across the district. Planned completion date for corrective action plan: June 30, 2024.

2023-005 FINDING: FAILURE TO FILE REAL PROPERTY STATUS REPORT Corrective Action Plan: The University already has existing procedures in place to ensure that required reports are submitted. The report not being submitted was just a misunderstanding on the part of the employee submitting the report as there was no real property acquired from the Early Head Start grant funds. The University believes that this matter did not have a direct and material effect on the University’s compliance with federal requirements. Responsible University Personnel: Andrea Middleton, Director of Financial Services/Assistant Controller; Villalyn Baluga, Associate Vice President for Finance. Anticipated completion date: Already implemented.

2023-004 FINDING: INADEQUATE CONTROLS OVER PAYROLL EXPENDITURES AND NONCOMPLIANCE WITH ALLOWABLE COST & COST PRINCIPLES REQUIREMENTS APPLICABLE TO THE HEAD START CLUSTER Corrective Action Plan: The University has updated its process to collect time and effort information on a semi-annual basis rather than quarterly, which relieves some burden from staff, but still complies with federal regulations. By collecting time and effort information on a semi-annual basis, staff will have more time to reconcile time and effort against actual payroll expenditures. The University has also redesigned the time and effort collection form to show the 100% distribution of work. Further, the University now has a full-time financial research administrator who will help ensure that payroll related adjustments are done timely. The financial research administrator will work with the Early Head Start program management to ensure that the related payroll reports are reviewed and reconciled timely, in accordance with existing University procedures. Responsible University Personnel: Erin Soto, Executive Director of Family Development Center; FeMia Norwood, Director of Office of Sponsored Programs and Research; Jessica Braddy, Financial Research Administrator. Anticipated completion date: Already implemented.

2023-003 FINDING: NONCOMPLIANCE WITH GRAMM-LEACH-BLILEY ACT Corrective Action Plan: The University is currently drafting the incident response plan and is working to secure a contract with an incident response firm. Additionally, the University recently hired an Information Security Analyst, a newly created position designed to address smaller-scale alerts and incidents. Responsible University Personnel: Charles Pustz, Associate Vice President for Information Technology Services and Chief Information Officer; David Weissbohn, Director of Information Security and Compliance. Anticipated completion date: Upon the Illinois Public Higher Education Cooperative’s (IPHEC) vendor decision and upon approved funding, ITS is hoping to have a firm engaged by end of Fiscal Year 2024.