Corrective Action Plans

Corrective Action Plan The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP). • Review and analyze audit findings with seasonal staff, Area Managers, and Administration in order to prevent findings. • Prepare additions to CPD Monitor manual to reflect the ISBE regulation to conduct at least one site review during first four weeks of operations and 2 follow up visits if required. • Nutrition Services will send weekly emails to remind staff requirements of SFSP documentation and utilize the Area Managers to assist with quality assurance and compliance with state/ federal regulations. • Provide weekly assessment of monitor reports to promote accuracy in meal distribution, and reduction of food waste by reducing second meals ordered. Conduct occurring review weekly on Wednesdays. • Continue train monitors to review SFSP binders, check food temperature, date of service and signature recorded on all invoices and DMC, and attendance. • Mandate that at least three of staff members per site are trained in SFSP (pending number of staff at park location) • Upload daily attendance list for day camp with weekly summaries, keep hard copies in binders to ensure access for audit purposes. • Provide multiple in person trainings before start of the season to all field staff emphasize the importance of accuracy and details when following the Policy and Procedures of the Summer Food Service Program. • Add audio to the electronic training offered through the Success Center. Anticipated Completion Date: September 30, 2024 Name of the Contact Person Responsible for Corrective Action: Sandra Olson, Director of Programming Meghan O’Boyle, Wellness Manager

We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have implemented a process that all grant claims/payment vouchers are formerly reviewed and initialed by our Executive Director.

We will implement procedures to ensure that our policies and procedures requiring the maintenance of documentation and formal review to support earmarking for federal awards be followed consistently for all programs in October 2024.

Management agrees with the finding. Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will provide a new updated Federal Awards and Accounting Manual to all management of Federal Awards.

Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024

Planned Corrective Action: Executive Director will be tracking their time spent on specific grants on a weekly basis. The Board of Directors will review and approve the time summary at least quarterly. Executive Director non‐payroll reimbursements will also be reviewed and approved by at least one board member. The Program Director will provide oversight of these two newly established processes. Name of Contact Person: Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024

Management will develop, adopt and implement a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process will include steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended, debarred, or otherwise excluded) to enter into an agreement, contract, or subaward with the City. The process will also include steps to ensure all necessary language, such as the Buy America Build America Provisions are included in the final contracts.

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

Management of the Town will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirement. The Town will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the Town's new procurement policy is followed.

Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed and approved by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

Management of the City will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirements. The City will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the City’s new procurement policy is followed.

Management of the City will work with their contractors, both the construction contractors and the engineering firms hired to oversee and monitor the construction projects, to ensure they understand the wage rate requirements that must be followed for federally funded construction projects. The City will implement a periodic monitoring program where the City verifies the contracted engineering or compliance vendors are adhering to the City’s contractual requirements such as obtaining the weekly certified payrolls.

Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will undertake a thorough review and subsequent update of our documented policies and procedures related to federal awards. This review aims to ascertain whether any adjustments are necessary to guarantee that subawarded federal funds are utilized exclusively for their designated purposes. We are dedicated to enhancing our internal controls to adhere to federal regulations concerning the monitoring of our subrecipients. We plan to engage a consultant to help us develop policies and procedures for subrecipient monitoring, as well as to propose an organizational framework for fiscal monitoring that will strengthen our internal controls. We anticipate having the finalized policies, procedures, and training implemented by 12/31/2024. We will develop and implement a risk assessment program for subrecipients, enabling management to monitor the outcomes and demonstrate compliance with federal requirements. Records will be maintained to show that risk assessments were performed. We are dedicated to offering annual training sessions aimed at reinforcing the single audit requirements to our subrecipients. We will establish a subrecipient monitoring/compliance workgroup to define roles and responsibilities for assessing and updating policies and procedures related to subrecipient monitoring and to strengthen internal controls. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: 12/31/2024

All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years, allowing clients to be seen by a medical provider quickly. This practice ended in 2023. 30-day eligibility is no longer allowed.

2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish the policies and procedures for reviewing and approving reimbursement claims to ensure that the claims are properly prepared and submitted timely.

We agree in part to this finding. The deficiency exists with approval of transactional funds that are utilized for the transportation and food voucher programs. Historically, authorization to purchase has been deemed as approval and this year some of those documentation processes were not consistently followed, as mentioned being done verbally or during other discussions that were not documented. We did not make any food voucher purchases without discussion prior to purchasing. That being said, we can formalize an approval process that is documented. Additionally, we will review our transportation program policies to ensure that a proper approval process is in place and continues to be supported by the processes we have in place.

Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.

Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." Condition: During testing, 2 of the 60 samples selected had an individual approving their own timecard. Questioned costs: None. Context: A sample of 60 was made from a population of over 250 paychecks processed during the year with costs charged to the major program. Out of the 60 timecards that were sampled, there were two instances where the individual whose timecard was being reviewed also approved their own timecard. Cause: At the time of these payroll runs, the Organization did not have procedures in place to identify an appropriate approver for the Executive Director's timecards. Effect: Without appropriate segregation of duties around the approval of timecards, there is an increased risk of errors and fraud in the timekeeping and payroll process, which could result in inaccurate financial reporting and misappropriation of funds. Repeat Finding: No. Recommendation: CLA recommends that another individual with knowledge of the Executive Director's time and effort on the various programs approve his timecards. The Organization has already identified a member of the executive team to perform such functions and will implement the change going forward. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The organization has implemented a policy such that no employee can approve their own timecard. As noted above, the organization has identified an appropriate executive team member to approve the Executive Director’s timecard. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024 If you have any questions regarding this plan, please call Gary Slater at 305-213-8829.

Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." In addition, 2 CFR 200.329(c)(1) states that “the non-federal entity must submit performance reports at the interval required by the Federal awarding agency or pass-through entity to best inform improvements in program outcomes and productivity”. Per the award agreement for contract W912DW-20-2-0003, "Recipient shall submit to the Agreement Administrator (see paragraph 1.2.1) progress reports on a quarterly basis utilizing the form included in Attachment B of this agreement. Reports are due no later than 30 days following the end of each reporting period. A final performance progress report shall be submitted within 90 days after the expiration date of the award." Condition: During testing it was noted that 3 of the 6 financial reports tested did not include documentary evidence of Executive Director review and approval. In addition, 2 of the 2 performance reports tested were filed after the filing deadline. Questioned costs: None. Context: A sample of 6 was made from a population of 17 financial reports, and a sample of 2 was made from a population of 4 performance reports. Of the 6 financial reports sampled, 3 did not have documentary evidence of Executive Director review and approval. Of the 2 performance reports sampled, both were filed after the submission deadline date. Cause: Late filing is due to a lack of adherence to the due dates as defined within the contract terms. The Organization does not have adequate controls in place to document the Executive Director's review and approval of the Federal Financial Reports (SF-425). Effect: Not filing reports on a timely basis can present risks, such as outdated and unreliable information or the inability to detect potential fraud or irregularities. In addition, delayed reports can impede regulatory authorities' ability to monitor compliance, detect patterns or trends, and assess risks in a timely manner. Without adequate documentary evidence around the review of financial reports, there is an increased risk of errors and fraud in the reporting process, which could result in inaccurate financial reporting and misappropriation of funds. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-004. Recommendation: CLA recommends for the Organization to place emphasis on stronger controls around the timely filing of required reports, such as retaining a monthly checklist of required reconciliations and reports. CLA also recommends implementing a procedure that documents the Executive Director's review and approval of the Federal Financial Reports (SF-425s), whether that be via an email chain or retaining a copy that also includes the Executive Director's signature on the report. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and strengthened our internal controls and training to all staff around the timely filing of required reports. This has included creating a calendar of required reconciliations and reports for all agreements. Further, we have updated our procedure for review, approval, and documentation of Federal Financial Reports. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: The Organization, as part of their stated controls, require that expenditures must be approved by the ED, CFO, or program directors / managers. In addition, § 200.303(a) requires the Organization to establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing, it was noted that 12 of 60 samples did not include sufficient records to substantiate approval of the disbursement. Questioned costs: None. Context: A sample of 60 was made from a population of over 250 disbursements charged to the major program. Of the 60 sampled costs, 12 did not have sufficient records to substantiate adequate approval. Cause: Approvals are not maintained for ACH transactions. Effect: Without adequate controls in place to ensure costs are reasonable and intended for the program charged, the Organization could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-003. Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by the Organization as proof of oversight of expenditure of federal funds. CLA would also recommend the use of an AP voucher, or similar, for each type of disbursement that leaves the Organization (check, ACH, EFT, credit card, etc.) to improve documentary evidence that costs are being reviewed and approved for appropriateness. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls and training for all staff on documenting evidence of approvals, including obtaining and retaining necessary documentation and proof of expenditure oversight for federal funds to ensure there is adequate evidence that costs are being reviewed and approved for appropriateness. As noted above, we have added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. We are also investigating an AP voucher process through our existing accounting software. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nationwide Children’s Hospital (the Corporation) uses a third-party to perform its suspension and debarment checks on a monthly basis. However, we noted the following matters: • The Corporation did not retain the monthly supporting documentation related to the monthly suspension and debarment check. The suspension and debarment checks performed at year-end were retained. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation in Q4 2023 to address this finding. • The Corporation does not have a process to reconcile the vendor list provided to the third-party vendor with the results received from the third-party vendor after the suspension and debarment checks are performed to ensure the listing is complete. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation to address this finding for the annual screening that was performed in Q1 2024 for year 2023. Management also implemented a monthly reconciliation process as quickly as practicable, beginning with January 2024 data. • The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. The Corporation relied on the results of the suspension and debarment checks performed by the third-party vendor without implementing an internal process to ensure the results provided by the third-party vendor were accurate. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented a process to verify the accuracy of the results produced by the third-party vendor. Management implemented the remediation to address the finding in the first quarter of 2024 for 4th quarter 2023 results. Responsible Person: Kathleen Dunn, JD – VP and Chief Compliance Officer Completion Date: January 31, 2024 • In addition, the Corporation performs a suspension and debarment check of all new vendors prior to activating them in the procurement system. The Corporation did not consistently maintain supporting documentation to support the vendor was checked for suspension and debarment before the “new”-vendor was set up in the procurement system. o Management Response In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented an audit process to ensure that screening documentation is maintained. This audit process flagged 2 of these 3 deficient documentation results, and documentation was subsequently uploaded to the file. The third vendor was an insurance company, which prior to mid-2023 was not screened at the time of setup based on vendor type. As of mid-2023, all vendors regardless of vendor type, are being screened at setup. Responsible Person: Mary Beth Colatruglio, CPA – Director of Accounting Completion Date: January 31, 2024