Corrective Action Plans

2024-106 Lack of Time and Effort Documentation Policy Condition: Time and effort reporting on actual hours spent on individual grant projects used to support the budgeted allocations of employee salary for each grant are not being kept. This is a systemic issue as a procedure for documenting time and effort by employee to justify the allocation of salaries across grants has not been put in place. Corrective Action Planned: We acknowledge the finding and have adopted a formal Time and Effort Reporting Policy. Standardized timesheets will be implemented and staff trained within 60 days, with supervisors reviewing submissions. The Finance Manager will monitor records monthly and conduct quarterly reviews to ensure compliance going forward. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: October 2025

2024-105 Lack of Payroll Review and Approval Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manger providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025 Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: October 2025

Methodist recognizes the current gap between Supply Chain Services and the Research Institute related to retaining documents for procurement activities. Supply Chain Services will develop processes to retain written documentation for procurement activities in accordance with regulatory standards. As Methodist is in transition to a new ERP system in Quarter 1, 2026, Supply Chain Services will include strategies to address the needs in both the short term and long term.

Communities In Schools of Georgia acknowledges the audit recommendation and is committed to strengthening internal controls related to journal entries and supporting documentation.Under the leadership of our newly hired CFO, we are continuing to improve our finance processes by implementing the following measures: Internal Controls for Journal Entries Segregation of Duties Workflow Approvals Training and Process Standardization During fiscal year 2025, we took the following actions to improve the integrity of our finance processes and controls over compliance with federal grant requirements: Engaged Senior Finance Contractor Completed Search for Permanent full-time CFO Initiated and Completed Search for an Accounting Manager

Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 7/1/2022-4/30/2023 Summary of Finding: The Personal Protective Equipment (PPE) and other COVID related supplies were not used within the period of performance outlined within the project worksheet. There were three FEMA obligations during FY 2024. An overstatement of expenditures in one of the projects (project 10) was identified with an obligation amount of $6,732,507. The period of performance as specified within the project 10 application is July 2, 2022 to April 30, 2023 and $1,077,759 of costs were not used by April 30, 2023. The overstatement represents approximately 16% of the amounts reported in the project 10 application and 14% of the total FEMA obligations in FY 2024. The total federal expenditures for FEMA for FY 2024 were $7,795,530. Corrective Action Plan: Management agrees that a thorough review of the claim was not completed prior to submitting the Request for Reimbursement to the State of Michigan, thus causing a control deficiency. In the future management will perform, document, and sign off on a thorough claim review to validate that all final adjustments have been submitted prior to submitting the Request for Reimbursement to the State. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller Cindy Brink, Director, System Accounting and Reporting. Timing of corrective action: September 1, 2025 and going forward.

Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.926 Healthy Start Initiative (HSI) Pass-Through Grantor: Not applicable Award Number: H4903591 Award Period: 5/1/2024-3/31/2025 Summary of Finding: Three instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in the FSRS in FY 2024. In addition, for all four FFATA reports that were submitted in FSRS in FY 2024, there was no evidence of review and approval of the reports prior to submission. Under the HSI program, there were four subrecipients that had a total of seven subaward (four new agreements and three amendments) in FY 2024. The three subaward modifications for which FFATA reports were not submitted totaled $278,805. Total subrecipient’s costs are $736,165 in FY 2024. The total federal expenditures for the HSI program for FY 2024 were $1,108,849. Corrective Action Plan: Leadership acknowledges a gap in the current FFATA reporting process specific to the submission of reports for amended subawards and review and approval of reports prior to submission. To address these deficiencies, leadership will develop a written procedure for FFATA reporting that includes specific instructions for reporting amended subawards throughout the award period. Additionally, the procedure will include review and approval of the report prior to submission. This process will be disseminated to the Office of Sponsored Programs and Research Finance teams and reviewed on a regular basis for ongoing education and compliance purposes. Individuals responsible for corrective action: Paula Schuiteman-Bishop, Vice President, Research Administration Joe Fugitt, Senior Director, Research Administration, Development and Billing Integrity Jodi Bonhorst, Director, Research Development Brandy Jurdzy, Manager, Research Sponsored Programs. Timing of corrective action: September 1, 2025, and going forward.

Finding 2024-002 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS) Assistance Listing: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Pass-Through Grantor: Not applicable Award Number: U3REP220676 Award Period: 9/30/2024-9/29/2025 Summary of Finding: For one of the two Federal Financial Reports (FFRs) submitted in FY 2024, incorrect project/grant period dates and federal share of expenditures amount was reported in the FFR. Two FFR reports were submitted in FY 2024. The FFR instructions required reporting the cumulative Federal share of expenditures amount ($2,253,211) from the date of inception of the award (9/30/2022) through the end date of the reporting period specified. However, Corewell reported only the current period expenditures ($933,054) for the current grant year and consequently, this error also resulted in incorrect amounts reported for the Unliquidated balance of Federal funds. The total federal expenditures for HPP for FY 2024 were $1,292,999. Corrective Action Plan: Leadership acknowledges the need for more robust deliverable tracking and review of Federal Financial Reports (FFRs) prior to submission. A written protocol and tracking matrix will be developed to record and track all federally funded projects that report through the Payment Management System (PMS) to ensure the correct period of performance report is created and a second level of review performed on a timely basis in accordance with sponsor requirements prior to submission. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller David Ross, Director, Research Finance and Analysis Timing of corrective action: September 1, 2025, and going forward

2024-002 Finding Subject: COVID 19: Coronavirus State and Local Fiscal Recovery Funds - IFA Grant - White Ditch– Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Procurement Federal regula􀆟ons allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisi􀆟on threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restric􀆟ve threshold of $150,000 or less for when small purchase procedures may be used. This informal process allows for methods other than the formal bid process. Micro-purchases are typically for those purchases $10,000 or under, and small purchase procedures are for those purchases above the micro-purchase threshold, but below the simplified acquisi􀆟on threshold. Micro-purchases may be awarded without solici􀆟ng compe􀆟􀆟ve price rate quota􀆟ons. If small purchase procedures are used, then price or rate quota􀆟ons must be obtained from an adequate number of qualified sources. Description of Corrective Action Plan: All purchases need to be made in accordance with the Sanitary District of Michigan City Purchasing Policy. All contracts will be supported by a written and signed contract document per Section 9.0 of the Sanitary District of Michigan City Purchasing Policy. Suspension and Debarment 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal awards 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)...." 2 CFR 200.320 states in part: "The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the following methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. (a) Informal procurement methods. When the value of the procurement for property or services under a Federal award does not exceed the simplified acquisition threshold (SAT), as defined in § 200.1, or a lower threshold established by a non-Federal entity, formal procurement methods are not required. The non- Federal entity may use informal procurement methods to expedite the completion of its transactions and minimize the associated administrative burden and cost. The informal methods used for procurement of property or services at or below the SAT include: . . . (b) Formal Procurement Methods. When the value of the procurement for property or services under a Federal financial assistance award exceeds the SAT, or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section. The following formal methods of procurement are used for procurement of property or services above the simplified acquisition threshold or a value below the simplified acquisition threshold the non-Federal entity determines to be appropriate: . . . (1) Sealed bids. A procurement method in which bids are publicly solicited and a firm fixed-price contract (lump sum or unit price) is awarded to the responsible bidder whose bid, conforming with all the material terms and conditions of the invitation for bids, is the lowest in price. The sealed bids method is the preferred method for procuring construction, if the conditions. . . . (2) Proposals. A procurement method in which either a fixed price or cost-reimbursement type contract is awarded. Proposals are generally used when conditions are not appropriate for the use of sealed bids. . . ." 31 CFR 19.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you do business is not excluded or disqualified. You do this by: (a) Checking the EPLS; or (b) Collecting a certification from that person if allowed by this rule; or (c) Adding a clause or condition to the covered transaction with that person." Description of Corrective Action Plan For all federally funded contracts exceeding $25,000, the Vendor will submit a statement indicating they were not suspended or debarred. For purchases not requiring a contract, the City Controller’s office will check the Excluded Parties List System prior to payment to the vendor. Anticipated Completion Date: 08/06/2025

FINDING 2024-001 Finding Subject: COVID-19- Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Procurement Federal regula􀆟ons allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisi􀆟on threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restric􀆟ve threshold of $150,000 or less for when small purchase procedures may be used. This informal process allows for methods other than the formal bid process. Micro-purchases are typically for those purchases $10,000 or under, and small purchase procedures are for those purchases above the micro-purchase threshold, but below the simplified acquisi􀆟on threshold. Micro-purchases may be awarded without solici􀆟ng compe􀆟􀆟ve price rate quota􀆟ons. If small purchase procedures are used, then price or rate quota􀆟ons must be obtained from an adequate number of qualified sources Description of Corrective Action Plan: All purchases need to be made in accordance with the City of Michigan City Purchasing Policy. Purchases made under the Special Purchase provision (I.C.5-22-10-1) will abide by section 7.4 of the Michigan City Purchasing Policy. This section describes the required record keeping. Suspension and Debarment Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal awards 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)...." 31 CFR 19.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you do business is not excluded or disqualified. You do this by: (a) Checking the EPLS; or (b) Collecting a certification from that person if allowed by this rule; or (c) Adding a clause or condition to the covered transaction with that person." 2 CFR 200.320 states in part: (a) "The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the following methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. Informal procurement methods. When the value of the procurement for property or services under a Federal award does not exceed the simplified acquisition threshold (SAT), as defined in § 200.1, or a lower threshold established by a non-Federal entity, formal procurement methods are not required. The non- Federal entity may use informal procurement methods to expedite the completion of its transactions and minimize the associated administrative burden and cost. The informal methods used for procurement of property or services at or below the SAT include: . . . (2) Small purchases– (i) Small purchase procedures. The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. . Description of Corrective Action Plan: For all federally funded contracts exceeding $25,000, the Vendor will submit a statement indicating they were not suspended or debarred. For purchases not requiring a contract, the City Controller’s office will check the Excluded Parties List System prior to payment to the vendor. Anticipated Completion Date: 08/06/2025 INDIANA STATE

U.S. Department of the Treasury, Passed through the City of Pittsburgh and the Commonwealth of Pennsylvania, Department of Community and Economic Development- Assistance Listing Number 21.027 Questioned Costs: None Condition: During 2024, the URA did not follow the internal control procedures to ensure review that all covered contracts and subawards were not conducted with entities that are suspended and debarred. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the entity did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. While the entity stated that such reviews are conducted, the lack of documented verification prevents confirmation that appropriate controls were consistently applied. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. Action: The URA will add suspension and debarment back to all agreements. For the agreements that have been administered, the URA will review SAM.gov to ensure the client is not in the system. This will take effect immediately.

2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City Council o City Manager o City Finance Director Anticipated Completion Date: June 18, 2025

FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2025

FINDING 2024-004 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include implementing a federal procurement policy. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Anticipated Completion Date: August 30, 2025

FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Department head will review and document their review for all Federal Grant disbursements for applicable grant requirements and Federal regulations. Anticipated Completion Date: August 30, 2025

FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Suspension and Debarment Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office implemented a contract to cover all suspension and debarment. This contract procedure was put in place in 2024 but was not implemented on all invoices over $25.000. It was believed to only be needed in instances where an invoice was not present. We will now have a contract for all vendors receiving payments over $25,000. Anticipated Completion Date: Completion is anticipated 12-31-2025.

FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.

Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.

Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.

Views of responsible personnel and planned corrective actions: Management concurs with this finding. The College has implemented immediate corrective actions including development of a comprehensive grant tracking spreadsheet and establishment of regular meetings between program and finance staff. Additionally, effective immediately, all grant applications must be reviewed and approved by the Controller prior to submission to ensure proper identification of funding sources and compliance requirements. The College will also implement cutoff procedures to ensure federal expenditures are reported in the correct period based on when eligible costs are incurred. The Controller will review all G5 drawdowns near year-end to verify proper period reporting. Formal written procedures for SEFA preparation will be implemented by October 15, 2025. The Controller will maintain the master grant listing and review all grant agreements to determine federal funding sources. Beginning with fiscal year 2026 SEFA preparation, the CFO will perform an independent review for completeness and accuracy, including verification of proper period reporting for all federal expenditures.

Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility documentation in maintaining compliance with SFSP regulations and ensuring program integrity. Corrective Action Taken: • The YMCA has implemented a formal monitoring protocol for all SFSP operating sites, including a pre-operational review checklist to verify eligibility documentation. • Site agreements now explicitly require submission of enrollment records and eligibility documentation prior to participation. Ongoing site monitoring includes periodic reviews to ensure continued compliance with eligibility requirements. Staff have been trained on 7 CER 225.6(c) and 2 CFR 200.303 to reinforce sponsor responsibilities. Responsible Individuals: Jeff Reynolds and Rachel Dumas Completion Date: Plan has been implemented as of the date of audit submission.

Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online software built to streamline payroll and automate taxes. It does include a job costing process that allows for identifying payroll costs to be distributed appropriately to funders. This electronic payroll system decreases the chances of human error. Also in August of 2025, there is a change in personnel to Finance & Operations Director rather than Finance and Operations Manager. The new position comes with increased responsibilities and increased skills. This position will be responsible for reconciling payroll allocations from Paychex to Payroll allocations in QuickBooks to government funding reports to ensure accuracy. These changes along with the systems that we have had in place should help prevent this issue from being repeated.

Due to lack of submission date field in Sam.gov system, we agree that we will add an alternate process to document timely submission for subawards reports on Sam.gov. This will be done by downloading the PDF report and confirming through email from Senior compliance officer.