Corrective Action Plans

Finding No: 2024-001 Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.917 Program: HIV Care Formula Grants Compliance Requirements: Activities allowed or unallowed/allowable costs, cash management and eligibility Award Year: October 1, 2023 through September 30, 2024 (a) Criteria or Requirement 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. (b) Condition Found The System lacked sufficient internal controls to ensure the allowability of expenditures charged to the HIV Care Formula Grants. Our testing of a sample of 40 transactions totaling $6,054 identified three charges, totaling $488, that were incorrectly billed to the federal program. These costs, although related to services provided to patients, were determined unallowable for the following reasons: • The patients had other insurance coverage that was not billed prior to submission to the federal agency. • The patients did not meet all eligibility requirements and should have been excluded from reimbursement requests. Additionally, management did not maintain adequate documentation to support the annual reverification of patient eligibility, which is required prior to receiving services each year to remain eligible for the program. Due to these deficiencies, an expanded sample of 23 additional charges totaling $2,799 was tested. Of these,12 were determined to be unallowable, totaling $1,808. Charges related to certain costs related to July through September 2024 were related to an agreement that was not fully executed, resulting in an additional $97,782 of unallowable costs. Lastly, management did not retain sufficient supporting documentation for certain amendments to the grant agreement. This documentation is necessary to substantiate various elements of patient eligibility criteria under the grant. The grant amendment includes specific language that the grant is for the treatment of females over the age of 13, however both males and females were expensed and reimbursed under the grant. The male population for the remaining nine months of year represents $404,710. Our testing identified 26 out of our expanded sample of 63 total patients were males that were not also identified in the above testing results, totaling $3,835. (c) Cause The System’s review processes for charges recorded against the grant and submitted for federal reimbursement were ineffective in preventing unallowable charges and inaccurate amounts. Additionally, the System could not provide documentation for certain grant agreement amendments that would have supported the eligibility of specific patients. (d) Effect Federal funds were expended for unallowable purposes or for inaccurate amounts and evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (e) Questioned Cost Expenditures related to patient charges of $222,016. (f) Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding (h) Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs as well as ensure all relevant documentation is maintained in accordance with Federal requirements. (i) View of Responsible Officials Invoices were submitted to Mississippi State Department of Health (MSDH) for the HIV Care Formula Grants (CFDA No. 93.917); however, clinic staff did not conduct a thorough evaluation to verify continued eligibility for the program among patients who had previously qualified. Additionally, the lack of a fully executed agreement was a management oversight which contributed to the uncertainty regarding allowable billing to the program for reimbursement. Supporting documentation, including paperwork and emails, was also not properly maintained by management. (j) Corrective Action Plan We have reinforced our records retention policy to ensure proper documentation in support of eligibility determinations. Due to a variety of issues with this grant, including incomplete and conflicting guidance from the State of Mississippi, North Mississippi Health Services, Inc., has elected to terminate our participation in the program. As the program has concluded, no further actions are required due to expiration of the contract terms. The Fee-for-Service agreement ended June 30, 2024, while the Ryan White Part B Subgrant Agreement ended March 31, 2025. We will reimburse any funds received that were deemed unallowable due to expenditures occurring outside the grant period or patient ineligibility. Anticipated Completion Date: 10/31/2025 Name of Contact Person for Corrective Action: Sharon Nobles, Chief Financial Officer

Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must demonstrate proper approval. Corrective Action: Utilize standard purchase authorization and maintain approval documentation with supporting invoices/receipts.

CONDITION: The Regional Office of Education No. 39 did not have sufficient internal controls over the preparation of the SEFA to ensure all federal expenditures during the fiscal year were reported and information in the SEFA was complete and accurately reported. PLAN: The Regional Office of Education No. 39 will implement controls over financial statements for both the internal Business Office Manager and the contracted accounting firm to prepare and review the financial statements including the schedule of expenditures of federal awards, to ensure program titles, assistance listing numbers and other pertinent information is accurate for financial statement presentation. ANTICIPATED DATE OF COMPLETION: Implemented August 2025

CONDITION: The Regional Office of Education No. 39 manually maintains and stores its inventory of property and equipment. Asset details in the property records include only the description of the property, manufacturer’s serial number or other identification number, source of funds, who holds title, acquisition date, and cost of the property. The other minimum requirements specified by the Code including FAIN, location, use and condition of the property are not included in the property records. PLAN: The Regional Office of Education No. 39 created a combined inventory documents to provide a complete detailed accounting of all property and equipment which provided majority of the required information for federal funds as well as a reconciliation to the capital outlay disclosures within the financial statements. The missing data requirements for the compliance with record keeping of Equipment from Federal funds will be added for Fiscal Year 2025. ANTICIPATED DATE OF COMPLETION: Implemented August 2025

CONDITION: The Regional Office of Education No. 39 did not submit or timely submit the required reports to the Illinois State Board of Education in compliance with the grant award agreement. PLAN: The Regional Office of Education No. 39 agrees with the audit findings and will provide close oversight for the timely submission of grant expenditures and performance reports. Checklist, due dates, and reminders are shared from the Regional Superintendent to the Business Office Manager and Program Directors. Management will review the grant report submissions in Illinois Web Application Security (IWAS) for accuracy and completion before approving and submitting to Illinois State Board of Education. ANTICIPATED DATE OF COMPLETION: Implemented July 2024

CONDITION: The Regional Office of Education No. 39 did not have adequate controls over subrecipient monitoring in compliance with the Code. PLAN: The Regional Office of Education No. 39 drafted subrecipient monitoring policies and procedures for Fiscal Year 2024 after receiving the Fiscal Year 2022 audit finding on December 2023. Policies and procedures included reporting, monitoring, and award notification for the subrecipients of the ARP- Social Emotional Learning and Trauma Response grant. Some of the subrecipient information was received late from subrecipients. The Regional Office of Education No. 39 will follow up with subrecipients to ensure that all information is received and in a timely manner whenever possible. ANTICIPATED DATE OF COMPLETION: Implemented August 2025

Finding 2024-003 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Equipment and Real Property Management Audit Finding: Material Weakness, Noncompliance Condition: An effective internal control system was not in place at the District to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The District did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. There was approximately $25.0 million of disbursements from federal funds related to the project as of December 31, 2024. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will compile a capital asset listing that lists out the District’s capital assets and notes the required information, which will include the federal funding source (if applicable). The capital asset listing will be updated on an annual basis. The Board of Directors will review the capital asset listing. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect immediately.

Management believes that in order to ensure that the amount being drawn down are timely and more accurate to the amounts being drawn upon, management is in the process of developing a more formal policy whereby the general ledger will be formally closed on a monthly basis and all amount will be reconciled to the ledger. Once all amounts are proven, then the drawdown amounts will be initiated with the proper documentation attached.

We will work to establish written procedures and policies related to the management of Federal awards, including reporting requirements.

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants,

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that Comanche County receives to ensure that proper internal controls are implemented.

Finding Number: 2024-001 Program Name/Assistance Listing Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Mark Ollerton, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District acknowledges and understands that the expenditures should have been reported as federal. The LEA will correct this oversight and ensure compliance going forward by implementing the following actions: 1. Grant Identification and Training – Provide annual training for all staff involved in grant management to ensure awareness of federal versus state funding sources and their respective reporting requirements. 2. Internal Controls and Oversight – Require that all new grants be reviewed and approved by the Business Manager prior to set-up in the District’s financial system, to confirm proper federal identification and ALN coding. 3. Quarterly SEFA Reviews – Implement quarterly reconciliations of grant expenditures against SEFA records to ensure completeness and accuracy throughout the fiscal year. 4. Management Review – Conduct higher-level review of SEFA preparation by the Superintendent and Business Manager before submission to auditors.

Views of Responsible Officials: Management agrees and was fully aware of the situation it found itself in when funding was cut. The Organization was not able to keep enough staff employed during this time to review and correct these errors before the audit fieldwork began. Now that these historical balances have been corrected, the team undergoes a rigorous month-end close process where these issues will be caught and addressed immediately going forward.

Review AP policies, train AP personnel, and require double approval before using grant funds

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County obtain certifications from vendors stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has ensured that any entity that receives American Rescue Plan (APRA) funding is registered on SAM.gov before any funds are disbursed by the County. An addendum will be added to new contracts with subrecipients of any Federal funds that will require signed certification from the vendors/contractors related to debarment and registration with SAM.gov. The county will do an annual check for existing subrecipients to ensure they are not subject to suspension or debarment. Name of the contact person responsible for corrective action: Craig McBrain, Deputy Director of Budget and Finance Planned completion date for corrective action plan: December 31, 2025

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends that the County review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding and that appropriate monitoring is performed for each subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For future awards the County will include compliance requirements to subrecipients in the award documents. For previously issued awards, the County will use appropriate subrecipient monitoring procedures to ensure compliance with the grants awarded throughout the remainder of the contract periods. Name of the contact person responsible for corrective action: Craig McBrain, Deputy Director of Budget and Finance Planned completion date for corrective action plan: December 1, 2025

A procedure has been created for this and will be implemented and looked at 1/4ly so funds can be spent down during the school year. Immediate steps were taken to do a spenddown plan and the food serviced fund was used for the program to bring down the fund balance to less than the three-month average expenditures.

Finding Number 2024-001: Eligibility Determination Process (Material weakness in Internal Control over Compliance and Material Noncompliance – Eligibility) Program: Housing Opportunities for Persons with AIDS Assistance Listing Number: 14.241 Response and Corrective Action Plan: Management agrees with the finding that the internal controls required for this program had material weaknesses. To ensure proper program management, program staff have created appropriate procedures and processes to demonstrate internal controls. These include a manager review of potential clients, a checklist for ensuring that the program collects and maintains required records, and a procedure for collecting and storing third-party documentation for client program intake/eligibility, diagnosis, and income. Anticipated Completion Date: by September 1, 2025 Responsible Person: Tiffany Major, Deputy Director

Grantee Response and Corrective Action Plan: AVLF concurs with the recommendation. The Organization will take the following corrective actions: 1. Remit corrected timesheets to the Agency for information purposes. 2. Revise the organization’s policy to include review and reconciliation of SER’s and timesheets prior to submission to the Agency. Responsible Parties: Jason Levister, Controller Date to be Completed: October 2025

Views of responsible personnel and planned corrective actions: Management concurs with this finding. The Cooperative will implement the following corrective actions prior to December 31, 2025: • The CFO will document written procedures for SEFA preparation that specifically address proper period cutoff based on when costs are incurred versus when funds are received. • All current grant agreements will be reviewed to identify federal funding sources and ensure compliance with the single audit threshold. • The CFO will perform quarterly and annual reviews of federal expenditure reporting for completeness, accuracy, and proper period reporting. • Prior to year-end, the CFO will independently review all award documentation to the draft SEFA against all grant documentation to verify completeness and proper period reporting.

The county will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented.

The Organization will revisit the internal control process around invoice submissions and reimbursement request review. The Organization has since hired an outsourced accountant to assist with record keeping and assisting with ensuring compliance with Uniform Guidance. The Organization strives to remain compliant with Uniform Guidance in all respects to present both accurate and transparent records. If the Missouri Department of Social Services or the U.S. Department of the Treasury have questions regarding this plan, please call Jennifer Gadsky, MSW, LCSW, Executive Director, at (314)-938-4414.

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.063 Condition: During our audit procedures, we noted that the 1 student withdrawal did not have a return to Title IV calculation completed timely as the student officially withdrew 8/29/23 and the calculation was not completed until 3/24/25. We also noted that the calculation that was performed did not include documentation of the control process to review and approve the calculations prior to changes being made to the student’s award. Auditors’ Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the federal student financial aid programs. Auditors’ Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. The new systems are Jenzebar products and are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Students tested in the Common Origination and Disbursement (COD) reporting were not properly reported based upon University documents, including disbursement dates and applied dates. Auditors’ Recommendation: We recommend that the University strengthen its internal controls to ensure that all disbursement dates are reported to COD accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The previous SIS was subject to frequent interruptions which prevent timely data exchange with COD. Beginning with the 2024-2025 award year a new financial aid processing system was implemented. The new processing system is a more secure environment and hosted by Jenzabar for added compliance assurance. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025