Corrective Action Plans

U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation prior to signing the check. Documentation of that review and approval shold be readily for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: All checks presented for signatures have supporting documentation attached. Authorized check signers are instructed to review all documentation for appropriate authorization, payee name, and amounts prior to signing checks. No checks are signed without supporting documentation. The agency will require check signers to initial the check request page or other supporting documentation when signing checks for grant expenditures. The Neighborhood Service Center, Inc. is implementing a procedure to provide the Finance Committee of the Board with a listing of all checks issued between Board meetings for their review/reference. The Finance Director keeps all check stock locked in their office to avoid any potential misuse of the check stock. Name of the contact persons responsible for corrective action: R. Andrew Hollis, Executive Director Michele Lednum, Finance Director Planned completion date for corrective action plan: For immediate implementation and ongoing.

The City acknowledges the finding. The City will develop and maintain written policies and procedures appropriate to its federal award activity and the terms and conditions of its federal awards, including internal controls, record-keeping, reporting responsibilities, allowable costs, procurement and conflict-of-interest requirements where applicable, and compliance monitoring.

Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2026

Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.

CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-003 Document Policies and Procedures Over Federal Awards Views of responsible officials: The Town agrees with the recommendation to implement written policies and procedures to be in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action: The Town plans to implement recommendations for the next fiscal year. Official Responsible for Implementing Corrective Action: Kurt Ginthwain Finance Director/Town Accountant

Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the organization is in the process of evaluating and implementing an electronic system to streamline and document approvals for accounts payable and credit card transactions. These steps will strengthen internal controls and ensure proper documentation of all approvals in accordance with organizational policies and federal requirements. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: May 31, 2026

Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026

􀀫􀁎􀁓􀁉􀁎􀁓􀁌􀀅􀀗􀀕􀀗􀀙􀑛􀀕􀀕􀀖􀀟 Significant deficiency in internal controls over financial reporting related to the recognition of grant and contract receivables and inventory Contact Person NAME: Keeley Foley PHONE: 206.381.0883 E-Mail: keeley.foley@aahi.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned Access to Advanced Health Institute’s (AAHI’s) response to the recommendation: 1. Engage Escalon Financial Services to review/update policies and procedures for grant receivable recognition per GAAP (FASB ASC 958) and Uniform Guidance (distinguish unconditional versus conditional grants, proper cutoff/revenue recognition) 2. Implement quarterly independent review of year-end receivable balances and revenue entries by Escalon. 3. Conduct training for finance staff on GAAP grant recognition (completion tracked via signed attendance sheets) (Escalon is GAAP trained and certified) 4. Test 100% of material grant receivables at next fiscal year-end close for proper recognition (Ensure process is full proof and no deviations of process in prior fiscal year occurred) 5. In addition, AAHI will implement controls over recognition of inventory Responsible party: Escalon with Operations Director and Keeley Foley(oversight) Anticipated Completion Date May 2026 􀀫􀁎􀁓􀁉􀁎􀁓􀁌􀀅􀀗􀀕􀀗􀀙􀑛􀀕􀀕􀀗􀀟 Significant deficiency in internal control over compliance and compliance as it relates to allowable costs and activities Contact Person NAME: Keeley Foley PHONE: 206.381.0883 E-Mail: keeley.foley@aahi.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned AAHI’s response to the recommendation: 1. Formalize written policies and procedures for allowable costs per 2CFR 200 Subpart E (necessary, 206.381.0883 222 5th Ave N, Seattle,WA 98109 www.aahi.org reasonable, allocable, documented). 2. Require pre-expenditure requisition approval by Principal Investigator (PI) for all grant-related expenses (tracked in project management system). 3. Mandate dual review and recertification of invoices and drawdowns: PI and Director of Operations (documented sign-off required before payment/submission) 4. Perform monthly compliance reconciliations (grant budget vs. actual expenditures) with variance resolution documented. 5. Deliver annual training, and otherwise as needed, to PIs and staff on allowable/unallowable costs (tracked via attendance and quiz scores above 80%) 6. Conduct quarterly internal monitoring of 25% sample of grant expenses for allowability and compliance. Responsible party: Keeley Foley (oversight), Director of Operations (daily enforcement), Escalon (support) Anticipated Completion Date May 2026

Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for a formalized, written policy governing expenditures charged to federal awards. To address identified material weaknesses, Wabash is committed to implementing a comprehensive written policy by June 30, 2026. This policy will formalize the coding, review, and reporting processes for all federal expenditures. Key improvements will include: • Enhanced Internal Controls: We will establish a clear segregation of duties to ensure oversight and accuracy. • Timely Reporting: We are refining our payroll allocation process. Previously, payroll expenditures were withheld pending budget verification, which occasionally led to reporting delays. New controls will ensure that all expenditures, including payroll, are reported within the required quarterly timeframes. • Monitoring: The Controller will oversee the development of these procedures and remain responsible for ongoing monitoring and compliance. These steps will ensure our financial practices meet federal standards and provide rigorous oversight of project funds. Contact person(s): Cheryl Gaither, Controller Justin Gephart, Chief Operating Officer

CORRECTIVE ACTION PLAN March 13, 2026 Chickahominy Indian Tribe - Eastern Division respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: December 31, 2024 The findings from the December 31, 2024 Schedule of Findings and Questioned Costs (the "Schedule" ) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS- FINANCIAL STATEMENT AUDIT 2024-001: Payroll Tracking and Allocation (Material Weakness) Condition The client was unable to provide a payroll allocation by fund that agreed to the payroll registers. Criteria Payroll allocations were not supported by adequate documentation and were not consistent with methods used in the prior year. Cause The prior CFO had created an allocation method in which the existing employees could not follow . After the CFO's departure, emailed allo cat ions were sent which only specified which funding source the payroll expendit ures would be paid from, not the fund the expenditures were incurred in. Effect Material audit adjustments were required. Recommendation We recommend that payroll allocations be supported by a logical method and be allocated by fund. Corrective Action The Tribe has implemented corrective actions to strengthen internal controls over payroll allocations including: • Development and implement ation of a standardized payroll allocation model beginning with payrolls processed from September 2024 forward. • Preparation of documented allocation schedules for each pay period reconciling payroll costs to payroll registers and accounting records. • Use of standardized spreadsheet templates to support calculation and documentation of payroll allocations across funding sources . • Direct upload of payroll allocation entries into the accounting system to reduce manual entry and improve reconciliation accuracy. These procedures have established a consistent and supportable methodology for allocating payroll expenditures by fund and maintaining documentation sufficient to support financial reporting and audit requirements. The payroll allocation model was implemented beginning September 2024 and was further refined during 2025. The corrective action is considered implemented. 2024-002: Material Audit Adjustments (Material Weakness) Condition In fiscal year 2022, the Tribe elected to convert from the cash basis of accounting to governmental accrual accounting. During 2024, the Tribe continued to function on a cash basis and did not record most accruals. Criteria Financial information provided shou ld be accessible and materially correct. Cause Tribe has not consistently used the accounting software and has relied on program­ specific spreadsheets. The Tribe did not fully switch to accrual basis for internal reporting. Effect Material audit adjustments were required. Recommendation We recommend that monthly reports be generated from Abila and reviewed for accuracy. Any discrepancies between Abila reports and program-specific spreadsheets should be reconciled or adjusted. These reports should be reliable and able to be used to present to Council as part of monthly financial reporting. Corrective Action The Tribe has taken steps to strengthen the use of the accounting system as the primary source of fi nancial reporting and to improve the reliability of financial reports generated for internal management purposes including: • Continued use of the accounting system (Abila/ M IP) as the system of record for all financial t ransact ions. • Development and implementation of a revised chart of accounts structure to improve financial reporting and fund tracking. • Comprehensive review and correction of historical accounting activity to improve data integrity within the accounting system. • Use of spreadsheets as supplemental tools for monitoring estimated fund balances and grant acti vit y where necessary. • Ongoing efforts to customize financial reports generated direct ly from the accounting system so they align with the reporting format requested by Tribal leadership. The Tribe is currently working to finalize customized accounting system reports that will allow monthly financial reports to be generated directly from the accounting system in the format required for Tribal Council repo rt ing. Substantial improvements were implemented during 2025. Full implement atio n of customized accounting system reporting will be completed in the second quarter of 2026. 2024-003 : Budget Approval and Adherence (Material Weakness) Condition The budget was not approved until February 2024 and did not contain sufficient detail nor was it an accurate reflection of financial operations. Criteria Budgets should be developed with sufficient detail to track organizational performance throughout the year. Budgets should be approved by Council prior to the start of the fiscal year. Cause Unqualified staff or lack of attention to the budgeting process. Effect A budget was approved after the fiscal year and was not measured to actual performance during the year. Recommendation A thorough and detailed budget should be developed at the fund and entity level and adopted by Council prior to the start of the fiscal year. We also recommend Council meetings include a formal discussion of budget to actual results, thus giving Council an opportunity to question variances. Corrective Action The Tribe has taken steps to strengthen its budgeting process and improve financial oversight by Tribal leadership including: • Development of a detailed fiscal year 2025 operating budget at the fund and entity level to improve monitoring of financial activity across funding sources. The FY2025 budget was adopted by Tribal Council on February 8, 2025. • Development of a detailed fiscal year 2026 operating budget at the fund and entity level. This budget was presented to Tribal Council on December 19, 2025 and formally adopted with minor revisions at the January 12, 2026 Council meeting very near the start of the fiscal year. • Implementation of enhanced monthly financial reporting for Tribal leadership to support improved financial monitoring and oversight. • Ongoing development of budget-to-actual comparison reporting to support regular review of financial performance by Tribal Council. Budget development improvements were implement ed during fiscal years 2025 and 2026. Full implementation of budget-to-act ual repo rting will becompleted in the second quarter of 2026. 2024-004: Segregation of Duties (Material Weakness) Condition Certain key financial operational responsibilities are not sufficiently segregated. Criteria Proper segregation of duties shou ld be in place detect of irregulariti es in a timely manner. Cause Small staff size combined with significant turnover. Effect Segregation of duties could not be maintained in several signi fi cant rol es during the year. Recommendation Management should review the current process and implement changes to better separate responsibilities so that no one individual is responsible for a transaction cycle. Where proper segregation is not possible, mitigating controls can be put into place to detect errors. Corrective Action The Tribe recognizes the importance of segregation of duties as an internal control and has taken steps to strengthen oversight and implement mitigating controls where full segregation is not feasible due to staffing limitations including: • Increased oversight of financial transactions and accounting activit y by the Director of Finan ce. • Implementation of improved documentation and reconciliation procedures for key accounting processes. • Development of standardized processes and templates to improve consistency and transparency in financial transactions. • Implementation of enhanced financial reporting to Tribal leadership to support independent review offinancial activity. • Ongoing review of financial responsibilities and workflows to identify opportunities for improved separation of duties as staffing capacity permits. Where complete segregation of duties is not possible due to organizational size, the Tribe will continue to rely on management review and reconciliation procedures as compensating controls that have proven effective in detecting errors and irregularities. Mitigating controls were implemented during late 2024 and throughout 2025 and will continue to be refined as staffing capacity allows. 2024-005: Grant Tracking and Reporting (Material Weakness) Condition Poor financial record keeping and lack of thorough grant expenditure and status tracking. Criteria Grant funding should be recorded in separate GL accounts and be reconciled to any ext ernal spreadsheets or drawdown requests and grant reporting. Cause Turnover and unqualified staff. Effect Some grant funding sources were drawn down without documentation of qualifying expenditures, while others appear to have had qualifying expenditures that did not have matching drawdowns. Recommendation Accounting systems should be properly uti lized to track expenditures incurred under each grant and be reconciled to external reporting and spreadsheets. Once a grant is fully expended, the grant shou ld be closed out by ensuring revenues match expenditures. If expenditures are greater than the revenue provided by the grant, a transfer from the general fund would be needed. If revenues are greater than expendit ures , it could be an indication of improper drawdowns or expenditures have not been properly recorded. Corrective Action The Tribe has taken steps to strengthen grant financial management and improve reconciliation between accounting records, grant expenditures, drawdown activity, and monitoring of fund balances including: • Implementation of a revised chart of accounts structure to improve tracking of grant revenues and expenditures within the accounting system. • Continued use of the accounting system as the system of record for all financial transactions associated with grant programs. • Review and reconstruction of grant financial records to ensure expenditures, drawdow ns, and grant balances are properly documented and reconciled. • Use of standardized tracking spreadsheets as supplemental tools to monitor grant activity and reconcile grant balances to the accounting system. • Implementation of improved financial reporting and reconciliation procedures to ensure grant revenues, expenditures, drawdo wns, and balances are reviewed on a regular basis. Beginning in 2026, the Tribe has established a process to perform grant drawdowns monthly to ensure that drawdowns are aligned with recorded expenditures and that grant balances are monitored on an ongoing basis. Corrective actions began during late 2024 and continued throughout 2025. Monthly grant drawdown and reconciliation procedures were implemented in the first quarter of 2026. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT 2024-006: Bureau of Indian Affairs -105(1) Leases ALN 15.048 and Pandemic Relief Activities: Local Food Purchase Agreements with States, Tribes, and Local Governments ALN 10.182, Late filing of Data Collection Form Condition The Tribe did not file the data collection form for the years ended December 31, 2022, 2023, or 2024 timely. Criteria Under the requirements of the Uniform Guidance and the Office of Management and Budget (0MB), all entities are required to file the annual data collection form with the Federal Audit Clearinghouse the earlier of 30 days after the issuance of the entity's annual audit or nine months after the entity's fiscal year-end. Management did not complete and certify the auditee portion of the form before the deadline. Questioned Cost N/A Repeat Finding Yes RecommendationManagement should take steps to ensure that the form is filed timely Corrective ActionThe Tribe has taken steps to ensure timely completion and submission of the annual data collection form going forward including: • Assignment of responsibility for preparation, review, and submi ssion of the auditee portion of the data collection form to the Director of Finance. • Establishment of a formal process to complete and certify the annual data collection form immediately upon completion of the annual audit. • Implementation of internal tracking procedures to monitor audit timelines and ensure compliance with Federal Audit Clearinghouse submission requirements. • Coordination with external auditors to ensure timely communication regarding audit completion and reporting deadlines. This corrective action has been implemented and the tribe anticipates comp liance in all future audit reporting periods beginning with FY202 5. 2024-007: Bureau of Indian Affairs -105(1) Leases ALN 15.048, Lack of Approvals (Material Weakness) Condition Criteria Cause Questioned Cost Repeat Finding Perspective Information Recommendation Corrective Action There were several instances of lack of approvals for disbursements. Federal grant recipients are required to maintain effective internal controls over federal awards, as out li ned in 2 CFR §200.303. Turnover and inadequate staffing. N/A N/A Nine of 27 tested. All disbursements should have one approval and ensure the expenditure is eligible under the grant. The Tribe has taken steps to strengthen internal controls over disbursement approvals and ensure that all expenditures are properly reviewed and documented including: • Establishment of a standardized disbursement approval process requiring documented approval prior to payment for non-routine/recurring expenditures. • Implementation of procedures to ensure all disbursements are reviewed for allowability under applicable grant requirements before payment is issued. • Maintenance of supporting documentation, including approval evidence, within the accounting records. • Ongoing review of disbursement procedures to ensure compliance with internal control requirements under 2 CFR §200.303. These measures are designed to ensure th at all disbursements are properly authorized, documented, and compliant with applicable grant requirements. Corrective actions began implementation during throughout 2025. These procedures are currently in place and will continue to be refined as part of ongoing internal control improvements. If the Federal Audit Clearinghouse has questions regarding this plan, please call Tim Emery, Director of Finance at 804-488-9392. Respectfully submitted, r Chief

Significant deficiency in internal control over compliance and compliance as it relates to allowable costs and activities. Federal Agency: All awards within the Research and Development Cluster Program Title: All awards within the Research and Development Cluster Assistance Listing Number: All awards within the Research and Development Cluster Award Number: All awards within the Research and Development Cluster Award Period: All awards within the Research and Development Cluster Criteria 2 U.S. Code of Federal Regulations (CFR) 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Section 200.303 requires that each recipient of federal awards “Establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Condition/Context for Evaluation During our audit, we tested nonpayroll costs charged to the federal awards for adherence to necessary compliance requirements and internal control over compliance requirements. Out of 25 sample selections, we noted the following related to seven sample items: - Five of seven sample items selected involved overcharges to the grants. All five showed management approval for the incorrect amounts. - One of seven sample items selected had no supporting documentation. - One of seven sample items had no management approval. Questioned Costs $1,790 Effect or Potential Effect AAHI may have charged unallowable or incorrect costs to the federal awards. Repeat Finding No. Recommendation We recommend AAHI implement the necessary internal controls to (1) ensure documentation is retained to support costs spent on federal awards and (2) ensure all costs are properly approved and for the correct amounts. Views of Responsible Officials of Auditee Management concurs with the finding and has provided the accompanying corrective action plan.

Finding 2024-002 Information on the federal program: Federal Agency: Federal Transportation Administration Pass-Through Entity: N/A Federal Program: Federal Transit Cluster Assistance Listing Number: 20.507 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs – Cost Principles Audit Findings: Material Weakness Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and local governments. To be allowable, under federal awards, cost must meet certain criteria: a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. c) Be consistent with policies and procedures that apply uniformly to both federally financed and other activities of the non-Federal entity. d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. e) Be determined in accordance with generally accepted accounting principles (GAAP), except, for state and local governments and Indian tribes only, as otherwise provided for in this part. f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally financed program in either the current or a prior period. g) Be adequately documented. h) Cost must be incurred during the approved budget period. Additionally, 2 CFR 200.303 indicates that non-Federal Entities receiving Federal awards must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations and terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Condition and Context: A summary of allowable charges for the grant was prepared for submission. Within the sample of 42, we noted that 9 timecards for bus operators did not have documented review. Documented review was implemented in September 2024. All instances of the error were prior to September 2024. We also noted 1 timecard showed 2 hours more than reflected on the pay register, resulting in a net underpayment. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. Each department is responsible for ensuring proper timecard records with approval are maintained. A documented review process for bus operators was implemented over timecard records in September 2025. Payroll is responsible for ensuring that the appropriate number of hours are paid to each employee. Additional review will be performed prior to issuance of pay checks to ensure that the appropriate number of hours are being paid.

The Creek County Clerk’s Office will work with the SEFA preparer to ensure that the correct paid dates are being used when reporting. This should eliminate the actual expenditures differences. We will work to educate all offices involved in the reporting process on financial statement and SEFA.

In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Report (CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. This finding has since been resolved in 2025, with a new policy developed and implemented on December 12, 2025.

Finding No.: 2024-050 Matching, Level of Effort, Earmarking Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures with applicable matching and earmarking requirements. GHS will also identify department personnel responsible.

Finding No.: 2024-047 Special Test and Provisions Provider Eligibility (Screening and Enrolment) Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. DPHSS is aware that deficiencies exist with the Medicaid provider enrolment process. DPHSS’s response to this deficiency is addressed in its modernization plan, which will automate certain provider enrolment functions. In March 2024, DPHSS performed site visits for 21 providers, and since then has continued to perform site visits year-round. Memorandums regarding provider compliance topics have also been communicated to providers and published on the provider portal, including information regarding criminal background checks. DPHSS is currently contracted with a consultant that is assisting in the implementation of compliant provider enrolment operations, which includes policy revisions, updates to provider applications and disclosure forms, development of standard operating procedures, and training for both staff and providers. In addition, DPHSS is currently in the process of establishing a Medicaid Program Integrity Unit (PI Unit) with a mission to conduct independent and objective Medicaid program integrity functions adherent to federal and local laws. The PI Unit will also assist DPHSS in addressing and managing Medicaid related Corrective Action Plans.

Finding No.: 2024-037 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital assets, is near completion with final testing in progress. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. Review of Assets acquired in FY2024 was completed, with FY2025 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.

Finding No.: 2024-023 Matching, Level of Effort, Earmarking Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.

Finding No.: 2024-019 Matching, Level of Effort, Earmarking Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing the management of Federal Grants to ensure robust handover and succession plans are in place for future programs. The sudden passing of the ERA Program Coordinator directly impacted overall management of the program.

Finding No.: 2024-014 Equipment and Real Property Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Implementation of a Fixed Assets Module as part of the new FMIS system that will help automate the tracking and reporting of Capital assets, is near completion with final testing in progress. DOA will update the SOP for the Fixed Assets for capital asset reporting accordingly. Review of Assets acquired in FY2024 was completed, with FY2025 in progress. As noted previously, the process is hampered by difficulties in recruiting personnel.

The Department should review and enhance controls and procedures to ensure that financial and programmatic/progress reports are reviewed and approved prior to submission. Copies of all reports should be retained and be readily available for audit. Response: The Department concurs with the finding and the need to enhance and strengthen controls and procedures to ensure programmatic/progress reports are reviewed and approved prior to submission and retain copies for audit. Prior to the conclusion of the audit, the Department formed a Grants Management Division and initiated the development of an internal grants management module for the agency. Corrective Action: The Department formed a Grants Management Division within the agency in 2025 responsible for the financial reporting of its federal grants. The Division prepares, submits, and retains copies of the financial reports and supporting documentation. Prior to submission, the prepared financial reports are approved by the responsible program. Programmatic/progress reports are the responsibility program. The program will track programmatic/progress reports to ensure all are reviewed and approved prior to submission and retained for audit purposes. Name of contact person responsible for the corrective action: Lucreta Tribune (Grants Management Division) and Theresa Kittle (Program-Epidemiology) Anticipated date for completion of corrective action: December 31, 2026

The Department should review and enhance its procedures to ensure that it follows its procurement policy and federal suspension and debarment regulations for all applicable goods and services purchased for the program. Response: The Department concurs with the finding and the need to strengthen controls to ensure the procurement policy and federal suspension and debarment regulations for all applicable goods and services purchased are followed. Prior to the conclusion of the audit, the agency went live with its new procurement system, OpenGov in March 2025. OpenGov ensures that services are procured following policy and regulations. Corrective Action: The Department will ensure procurement rules and regulations are followed by enforcing the use of OpenGov throughout the agency. Name of the contact person responsible for the corrective action: Dorthy Young Anticipated date for completion of corrective action: July 1, 2026

The Department should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Department of Health should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Response: The Department concurs with the finding and the need for a proper method of time recording for accurate time and effort reporting. Prior to the conclusion of the audit, the agency created an internal review group to assess the need for an efficient time keeping system to be utilized throughout the agency to allow for uniformity and accuracy. Corrective Action: The Department will continue to move forward with the implementation of the new time keeping system which allows for proper time and leave collection for documentation and allocation of employee time. In the system, the employee time will be recorded and approved by supervisory personnel for accuracy prior to submission payroll processing. The system will allow documentation to be assessed when needed. Name of contact person responsible for the corrective action: Lucreta Tribune Anticipated date for completion of corrective action: July 1, 2026

The Department should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Department of Health should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Response: The Department concurs with the finding and the need for a proper method of time recording for accurate time and effort reporting. Prior to the conclusion of the audit, the agency created an internal review group to assess the need for an efficient time keeping system to be utilized throughout the agency to allow for uniformity and accuracy. Corrective Action: The Department will continue to move forward with the implementation of the new acquired time keeping system which allows for proper time and leave collection for documentation and allocation of employee time. In the system, the employee time will be recorded and approved by supervisory personnel for accuracy prior to submission payroll processing. The system will allow documentation to be assessed when needed. Name of contact person for the corrective action: Lucreta Tribune Anticipated date for completion of corrective action: July 1, 2026.

Assistance Listing No. 17.258, 17.259, 17.278 and Workforce Innovation and Opportunity Act Cluster Type of Compliance Requirement: Reporting - FFATA Response: There is no disagreement with the audit finding. Corrective Action Plan: MDES agrees that the FSRS system generated reports provided to CLA did not indicate the date of submission and therefore CLA was unable to determine if the reports were submitted timely. MDES will strengthen controls to ensure that future system generated reports have a confirmed submission date documented. Name(s) of the contact person(s) responsible for corrective actions: Contact person(s) responsible: Tyler Berch Contact Phone number: 601-321-6214