Corrective Action Plans

Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

We understand how crucial it is to have strong policies and procedures in place. Here’s how we plan to move forward: 1. Review of Existing Policies and Procedures: We’re currently taking a close look at our existing policies and procedures to ensure they align with the Uniform Guidance. This will help us identify any gaps and make necessary updates so that we’re fully compliant. 2. Development of New Policies: Alongside this review, we will create clear and comprehensive written policies in key areas, such as: • Cash Management: Setting up procedures that comply with 2 CFR 200.305 to ensure timely payments. eCFR :: 2 CFR 200.305 -- Federal payment. • Allowability of Costs: Crafting guidelines that follow Subpart E—Cost Principles, so we can confidently determine which expenses are allowable. https://www.ecfr.gov/current/title-48/chapter-7/subchapter-E/part-731/subpart-731.7/section-731.770. • Conflict of Interest: Establishing standards of conduct that address potential conflicts and promote transparency. • Equipment and Real Property Management: Developing policies for managing equipment acquired under federal awards in line with 2 CFR 200.313(b). eCFR :: 2 CFR 200.313 -- Equipment. • Procurement Procedures: Creating clear procurement guidelines that align with 2 CFR 200.318 through 200.326 to ensure fairness and oversight. eCFR :: 2 CFR 200.318 -- General procurement standards. 3. Training and Communication: The Finance Department will be responsible for training all staff involved in managing federal awards. Training sessions will ensure that everyone understands the requirements and their roles in maintaining compliance. This training will be completed by December 31, 2024. Personnel responsible: Eduardo Cedeno, Director of Finance Anticipated completion date: December 31, 2024

Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review and update our policies and procedures for managing accounts payable. Furthermore, we will provide additional orientation and training sessions focused on disbursements for subrecipients involved in federal grant programs. We will improve the enforcement of policies and procedures by setting up a system to track the receipt and payment of bills. Additionally, we will implement a weekly review by the compliance team to ensure that payments are made on time and that accurate documentation is retained to support any delays in payment requests that are found to be inappropriate. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO) Planned completion date for corrective action plan: 12/30/2024

Finding Number: 2023-003 Condition: The Organization does not have written procedures to implement the requirements of CFR 200.305. The advance payment of the Federal award was not maintained in an interest-bearing account and no interest was remitted back to the Federal government. Planned Corrective Action: Management is in the process of updating written procedures for Federal award compliance. Management will calculate and remit interest for 2023 to the Department of Health and Human Services Payment Management System (PMS). Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: October 15, 2024

Individual Responsible for Corrective Action Plan: Alliance Director and staff – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024

The Township will adopt a written policy regarding cash management of funds designed to minimize the time elapsing between the transfer of funds from the US Treasury and when distributed by the Township.

CORRECTIVE ACTION PLAN The Spero Project, Inc. ( “Organization”), respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: HSPG & Associates, 5400 N. Grand Blvd., Suite 330, Oklahoma City, OK 73112. Audit period: As of and for the year ended December 31, 2023. The findings from the December 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS – COMPLIANCE AND INTERNAL CONTROL Identifying Number: 2023-001; Lack of Written Policies and Procedures Recommendation: The Organization should develop and implement comprehensive written policies and procedures in accordance with the requirements of the Uniform Guidance. These should include, but not be limited to, the following areas: 1. Financial management, including procedures for payments and cash management. 2. Internal controls to ensure compliance with federal requirements. 3. Determination of allowable costs in accordance with federal regulations and the terms and conditions of the award. 4. Procurement standards and conflict of interest policies. 5. Time and effort reporting and compensation. The Organization should also ensure that staff are adequately trained in these policies and procedures to enhance compliance and operational efficiency. Action Taken: In response to the finding, management and will take action to develop and implement the necessary written policies and procedures by December 31, 2024. Comprehensive training will be provided to all relevant staff to ensure compliance with federal requirements. Anticipated completion date: December 31, 2024 Name of contact person and title: Ms. Kim Bandy, Executive Director

WIA management will implement the following corrective action plan: In order to ensure compliance with the timeliness of disbursements of federal funds contemplated under 2 CFR 200.305(b), WIA will implement the following additional procedures for federally-funded expenses. A detailed evaluation of project deliverables and timelines will be conducted by the Project Manager and Project Director for any program subject to compliance with Federal guidelines. The timelines, deliverables and affected funding mechanism(s) will be aligned to determine if there may be a delay beyond a reasonable period which would impact the submission and processing of payments to subcontractors. If it is determined that a delay is possible or likely, consideration will be given to contract amendments which better support the processing of payments aligned with 2 CFR 200.305(b). Further, the Finance team member assigned to the associated program will provide regular guidance to the project team which may include a detailed briefing on the CFR and any relevant concerns with cash management. Disbursements of federal funds will be issued in a timely manner in all instances. The additional set of procedures described above will be implemented in September 2024. In addition, we are currently working through finalizing the contract for Phase 2 of the specific contract related to this finding. We anticipate these negotiations will be completed by October 31st, 2024. Once the Phase 2 agreement has been reached, we will immediately release the Phase 1 funds to the vendor and obtain guidance from The Ohio State University as to the proper disposition of any interest that has been earned by WIA from the withheld Phase 1 payment. Marta Sokol, Chief Financial Officer is the individual responsible for oversight of this corrective action plan. Mrs. Sokol can be reached at 703.535.7447 or Marta.Sokol@wia.org.

Corrective action planned: Cash flow requirements to fund daily operations will be reviewed more thoroughly so that awarded funds are expended consistent with the terms of their respective agreements. Projects presently on quarterly cost reimbursement schedules will be changed to monthly cost reimbursement requests. Contact person responsible for corrective action: John D. Pepe, Controller. Anticipated or actual completion date: October 1, 2024.

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standardized process for review and approval of drawdowns before request for reimbursement by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

Condition: Controls in place were not adequate to ensure the Authority complied with all requirements under 2 CFR. Planned Corrective Action: The Authority will work to establish a written procedure to follow requirements in 2 CFR 200.305. Contact person responsible for corrective action: Shedreka Miller Anticipated Completion Date: 12/31/2024

2023-002 U.S. Department of Environment Protection – Assistance Listing # 66.468 Capitalization Grants for Drinking Water State Revolving Fund (Drinking Water State Revolving Fund Cluster) Lack of Required Written Policies & Procedures – Compliance Condition & Criteria: The Authority does not currently have all the written policies and procedures in place as required by the Uniform Guidance as it relates to financial management and determining allowability of costs for the federal program (Title 2 U.S. Code of Federal Regulations (CFR) 200.302 & 200.305). In addition CFR sections 200.318, 200.319, and 200.320 require there to be written policies and procedures regarding procurement and conflicts of interest. Planned Corrective Action: The water systems improvements federally funded project is the Authority’s first time subject to the requirements of the Uniform Guidance as we have not had any significant grant funding since 2004. The Authority does have a set of informal policies and procedures that are followed as it relates to financial management, allowability of costs, procurement, and conflicts of interest, and have been very careful to carry out all federal program activities in accordance with established regulations; however, the Authority was simply not aware of the requirement that these polices and procedures be documented in writing. The Authority has been working over the past year to draft and develop these policies and procedures as they relate to federal programs, and to get them documented in writing. The Authority is currently working with their attorney to have the written polices established and plan to have this completed within the next fiscal year. Once the required policies are written, the Board of the Authority will review the policies, revise as appropriate, and adopt the policies for the Authority to comply with the federal funding requirements.

Effective June 1, 2023 Texas Biomed implemented enhanced controls to ensure timely entry of subrecipient invoices into the financial system and timely approvals by Principal Investigators (PIs) of invoices. While these controls were operating effectively after the implementation date, turnover within the Accounts Payable team had not been anticipated and led to delayed payment processing. In mid-2024, Texas Biomed implemented a new electronic AP/invoice system as part of a comprehensive Enterprise Resource Planning system (and associated supporting systems) conversion to enhance efficiencies and functionality. With implementation of new systems, control enhancements enabled by the systems were implemented. This included setting up subawards as Purchase Orders, which enabled automation of a previously manual process to secure PI approval of invoices. Accounts Payable staff have been trained on how to properly enter subaward invoices into the system to trigger electronic routing to the PI for approval. While these steps will streamline the approval process, a further mitigating control will be implemented, with Accounts Payable staff periodically tracking approvals of pending subrecipient invoices and notifying the appropriate Sponsored Program Administrator for follow up with PIs in the event of delayed approvals. Responsible Parties: Eva Zepeda, Director, Finance; Michelle Hyde, Controller Completion Date: September 30, 2024

The HIDTA Financial Manager, in conjunction with the City's Finance Assistant, will request smaller dollar amounts with new advances in order to liquidate the prescribed HIDTA guideline of 21 days.

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2023-002 (repeat finding of 2022-001) Continuum of Care Program, ALN #14.267 Auditor’s Recommendation: We recommend that when a check is paid, the expense is allocated through the accounting system. At the time a grant voucher is prepared, only actual expenses should be requested. We recommend that each reimbursement request agrees to what is allocated through the accounting system by grant or program for actual expenses. This will help support the request and, if needed, a method to provide the actual invoice for the expense being requested. Action Taken: Supportive Strategies has set up cost centers so all Grant vouchers/expenses are allocated to the proper Grant.

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Immunization Cooperative Agreements, ALN #93.268 Criteria: According to 2 CFR Section 200.305(b)(3), all reimbursement requests should be based on supporting documentation that shows the cost was incurred before the request for payment and that the payment to vendor was made. Condition: 4 of the 7 cash drawdown reports tested contained expense reimbursements requested for which there was missing supporting documentation for some of the expenses requested for reimbursements. Total questioned costs were $115,617. Cause: The extra expenses that were missing in the test were because IAFP used staff instead of consultants and the Organization did not update our policies and procedures to include time sheets to show how staff was allocated to the grant to support the charges. Effect: The effect is that the Organization requested funds but did not have back up to support that the actual expenses were incurred and was therefore not in compliance with the cash management requirements under Uniform Grant Guidance in relation reimbursement requests. Auditor recommendation: We recommend that the accounting department verify that the expense has been incurred and paid to the vendor before requesting reimbursement from the grantor and ensure that the backup documentation is filed where it can be located. We recommend hiring or training staff in relation to cash management and documentation of allowable cost. Management response: Management will follow the advice and undergo training in cash management and documentation of allowable costs.

Ineffective Controls Over the Cash Management Requirement Condition Community Health Concern, Inc. (“CHC”) did not minimize the times between drawdowns and disbursements of Federal funds in accordance with Federal regulations. There were three cash drawdowns made by management that were at least two months (60 days) in advance of actual expenditures or immediate requirement needed for payment. Management’s Views: Management concurs with the audit findings and will implement various steps that will strengthen our internal control processes to mitigate any potential cash drawdown noncompliance in the future. Corrective Action Plan: In response to the Cash Management finding, the following actions will be implemented to ensure compliance with federal grant guidelines and to maintain transparency and accountability, CHC will: 1. Seek HRSA Guidance • In situations that are out of the ordinary or not explicitly covered by existing grant guidelines, the Director of Finance or his/her designee will seek guidance from the Health Resources and Services Administration (HRSA). • This step ensures that all actions taken are compliant with HRSA’s grant guidelines, 2. Consult the External Auditor • For additional guidance and to ensure proper procedure, the Director of Finance or his/her designee will consult with the external auditor. • If HRSA guidance is available, it will be shared with the external auditor to confirm that all steps align with federal requirements and best practices. 3. Continually Communicate and Engage with the Finance Committee and the Board of Directors • Ongoing communication and engagement with the Finance Committee and the Board of Directors will be maintained. • Regular updates will be provided on the status of grant fund requests, drawdowns, and any guidance received from HRSA or the external auditor. • This practice ensures that the Finance Committee and the Board of Directors are fully informed and can provide oversight and support as needed. Anticipated Date of Completion: Management has implemented approximately 85% of the strategies described in the Plan above. Management believes by implementing these actions, the compliance with federal grant guidelines will be enhanced to ensure transparency to the financial operations as well as maintain robust oversight by involving key stakeholders in the process. Management anticipates the successful completion date for the entire Plan to be no later than August 31st, 2024. Contact Person: For inquiries regarding this finding, please contact Benjo Reyes at BenjoR@CamillusHealth.org who is responsible for the corrective actions.

Assistance Listing Number: 84.425F Program Name: COVID-19: HEERF – Institutional Portion Pass Through Identifying Number: N/A Award Year: 2022-2023 Federal Agency: U.S. Department of Education Management agrees with the findings and, as discussed, the College is currently searching for a candidate to fulfill the CFO position with the appropriate level of training. The College does intend to interview accounting professionals from the community to determine if appropriate levels are present. Responsible Party: Dr. Justin Hoggard, Board President and Dixie Lytle, Director of Human Resources Expected Completion: December 31, 2024 Anticipated Completion: December 31, 2024

2023-001 CASH MANAGEMENT Recommendation: The IRL Council should obtain clarification in writing from the grantor on guidance outside of the established procedures to prevent future misunderstandings. Management’s Response: Initial discussions with EPA staff regarding fiscal management of the funds from the Bipartisan Infrastructure Law (BIL) suggested that management of the cash for the BIL award was different than the Section 320 grant award. During these discussions, cash flow was brought up as a possible concern by IRL Council staff. EPA staff initially indicated that the grant funds were not reimbursable and that all funds would be available as soon as an award was made. The Council was not made aware that the RAIN polices would be in effect for BIL funds. The Council interpreted EPA correspondences as authorization to withdraw funds immediately upon receiving the award. Upon making the draw, EPA provided the IRL Council with clarifying information with regards to the RAIN policy. The IRL Council responded quickly to this new information and the appropriate amount of funds were returned in a timely manner. The EPA was satis􀀁ied with the corrective response and outcome. The IRL Council will continue to manage all EPA federal grants as a reimbursable grant award to ensure the RAIN policy is followed correctly. For any other Federal agency grants that may be awarded, strict adherence to that agency’s policies for treasury draws will be made. Responsible Party: Daniel Kolodny, Chief Operating Officer

Finding 2023-004: Timely Remittance of Earned Interest Federal Programs ALN: 93.575, 93.596, 93.558 Criteria: The Organization is required to remit all interest earned on federally funded advances to DEL within 30 days after the fiscal year end per DEL Program Guidance 240.01 Cash Management and 2 CFR 200.305(9). Condition: The Organization failed to remit all earned interest to DEL within the 30 day deadline in accordance with the grant agreement. Cause: The Organization experienced high management turnover which delayed the calculation of interest earned and remittance to DEL. Effect: The Organization did not meet the remittance submission deadline requirement as set forth by DEL Program Guidance 240.01 Cash Management and 2 CFR 200.305(9). The earned interest was remitted August 2, 2023. Recommendation: We recommend the Organization designate an individual to calculate interest earned and closely monitor the submission deadline. Corrective Action Plan: ELC Management will make sure that measures are in place to ensure all interest earned is reconciled monthly and paid timely back to DEL. Responsible Party: Jenny Longo, CFO Anticipated Completion Date: August 2024

Corrective Action Plan: The Institute implemented the recommendations in the fourth quarter of fiscal year 2024.

In 2024, all required interest refunds were remitted. Additionally, management established a policy to remit annual calculated interest refunds by March 31st of the subsequent year.

The Department concurs with paragraph A that some of the cash draws were not performed in a timely manner. The finding was due to a shortage of trained personnel. The Department is in the process of hiring and training additional personnel and reviewing its policy and procedures on cash draws. The Department concurs with paragraph B. The Department can show that the subrecipients disburse payments for program advances within a few weeks from original receipt starting with the first check runs to fuel vendors shortly after receiving the advance. However, the Department will work on reviewing its policies and procedures to ensure the Department monitors the subrecipients’ written procedures to minimize the time elapsing between the transfer of funds and disbursement by the subrecipient. The Department is also creating a tracking method to show the time elapsed when an advance is originally paid to the subrecipient and when it is fully disbursed.

NCHE will implement a process for review of the reimbursement request before it is submitted to verify that the expenses included in the request have been paid for before the request is submitted. Anticipated completion date is July 1, 2024.

2023-002: Cash Management-Subrecipient Federal Program Title: Research and Development Cluster Assistance Listing Number: Various Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Recommendation: ISU should evaluate its procedures and implement an additional control to review and approve the subrecipient reimbursements timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Grant accounting staff will follow payment requests through the system to make sure payments are made in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Kirsten Broughton, Director Grant Accounting Planned completion date for corrective action plan: Implemented in FY24