Corrective Action Plans

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

Management will implement the necessary changes to WHCA's policies and procedures.

Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System will review, modify, and implement policies and procedures over the program to ensure funds are disbursed for expenditures incurred prior to requesting reimbursement and that expenditures are incurred within the contract’s performance period.

Management agrees with the finding. Our current federal project is substantially completed, however, should the Township receive additional federal grants, the Township will adopt the required written procedures. The anticipated completion date is prior to receiving another federal award.

Research and Development – Assistance Listing No. 43.008 Research and Development – Assistance Listing No. 93.433 Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Langston is strengthening accounts payable processes and sign-off approvals in order process appropriate reimbursements to subrecipients timely. Name(s) of the contact person(s) responsible for corrective action: Mr. Robert Dixon, Director, Grants and Contracts Fiscal Administration at Oklahoma State University and Mr. Chris Kuwitzky, Vice President for Fiscal and Administrative Affairs. Planned completion date for corrective action plan: June 2024

Finding 2023-003 – Cash Collateralization Criteria: Uniform Guidance 2 CFR, Part §200.305(b)(7) requires advance payments of Federal funds to be deposited and maintained in insured accounts whenever possible. Condition: During our review of the Coalition’s cash, it was noted that as of September 30, 2023, they have. not collateralized cash balances in excess of the amounts insured by the Federal Despot Insurance Corporation. Cash balances of $10,608,222 were uninsured at September 30, 2023. Unearned revenue was reported at approximately $5,389,532 which includes advance payments of Federal funds. Questioned Costs: None Cause: The Coalition has not entered into a cash collateralization agreement with their financial institution. Effect: The Coalition is not in compliance with Uniform Guidance 2 CFR, Part §200.305(b)(7) as not all cash balances received in advance from the funding agency were adequately insured or collateralized and were exposed to custodial credit risk in the event of a bank failure. Recommendation: We recommend the Coalition enter into a cash collateralization agreement with their financial institution to ensure that all amounts related to grant agreements and awards received in advance are not exposed to custodial credit risk in the event of a bank failure. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs. Responsible Officials; Dr. Donna L. Polk CEO, Carlett Gregory CFO, Anne Steinhoff Board Treasurer. Corrective Action: In response to the finding regarding the lack of collateralization for cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation (FDIC). NUIHC will get clarification from I.H.S. and our financial institution to address the best way to resolve this issue. Possible options are using the CDARS program or finding a local DIF member institution. The Coalition will take the following corrective actions: 1. Establish Cash Collateralization Agreement: o The Coalition will promptly enter into a cash collateralization agreement with our financial institution. This agreement will ensure that all cash balances, including those received in advance from federal funding agencies, are adequately insured or collateralized. 2. Review of Cash Management Policies: o We will review and update our cash management policies to ensure compliance with Uniform Guidance 2 CFR, Part §200.305(b)(7). This review will include assessing our current banking arrangements and making necessary adjustments to mitigate custodial credit risk. 3. Monitoring and Compliance: o The Coalition will implement a monitoring system to regularly review cash balances and ensure that they do not exceed insured limits without proper collateralization. This system will involve periodic checks and coordination with our financial institution to maintain compliance. 4. Training and Education: o We will provide training to our financial and accounting staff on the importance of cash collateralization and the requirements of Uniform Guidance 2 CFR, Part §200.305(b)(7). This training will ensure that all relevant personnel are aware of the new procedures and the need to maintain insured or collateralized cash balances. Timeline for Implementation: The corrective actions outlined above will be implemented within the next 30 days. The cash collateralization agreement will be established immediately, and updates to cash management policies will be completed within this period. Training sessions for relevant staff will be conducted promptly following the implementation of these changes.

Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned to the grant will review interest income earned throughout the fiscal year and ensure any amount exceeding $500 is returned to the Department of Health and Human Services. Contact person responsible for corrective action: Vanessa Barker Anticipated Completion Date: 06/30/2024

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish and maintain written policies, procedures, and standards of conduct including internal controls over the Federal awards that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award. Specific requirements relate to the following: § 200.302 Financial management  § 200.305 Payment  § 200.319 Competition  § 200.320 Methods of procurement to be followed  § 200.430 Compensation—personal services  § 200.431 Compensation—fringe benefits We recommend that the City implement the required written policies and procedures. Action Taken: Management, namely Jan Boutwell, City Clerk, agrees with the finding and will implement the necessary written policies to comply with the UG. Management anticipates completion by September 30, 2024.

Federal Aid Policies Finding 2023-002 Auditor Description of Condition and Effect: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. As a result, the Authority is noncompliant with 2 CFR 200. Auditor Recommendation: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Corrective Action Plan: The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

Views of Responsible Officials and Planned Corrective Actions – We have since developed an organization policy for cash management for federally sponsored grant programs. SEH has provided and will continue to provide staff education on this policy in the future.

Medical Teams has identified the process gap that led to the delay of ths payment. A combination of system improvements and capacity building at the program and AP staff level will be implemented to ensure that review, approval, and payment processes are compliant and timely. Correction action plan will be led by the Controller, Matt Kinsella, and the Director of Global Finance, Florence Ruona. The corrective action plan has started in May and is anticipated to be completed by September 30, 2024.

Medical Teams International already has the personnel and resources needed to Calculate the interest earned in relation to Federal awards and included in the month close cycle process for tracking purposes. Medical Teams will set a process in place to ensure funds in excess of the stipulated $500, are identified during the year and remitted. This action plan will be led my the Director of Global Finance, Florence Ruona, with an estimated completion date of September 30, 2024

Finding 2023-001: Cash Management – Disbursement U.S. Department of Education – Education Stabilization Fund ALN 84.425F COVID-19 Institutional Portion Criteria: Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). Condition: Management implemented a financial management system that meets the specified standards for fund control and accountability, but the system failed to ensure disbursement of funds within the required timeframe. Questioned Costs: None noted. Repeat Finding: This is a repeat finding. Management was only made aware of this finding after it was repeated. Cause: Management did not accurately identify the required timeframe of disbursement for funds received under the Institutional Portion subprogram. A mitigating factor is the uniqueness of the Institutional Portion subprogram. Effect: Institutional Portion funds used to defray expenses associated with coronavirus were not disbursed within the required 3 calendar days of the drawdown from ED’s G5 grants system. Planned Corrective Action Management concurs with the finding. Since the program is not applicable to the organization after the issuance date of the financial statements, no corrective action is necessary. Responsible person: Sholom Goldstein, Executive Director Completed date: June 11, 2024

Finding 2023-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: AVC staff were unable to complete a drawdown for the HUD grants due to a change in staff. AVC is working with HUD to resolve the matter. AVC staff is currently drawing down all other funds in a timely matter. AVC has limited unrestricted cash. AVC is currently looking for opportunities to increase unrestricted cash, such as increasing prices for gas and electric. Proposed Completion Date: July 31, 2024

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the internal controls surrounding the cash management of the Federal Research and Development Programs was not in compliance for federal standards. The University is in the process of enhancing the internal controls and cash management procedures to prevent this from happening in the future. Going forward all federal grant funds that are allocated for the Challenger Learning Center will go directly into the appropriate bank account and will be drawn down and spent in the correct time frame. When operating expenses are incurred for the Challenger Learning Center the payment will be processed from the University’s general checking and the federal grant funds will reimburse the University that day. The same is also true for the payroll expenses incurred by the Challenger Learning Center. Wages will be paid out of the university’s general checking account and then reimbursed to the university from the bank account that hold the federal grant funds. Anticipated Completion Date: June 2024

Finding 2023-004: 2023-004 - Significant Deficiency in Internal Control over Compliance and Noncompliance – Cash Management Contact: Michael Bailey, Chief Financial Officer Corrective Action Plan: The Accounting department at Alaska Behavioral Health has stabilized staffing in accounting personnel, including the replacement of the Chief Financial Officer. The CFO will develop and maintain a Master Grants tracking system that identifies cumulative allowable expenditures, determining the maximum cash drawdown of Federal Funds for the appropriate reporting time period and assuring that drawdowns are made in a timely manner. Proposed Completion Date: 09/30/2024