Corrective Action Plans

Finding 2022-021 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness over Cash Management Repeat Finding: Yes Auditee?s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD's fiscal team enters the drawdown request into the Federal Payment Management System (PMX). Baltimore City's treasury department is notified. After BCHD's fiscal team enters the request into PMX, there is no control over the timing of when the funds are received and when the funds are posted to the GL, as this is the responsibility of the City's Treasury department. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-020 U.S. Department of Health and Human Services AL No. 93.914 HIV Prevention Activities Health Department Based Material Weakness over Cash Management Repeat Finding: Yes Auditee?s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD's fiscal team enters the drawdown request into the Federal Payment Management System (PMX). Baltimore City's treasury department is notified. After BCHD's fiscal team enters the request into PMX, there is no control over the timing of when the funds are received and when the funds are posted to the GL, as this is the responsibility of the City's Treasury department. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Date: April 21, 2023 Subject: Corrective Action Plan Please find below the Medical University of South Carolina?s (MUSC) Corrective Action Plan for the finding presented by KPMG relating to our fiscal year 2022 audit conducted under the Uniform Guidance. Audit finding reference number: 2022-003 Cash Management Cause and potential effect as presented in the Summary of Findings and Questioned Costs: For 3 of the 40 samples tested, taxes were properly accrued as allowable costs but were drawn prior to payment by the University. While these costs are deemed allowable, they were not paid for prior to seeking reimbursement from the federal agency. The taxes drawn prior to payment totaled $4,035 out of a total of $784,941 tested in the sample of 40. The control to ensure that all costs were paid for prior to seeking reimbursement was not operating effectively to identify instances of noncompliance related to the applicable taxes. Name(s) of the contact person(s) responsible for corrective action: Velma G. Stamp, Director, Grants and Contracts Accounting Michael Laird, Manager, Financial Reporting, Grants and Contracts Accounting Corrective action planned: MUSC tested purchases to determine the extent of the finding. It was found that this issue was isolated to the Department of Lab Animal Research (DLAR) animal purchases made with the departmental Purchasing Card. Once this determination was made all DLAR animal purchasing card transactions were identified, for the period being audited, in order to calculate the use tax required to be paid. MUSC?s tax office then submitted amendments for each month, remitting the additional use tax as well as the applicable penalties to the South Carolina Department of Revenue. No adjustments were needed to be made to the grants impacted as these are otherwise allowable costs. We believe MUSC?s system operates adequately when use tax is flagged as required by our policies and procedures. This instance occurred due to input errors by the employee responsible for this area. As such, we have conducted training with the employee as well as the employee?s manager instructing how purchasing card transactions subject to use tax must be identified when allocating credit card purchases. In addition, we will monitor DLAR credit card purchases to ensure MUSC?s policies and procedures are being adhered to. Anticipated completion date: This corrective action has been implemented and the monitoring will be ongoing. Questions or requests for additional information related to this Corrective Action Plan may be directed to me via email at stampvg@musc.edu or by telephone at 843-792-3657. Sincerely, Velma G. Stamp, Director

View of Responsible Official Management agrees with the auditor?s recommendation and will strengthen procedures on the preparation and review of ROE and the SEFA to ensure the correct amount of expenditures allowable for reimbursement are reported. Management will confirm agreement between the quarterly ROE and the general ledger at that time prior to submitting for reimbursement. Further, management is correcting the reimbursement report for the quarter ending March 31, 2023, to account for the $409,485 of questioned costs.

FINDING 2022-005: CRIME VICTIM ASSISTANCE (16.575) ? CASH MANAGEMENT ? REIMBURSEMENT REQUESTS AND SUPPORTING DOCUMENTATION CONTACT PERSON: Robyn Young, Executive Director CORRECTIVE ACTION: Safenet, Inc. has implemented procedures to ensure that reimbursement requests are first agreed to underlying accounting records and amounts are substantiated with backup. Costs will also be reviewed for availability by someone with suitable knowledge of the particular award. This reviewer will check the accuracy of the request prior to submission. PROPOSED COMPLETION DATE: Immediately

Corrective Action Plan FINDING 2022-005: Cash Management Contact Person: Randy Cates rcates@yesomaha.org 402.345-6704 Regarding Cash Management?The process we have put in place includes the following: ? All fund receipts will be reviewed by Development Team and CFO for authenticity and accuracy. ? All approved fund receipts and invoices will be coded by the CFO. ? All fund receipts information will be forwarded to our CPA firm. ? Our CPA firm will: o Scan all deposits and create a file for which the CFO and Executive Director will also have access. o Input all fund receipts into our Accounting Software ? CFO will review all Fund Receipts monthly with Executive Director Reasonable completion date: Process is place as of July 7, 2023 Responsible Party: Randy Cates, CFO

FINDING NUMBER: 2022-002 Condition: The Organization is either lacking or has non-conforming written policies and procedures for the following administrative functions, required by the Uniform Guidance: 1. Financial Management - 2 CFR 200.302(b)(6) 2. Allowable Costs - 2 CFR 200.302(b)(7) 3. Federal payment - 2 CFR 200.305(b)(1) 4. Procurement - 2 CFR 200.318(a) and 2 CFR 200.318(c)(1) 5. Competition - 2 CFR 200.319(d) 5. Competition ? 2 CFR 200.319(d) 6. Methods of procurement to be followed - 2 CFR 200.320 7. Compensation (Personal Services) - 2 CFR 200.430(a)(1) 8. Compensation (Fringe Benefits - Leave) - 2 CFR 200.431(b)(1) 9. Relocation costs of employees - 2 CFR 200.464(a)(2) 10. Travel costs - 2 CFR 200.474 Planned Corrective Action: Management agrees with the finding and plans to review Uniform Guidance, modify and create policies and procedures where necessary to meet administrative Uniform Guidance requirements. The adopted policies and procedures will be reviewed and approved by the School Board of Directors at the organization?s next scheduled Board meeting. School Representative Responsible for Corrective Action: Carlos Perez, Executive Director Anticipated Completion Date: June 14, 2023

#2022-002: Material Weakness in Controls over Compliance: Administrative Requirements of Uniform Guidance -Administrative Policies Recommendations: Grand Rapids Christian Schools should consider the following written policy additions or updates: ? Financial Management (2 CFR 200.302) The financial management policy should include records documenting compliance, and the tracking of funds to determine that expenditures are in accordance with the terms and conditions of the federal awards. The financial management and reporting system must provide the following : ? Identification - Title of the award, CFDA number ? Complete disclosure of accurate and current financial results of each federal award ? Source and application of funds for federal award activity ? Record retention and access - define the time period for which records must be kept (can vary by grant agreement), and who has the ability access the records (?200.333 - ?200.337) ? Written procedure to implement cash management requirements (see below) ? Written procedures for determining the allowability of costs (see below) ? Cash Management (2 CFR 200.305) A written policy is required by Uniform Guidance detailing the Organization's procedures to minimize the time that elapses between draw and expenditure of federal dollars. ? Allowable Costs (2 CFR 200.302(b)(7)) The Organization must have written procedures for determining the allowability of costs in accordance with Subpart E - Cost Principles of Uniform Guidance and the terms and conditions of the Federal award. This includes the determination of allowable costs and the review of this determination. The standard assumes policies and procedures are in place for disbursements, and the allowable cost policy will demonstrate how the Organization ensures compliance. The criteria for costs to be considered allowable are documented within 2 CFR 200.403. ? Procurement Standards (2 CFR 200.317 - 200.326) The Organization must have a written policy that promotes full and open vendor competition, conflict of interest policies should cover employees as well as the organization, and general purchase requirements with specific thresholds as set forth by the Uniform Guidance. There are five allowable procurement methods as described in ?200.320, depending upon the dollar value of the purchase or contract. Views of Responsible Officials and Planned Corrective Actions: ? Grand Rapids Christian Schools follows procurement and record retention standards provided by the USDA. ? GRCS does not have actual written policies and procedures for Financial Management, Cash Management, Allowable Costs, and Procurement Standards, but do have practices in place to follow USDA guidelines. In the case of cash management, the only location that takes cash is GRCHS. In that instance, along with Meal Magic, cash registers are zeroed out and balanced to Meal Magic and cash deposits are made daily. ? GRCS Business Office will work with the Food Service Director to begin formulating written policies and procedures specific to Grand Rapids Christian Schools. GRCS will utilize the resources from Uniform Guidance and Code of Federal Regulations (CFR) to develop policies that are compliant with those requirements prior to June 30, 2023.

Section III-Federal Awards Findings and Questioned Costs 2022-002 coy10-12 Higher Education Emergency Relief t'und fHEERF} Condition: Criteria: Repeat finding. The College did not have adequate internal controls in place to ensure proper record keeping for grant funds. U. S. Department of Education cash management requirements are consistent with 2 CFR 200.305 which requires a grantee minimize the time elapsing between the transfer of funds from the United States Treasury and the disbursement by the non-Federal entity. According to the Higher Education Emergency Relief Fund (HEERF) II Frequently Asked Questions (FAQ) #17, grantees must pay the incurred obligation (liquidate) within 3 calendar days for HEERF ALN 84.425F (Institutional Portion) and within 15 days for HEERF ALN 84.425E (Student Portion) of receiving the funds. The design and implementation of proper internal controls and the corresponding proper record keeping procedures are essential to comply with cash management requirements. Cause: Effect: Recommendation: Views of Responsible Officials: Corrective Action Plan: It was determined that the College drew down funds expended under both ALN 84.425E and ALN 84.425F from the wrong grants management system accounts. A portion of expenses for ALN 84.425E were drawn from and/or were recorded to the sub-fund for ALN 84.425F and a portion of expenses for ALN 84.425F were drawn from and/or were recorded to the sub-fund for ALN 84.425E. This incorrect recording resulted in substantial positive cash balances reported during the fiscal year under ALN 84.425F which were mostly offset with substantial negative cash balances reported under ALN 84.425E. However, at one point during the fiscal year, this incorrect reporting and drawing down of funds resulted in an overall substantial cash balance recorded for the combined funds." Due to a lack of properly designed and implemented internal controls, even though based on our test, there were no repeat instances of the College drawing down funds from the wrong grants, it was determined that the College has not put proper controls in place as of September 30, 2022 to sufficiently eliminate this finding in the current audit period. The College should design and implement internal controls to ensure proper record keeping for grant funds and monitor cash balances by individual grants. Management agrees with this finding and has taken corrective action. The College will ensure that employees who are responsible for the administration of the Higher Education Emergency Relief Fund (HEERF) grants are properly trained on allowable uses of those funds and on correct administrative procedures relating to the administration of these funds. This will be accomplished individually through training and education via various sources, including the U.S. Department of Education's published guidance and previously provided guidance from the Alabama Community College System. In addition to this training, additional internal control processes will be implemented to ensure that HEERF grant funds comply with cash management requirements and are liquidated within the prescribed timeframe. Additional review and approval procedures will be implemented to ensure that funds are drawn down from the correct grants management system accounts. These internal control processes, procedures and training will ensure proper record keeping for grant funds and proper monitoring of cash balances by individual grants.

Views of Responsible Officials and Planned Corrective Actions: During this fiscal year, management experienced a turnover in the financial functions as well as new staffing and a new Director of Finance. In addition, the organization changed drastically in size and scope, thereby going through a substantial adjustment period. Corrective actions: 1. Management hired an Assistant Director of Finance in order to share the workload, add an extra layer of review for all documentation, account reconciliations, finance staff oversight, and banking functions. 2. Management hired an Associate VP of the Programs and Operations Division which has oversight over the Finance Department. 3. Monthly reconciliations and reviews and approval processes have been put in place to ensure proper recording of all expenses, revenues, and accompanying Federal Fund drawdowns and AP payments. 4. The federal department this occurred within was notified and the funds were spent on costs incurred in the next fiscal year.

Research and Development Assistance Listing No Various 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 planned/taken in response to finding: Management concurs. Departments are entrusted with considerable latitude in determining needs and purchasing products, services, and technical support required to perform educational and outreach duties as well as research with sponsored projects. Because of this, it is reasonable for departments to verify the delivery of these purchases, establish the quality and quantity of the items, and begin the process of paying the corresponding invoices. Delays in the workflow sometimes occur due to valid reasons, and other times are due to a breakdown in the administrative process. Information will be shared with departments regarding delays in invoice processing. This will include sharing the information with academic and research heads in the colleges that processing of invoices must occur quickly, discrepancies affecting the expedient payments will be noted on invoices, and explanations will be recorded. Name(s) of the contact person(s) responsible for corrective action: Robert Dixon, Director of Grants and Contracts Financial Administration Planned completion date for corrective action plan: Spring 2023

Contact Person Jolene Palme, Finance Manager Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023

Finding 2022-002 ? Cash Management ? Pass-Through Entities Condition: Texas Biomed did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days of requests for reimbursement received by Texas Biomed. Texas Biomed paid 2 of 23 subrecipients after 30 days of receipt of the request for reimbursement from the subrecipient, resulting in noncompliance with 2 CFR 200.305(b)(3). Corrective Action Plan: Texas Biomed will implement a more effective operating procedure for subrecipient invoice approval and timely payment that will include timeline expectations for the initial approval request to the applicable principal investigator upon receipt of invoices from the subrecipient, timeline for following-up with the principal investigator on approval requests, timeline and direction for seeking proxy approval if the principal investigator is unavailable or unable to provide a timely response, and timeline for entering the subrecipient invoice in Texas Biomed financial systems facilitating payment upon approval. Responsible Parties: Eduardo Meza, Director, Sponsored Programs Administration Completion Date: June 1, 2023

The City has identified federal grants subject to the Uniform Guidance and will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.

A vendor was utilized in Fiscal Year 2023 to assist the State with these tasks. For Fiscal Year 2024, IDOR’s role was transitioned from IDOR to the Illinois Department of Human Services.

Corrective Action: The lack of timeliness in payouts to SSVF subrecipients was largely due to the transition CAPO underwent in fiscal providers in 2022, and to a lack of sufficient internal staff to adequately manage the SSVF program’s growing fiscal requirements. The amount of SSVF funding CAPO passes through has increased significantly since 2021, and existing staffing was insufficient to assure timely tracking of draws and payments. Since moving to SMJ and hiring a Finance Manager, CAPO has improved the fiscal management of this grant considerably. CAPO is also hiring an Account Specialist to be assigned directly to SSVF invoicing and accounting needs. They will be charged to the VA grant and will work with the SSVF Program Manager and CAPO’s Finance Manager to process invoices, draw funds, and issue payments. Person Responsible: Janet Allanach, Rose Bradshaw, SSVF Program Manager; Shane Melton, Finance Manager. Timing for Implementation: Partially complete/In progress until December 31st, 2023, completion.

Assistance listing number and program name: 84.425 COVID-19 Education Stabilization Fund-Higher Education Emergency Relief Fund (HEERF) Institutional Portion Agency: Northern Arizona University (NAA) Name of contact person and title: Bradley Miner, Interim Vice President and Comptroller Anticipated completion date: August 18, 2023 Agency’s Response: Concur See University response section at the end of this report for the corrective action response for finding 2022-125.

Beginning immediately on the date of the single audit report, management will recalculate expenses monthly as well as on a YTD grant year basis after the month has closed and request reimbursement for only those expenditures.

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

• Condition: During our testing of reimbursement requests, we identified amounts that were requested for reimbursement prior to the expenses being incurred. • Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the account is being invoiced for the correct expenses during the proper timeframe. • Planned Corrective Action: During the newly established monthly meetings that will take place, MHA and the Accounting Rep will review the expenses being submitted for reimbursement together to ensure no invoices are submitted in advance.

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- 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)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

We concur with the recommendation, and a formalized and independently monitored process was implemented to reconcile refundable advances routinely and in coordination with the recognition and allocation of allowable costs effective August of 2023.

2022-005- Internal Control Over Compliance and Compliance – Cash Management Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: June 2024 Management’s Corrective Action Plan:NGA has developed procedures to capture all required documentation during the federal disbursement request process. Staff were informed in January 2023 of the requirements for federal drawdown documentation and the CFO proceeded with a desk audit of compliance for the first and second quarter of fiscal year 2023 in April 2023. The CFO will continue to monitor compliance and adequate document retention in the second half of the fiscal year and provide training to staff when documents are not available in shared drive folders. We will also implement a regular review of the SEFA beginning in September 2023 and use that review to ensure that revenue and cash transactions correspond to the expense reports they were based on.