Corrective Action Plans

Special Programs for the Aging-Title III, Part C-Nutrition Services – Assistance Listing No. 93.599 Recommendation: We recommend the Organization put procedures in place to retain documentation of supervisory approval of time and effort reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program leadership will review and retrain staff of the volunteer hour log requirements, including signatures, matching of hours to digital logs, properly documentation of updates made, and retention of documentation. Program leadership will conduct reviews of documentation for all their locations on a frequent basis to address any deficiencies and address as needed. Finally, administrative staff will conduct rotating reviews of site documentation as a secondary verification. Name(s) of the contact person(s) responsible for corrective action: Drew Erickson Planned completion date for corrective action plan: 02/28/2026

Matching – Assistance Listing No. 93.671 Recommendation: We recommend the Organization enhance its internal controls over the review of the payroll allocation to ensure matching contributions are accurately calculated and supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Senior Accountant or Director of Grants and Compliance will conduct the initial review to ensure that match costs are allowable, properly supported, and accurately calculated. The Chief Financial Officer will perform a secondary review and approval to validate completion of the initial review and confirm that reported match amounts reconcile to supporting documentation. Evidence of review will be documented through dated signatures or electronic approval within the grant billing file. Name of the contact person responsible for corrective action: Ashley Freivogel Planned completion date for corrective action plan: September 30, 2026

The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to Accounts Payable after delivery, indicating that the goods or services have been provided and requesting payment. Accounts Payable then reviews the vendor invoice, purchase order, and goods receipt in SAP to perform the required three-way match (PO, GR, and vendor invoice) before processing payment. 1. The Accounts Payable team will collaborate with the Procurement Services Division to establish and implement a process that ensures the timely review and reconciliation of Goods Receipt (GR) entries. This will include the development of clear guidance / training materials for schools and offices to periodically review their GR balances. Training will be conducted via Virtual Office Hours on a quarterly basis for sites to make necessary adjustments when the goods or services received differ from the original Purchase Order (PO) or the corresponding invoice. 2. The Accounts Payable team will collaborate with the Procurement Services Division to develop supplemental documentation and guidance regarding proof of delivery for goods and services received. 3. Accounts Payable staff will receive ongoing training throughout the year on documentation and reconciliation requirements, particularly when new internal controls, procedures, and processes are created. Training will be incorporated into regular team meetings, procedural updates, and onboarding for new team members to maintain alignment and accuracy across the department. The implementation target date for the above corrective action plan is June 30, 2026. Name: Rocio Saucedo Title: Director of Accounts Payable Contact Information: Rocio.Saucedo@lausd.net

Higher Education Institutional Aid – Assistance Listing No. 84.031 Condition: The Institution did not adjust the employee’s payroll costs to reflect the reported effort. We noted that the actual time and effort charged to the grant did not agree to the time and effort report. Recommendation: We recommend that the Institution strengthen its internal controls to ensure expenditures are reviewed and adjusted for, if necessary, in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As a corrective action, Coppin State will complete the implementation of the following: 1. Award PI will provide training regarding proper submission of Time and Effort Reports. 2. Award PI will review distribution of time and percentage. 3. Award PI will review compensation and fringe benefits. 4. Award PI will approve Time and Effort Reports and route to the Payroll Office. 5. Award PI with the support of the Controller will obtain the appropriate role in Workday that allows for the review and confirmation of approved payroll allocations and adjustments.

Higher Education Institutional Aid – Assistance Listing No. 84.031 Condition: Time and Effort documentation were not being documented and reviewed timely. Recommendation: We recommend that the Institution strengthen its internal controls to ensure that Time and Effort are documented, expenditures are reviewed and adjusted for, if necessary, in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In June 2024, we successfully implemented a new ERP system designed to automate the documentation of Time and Effort. This system streamlines the process by capturing and organizing data more efficiently, reducing manual effort and enhancing accuracy. As part of the implementation, we have established a process for regular reviews and adjustments of expenditures, ensuring ongoing compliance with regulatory requirements and maintaining the integrity of financial records. We are providing comprehensive training for relevant staff members, focusing on how to utilize the new system effectively. This training will ensure that documentation is completed in a timely, accurate, and consistent manner, minimizing the risk of errors and improving overall operational efficiency. Moving forward, we will continue to monitor the system's performance and provide ongoing support to ensure its success. Name(s) of the contact person(s) responsible for corrective action: Miliani Sinclair Planned completion date for corrective action plan: April 2025

Finding Number: 2024-043 Audit Type: Single Audit Finding Title: Use of Unapproved Federal Funds to Satisfy Required Local Match Related Finding: 2024-022 (Yellow Book) 1. Contact Person Responsible for Corrective Action Name: Shannah Weaver Title: City Clerk Department: Finance Department2. 2. Planned Corrective Action The City will revise its grant accounting procedures to ensure only eligible local funds are used for matching requirements. 3. Anticipated Completion Date September 30, 2026 4. Management's Response Management concurs and will coordinate with granting agencies to confirm match eligibility. 5. Status of Prior Year Finding This is a new finding.

Finding Number: 2024-035 Audit Type: Single Audit Finding Title: Internal Control Deficiency Over Federal Matching Requirements Related Finding: 2024-024 (Yellow Book) 1. Contact Person Responsible for Corrective Action Name: Shannah Weaver Title: City Clerk Department: Finance Department 2. Planned Corrective Action The City will implement a formal review process to verify matching fund eligibility prior to grant submission and reimbursement. 3. Anticipated Completion Date September 30, 2025 4. Management's Response Management concurs and will ensure compliance with federal matching requirements going forward. 5. Status of Prior Year Finding This is a new finding.

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the support and documentation we provided we captured $191,000 (25% non-federal match) of in-kind to meet our obligation of $189,250 for grant award Year 1, 2023. And although we met our in-kind obligation, we experienced several delays which were recognized by our grantee, MBDA. The delay in funding the grant award took place from July 2023 to September 2023 and subsequently after funding was released an additional black-out period from September 2023 to October 2023 was experienced due to a system transition from BAS to GEMS/era Commons. Acknowledgement of these delays was addressed by an official during an MBDA All Equities call on October 18, 2023. During that call awardees were advised to continue focusing on our program activities and clients as the situation was being addressed. To account for the delays, we later submitted a budget revision request through the new system, eRA Commons on 12.09.2024 asking for a budget carryover of $337,825.00 which also outlines how the funds will be expended. Additionally, it is noted in your finding that the allowable in-kind contribution is being reduced given that budget categories were not met by line item. However, our interpretation of MBDA Capital Readiness NOFO (pg.14), we are directed to Section CFR200.306 [https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-D/section-200.306] which does not cap in-kind by line-item. Lastly, the MBDA organization has changed dramatically since the inception of the Capital Readiness grant in 2023, yet we have been in communication with an MBDA government official who acknowledges the delays during the time outlined above and ask that flexibility for this non-federal share requirement be re-considered. Supporting documentation has been sent to support the statements. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: We plan to continue to seek validation of our position from our grantor and grant management entity – 4th Quarter 2025.

In January and February of 2024, TRAC was transitioning from being a program of CitySquare to becoming an independent 501(c)(3). Following the transition, two staff members previously allocated to the match departed in September 2024, and their associated match was not reassigned. To address this, TRAC has implemented monthly accounting reports (effective August 1, 2025) to compare budgeted vs. actual match requirements. The Finance Director reviews these reports each month, and variances greater than 10% are reported to the CEO for corrective action. This process ensures that match requirements are budgeted, tracked, and reconciled in accordance with federal regulations. Completion Date: October 1, 2025.Responsible Parties: Nicole Binkley, Chief Executive Officer Josh Runnels, Director of Finance and Operations

With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance with federal grant matching requirements. The new policy and procedures are attached.

DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will develop a match policy to include documented review and signed document retention for matching contributions, ensuring compliance with CFR §200.306. a. We will then follow this policy and retain signed documentation of matching contributions. Proposed Completion Date – October 31, 2025

Finding Number 2024-008: Matching – Significant Deficiency in Internal Control Over Compliance Corrective Action: The inclusion of certain costs in the matching pool was due to a misinterpretation of the requirement; the federal agency has accepted this approach for multiple years, and there was no impact as the Village exceeded the required match due to its commitment to serving the homeless. Management will further enhance its policies and procedures and implement a documented review process to ensure only allowable costs are included in the matching pool. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari and Luz Gonzales-Toscano Anticipated Completion Date: June 2025

Corrective Action: 4-C will implement procedures for tracking and documenting matching contributions. Responsible for Corrective Action: Executive Director, Business Manager Anticipated Completion Date: 12/31/2025

Management recognizes its responsibility for understanding and adhering to the Cost Sharing rules outlined under 2 CFR 200.306. Management is working with the New Hampshire Dept. of Environmental Services to correct any funding requests for the Webster Ave. Pump Station project in which ARPA funds were used as a match against the project’s federal CDS grant. Prior to submitting its first CDS funding request to EPA, engineers for the project requested guidance from an EPA representative on matching local funding for the project with CDS funding. The feedback they received led us to believe that using ARPA against CDS funding was not an issue since in total the project’s local funding source (CWSRF) far exceeded the 20% CDS match requirement. Considering the actual Cost Sharing rules under 2 CFR 200.306, the feedback was misinterpreted.

Audit Finding The audit found that during the reimbursement request process, WITA included total expenditures on the A-19 form without excluding the 10% required match, as outlined in the grant agreement and under 2 CFR § 200.306. The error was identified by the Washington State Department of Commerce and corrected before the reimbursement was issued. This was the sole instance of noncompliance identified within the 28 sampled requests. Cause of the Finding This error occurred early in WITA’s management of federal funds, during a period when the Association was still building internal knowledge and procedures for federal grant compliance. At the time, WITA unknowingly lacked fully developed internal controls specific to federal match reporting, and the staff involved had limited experience with federal grant administration. Corrective Actions and New Controls Implemented To address this issue and strengthen internal compliance, WITA has implemented the following controls: • Grant Management Procedures: A formalized checklist has been created for preparing reimbursement requests, which includes a step to verify exclusion of the 10% match. Manual calculations are performed on each Match Submittal Form to verify the requested amount excludes the 10% match. • Dual Review Process: All reimbursement requests are now subject to a dual review and approval process before submission to the granting agency. Responsible Party for Monitoring Compliance The Grant Management Assistant, Maranda Davis, is responsible for overseeing compliance with federal grant requirements and ensuring all reimbursement requests meet applicable match exclusion rules. Ongoing oversight is provided by the Executive Director. Timeline of Implementation • February 2024: Error identified and corrected in partnership with the Department of Commerce • March 2024: Grant reimbursement checklist developed and implemented • Ongoing: Dual reviews of requests initiated WITA is committed to ensuring strict compliance with federal grant requirements and continuously improving our internal controls. We appreciate your attention to this matter and the opportunity to strengthen our grant management practices. Sincerely, Betty Buckley Executive Director, Washington Independent Telecommunications Association

Corrective action planned: Housing Connector will develop and implement a written policy to address company match contributions used to meet federal cost share requirements, in alignment with 2 CFR 200.306. The policy will provide general guidance on the allowability, tracking, and reporting of match to ensure compliance with federal grant regulations. Relevant staff will be informed once the policy is finalized.

Corrective Action Plan: The Organization will ensure to track minimum level of effort requirement in regard to any key staff to stay in compliance. All invoices will be reviewed by accounting management staff to ensure level of effort requirements are in compliance. Estimated completion date: June 30, 2025 Contact person: Chue Vang, Chief Financial Officer

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from the employee’s total hours when calculating the amount of match for the federal program. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could claim as match disallowed costs under the federal award and would not be able to detect and correct noncompliance in a timely manner. The employee’s Medicaid hours were not properly included within a revenues report due to the employee’s provider number not being included within the report parameters. Responsible Individuals: CEO (Dan Ries) Corrective Action Plan: CEO will double check and confirm that all revenue reports run have data for the correct staff to ensure that the accurate information is being used to calculate match hours. Anticipated Completion Date: September 2024.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to a Means of Financing Reallocation. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to a Means of Financing Reallocation Recommendation: LDH management should strengthen the system of internal controls over preparation and review of the quarterly CMS-64 reports to ensure expenditures are accurately reported and that the required amount of state and/or local funds are available and used to match the state’s allowable expenditures. LDH Response: LDH Management concurs that the reallocation of the Medicaid expenditures that include federal and state shares should have been excluded from the June 30, 2024 CMS64 report. LDH Management recognizes its responsibility to accurately report financial data, but also acknowledges that staffing shortages and inadequate/insufficient training resulted in less-than-ideal reporting conditions creating limited knowledge and experience with the data and reporting requirements and time for thorough reviews Corrective Action Plan: LDH Fiscal Management has already taken steps to aggressively work towards improving staffing knowledge and skills by way of securing the services of a vendor who offers CMS64 support and training for federal reporting requirements. In addition, LDH Fiscal is working with the vendor to develop a comprehensive training/development plan for staff responsible for CMS64 reporting and establish collaboration with Human Resources to address staffing efforts. The corrective action plan completion date to address this compliance was effective immediately upon notification of the error, recognizing that this will be an ongoing corrective action plan of monitoring as LDH Fiscal works to create a culture of continuous improvement. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Inadequate Controls over and Noncompliance with Matching and Reporting Requirements Related to the Cost Share Process. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over and Noncompliance with Matching and Reporting Requirements Related to the Cost Share Process Recommendation: LDH management should ensure the cost share tables are appropriately updated for all periods during the fiscal year. In addition, LDH should strengthen controls over preparation and review of the quarterly CMS-64 federal expenditure reports to ensure that the appropriate federal match is applied to qualifying expenditures and the required amount of state and/or local funds are available and used to match the state’s allowable expenditures. LDH Response: LDH management concurs that the cost share tables were not updated for all periods during the fiscal year in LaGov. Although the rates in LaGov did not impact accurate federal reporting in MBES, we recognize that for comparison and accuracy, the rates should have been verified in both instances. Our expenditure reporting to CMS via MBES is entered based on total expenditures as MBES calculates the FMAP automatically. However, we are implementing additional controls in our SOPs that will ensure the FMAP information in LaGov remains current. Corrective Action Plan: The tables have been updated in the LaGov system as of January 2025 and we are currently adding a task to quarterly checklist to ensure the rates are aligned between LaGov and MBES. In addition, we are exploring the possibilities to update queries and reports, where possible, to further strengthen reporting accuracy by automatically tying to the FMAP information in LaGov so queries and reports can automatically calculate the appropriate federal and state match which will also avoid any potential discrepancy that may arise from manual intervention/calculations. This corrective action plan to address the feasibility of updating queries and reports is ongoing, but an anticipated assessment date is May 30, 2025. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 Fish and Wildlife Cluster (Assistance Listing #15.605, #15.611, #15.626) State Agency: NH Fish and Game Department Audit Contact: Kathy LaBonte Title: Business Division Chief Telephone: 603 271-2274 E-mail address: kathy.a.labonte@wildlife.nh.gov Audit Report Reference: 2024-008 - Matching Anticipated Completion Date: June 30, 2025 Corrective Action Planned: To have revised procedures in place to include additional documentation to ensure accuracy from the subrecipient. We concur with the finding; A. In-kind match documentation earned requires additional documentation to support subrecipient match contribution. Revised procedures will be implemented to include additional documentation from the subrecipient to ensure accuracy. B. Internal review of volunteer in-kind match calculations are in place, however, in one instance, prior year rates were used resulting in under reported in-kind match earned. The Department does review and track match received from the subrecipient. We do not agree there are questioned costs of $201,250.

The Crenulated will request a quarterly in-kind contribution report from DOE and will ensure the in-kind contributions are recorded in the financial statements. The Crenulated plans to hire an in-house Controller with expertise in accounting for grants, and review its existing contract with current third-party accounting provider.

FEDERAL AWARD FINDING Finding: 2024-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Setup and Monitoring of Reporting and Match Name of Contact Person: Angie Flick, Director of Finance Corrective Action: The accountants will be going through additional training on setting up grants in the system and how to reconcile them. CBJ will also be completing a grant reconciliation process quarterly instead of annually. This will act both as a control as well as an opportunity to make timely corrections in the case of error. Proposed Completion Date: September 30, 2025

Matching, Level of Effort and Earmark Significant Deficiency in Internal Control over Compliance, Instance of Noncompliance We concur. Corrective Action Plan: The City was not provided with payroll registers or pay stub copies for the in‐kind local match contribution from Solano County and the Travis Community Consortium. However, the City did maintain hourly tracking for the two agencies when they attended meetings and used a lower pay rate, as outlined in the approved grant budget, when reporting back to the agencies. The required 10% in‐kind match was exceeded by $9,224.28, with a portion of the $30,000 mentioned above included in the excess match. Additionally, the grant had a pay rate cap of $87 for one of the County employees, so using the actual pay rate to calculate the in‐kind match was not permitted. The City will collaborate with the other agencies to obtain better documentation for the shared local match. Responsible Individual(s): Liz Aptekar, Assistant to the City Manager Anticipated Completion Date: To be completed by 6/30/2025

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted item is not already written into another grant ● Presenting a list of budgeted items and their corresponding fund codes at a grants meeting prior to submitting the budget ● Notifying the Business Manager when the budgets have been approved and that those budgeted items can now be allocated to the corresponding grant under their specific fund code ● Checking the expenditure report to make sure it accurately reflects what was written in the grant before submitting information to the state ● Reporting any errors in coding to the Business Manager to ensure an accurate representation of expenditures is reported before submitting to the state 3. Anticipated completion date: Implementation of the corrective action plan began March 15, 2025.