Corrective Action Plans

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office’s findings related to the Special Tests and Provisions Requirements. LSU Health Sciences Center Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. We concur with your recommendations for addressing the finding and provide the following response and corrective action plan. Recommendation: Management should monitor changes in effort for key personnel and verify that prior written approval is obtained from the federal grantor for changes that exceed the thresholds set in federal regulations. Management should revise the Time & Effort Certification policy or implement alternative controls designed to ensure compliance with Special Tests & Provisions requirements. Response and Corrective Action Plan: LSUHSC-S is continuing to strengthen the management, internal controls, and efficiency of the sponsored programs management. In the Fall of 2024 LSUHSC-S began a re-organization of Research Administration, including sponsored programs management. The historical organizational structure supported an office of grants administration (pre-award) that functioned separately from the grants accounting (post-award) functions. This structure created a disconnect between the two functions, caused gaps in the services provided to faculty, and left some responsibilities unattended. The recent re-organization combined Pre-Award Administration and Post-Award Administration into one office, The Office of Sponsored Programs. This team is supervised by the Executive Director for Sponsored Programs and operates under the direction of the Chief Financial Officer and Vice Chancellor for Research Administration. As part of the overall re-organization and improvement of services, several processes are under revision. Time and Effort Reporting: Time and Effort Certification (T&E Certification) transitioned to an electronic process in January 2025. The electronic process is designed to ensure a more efficient certification process and one that is easily documented. T&E Certification is performed on a bi-annual basis. In addition to the certification process, comprehensive training will be provided for Business Managers, Principal Investigators, and other designated departmental staff on an annual and PRN basis. A Post-Award Monitoring process is currently being established for all sponsored programs. Quarterly meetings will be held with Principal Investigators (PIs), Business Managers, and other designated department staff to review documentation of monthly grant account reconciliations, assist and review payroll cost transfers, changes in key personnel, etc. These regular meetings will serve as a checkpoint to review all personnel, payroll and effort supported by grant accounts. PIs and/or departmental staff are expected to perform monthly reconciliation of grant accounts, and the Post-Award Monitoring Meetings will serve as the platform for reviewing the documentation. Post-Award Monitoring Meetings: All agenda items reviewed and discussed in the Post-Award Monitoring Meetings will be documented and follow-up on a quarterly basis or more frequently as needed. Changes in Key Personnel: All changes in key personnel that require federal agency approval must have documented approval from the federal agency prior to the change in personnel occurring. Federal agency approval for key personnel changes must be received prior to the submission of a PER for any employee changes. Changes in key personnel will be reviewed during the Post-Award Monitoring meetings. Training: LSUHSC-S continues to improve training materials covering federal, state, and institutional requirements. Additional training will be provided covering the responsibilities of sponsored programs management and who owns each responsibility. The annual training required for all employees involved in research activities will include Time & Effort, cost allocations, changes in key personnel and other related topics. Continuing education will be provided for Principal Investigators, Business Managers, and designated departmental employees. One-on-One departmental training will also be provided on an as needed basis. The Post-Award Monitoring meetings with department staff will serve as an additional opportunity for training. Name of Contacts Responsible for Action Plan: Ramey Benfield, Chief Financial Officer & Vice Chancellor for Research Administration Ashley Krukowski, Executive Director for Sponsored Programs Valarie White, Director for Pre-Award Administration in Sponsored Programs Tracy Calvert, Director for Post-Award Administration in Sponsored Programs Anticipated Completion Date: June 30, 2025 If you have questions or require additional information, please contact me at 318-675-6327 or via email at ramey.benfield@lsuhs.edu

FINDING 2024-005 (Auditor Assigned Reference Number) Finding Subject: Special Education Cluster (IDEA)- Period of Performance Contact Person Responsible for Corrective Action: Julie Remschneider Contact Phone Number and Email Address: julie.r@nn.k12.in.us, 219-285-2228 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will ensure the Special Education Co-op will have controls in place to make sure payments are made within the period of performance. Anticipated Completion Date: September 30, 2025

Boston Public Schools will take a multi-step approach to ensure accuracy of spending to the grant award period. Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Substance Abuse and Mental Health Services Projects - Assistance Listing No. 93.243 Recommendation: Perform a review policies and procedures regarding proper monitoring of period of performance related to grant end dates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MURC will perform a review of policies and procedures to ensure recorded transactions are within the proper period of performance related to grant end dates. Name(s) of the contact person(s) responsible for corrective action: Jennifer Wood Planned completion date for corrective action plan: June 30, 2025

Research and Development Cluster- Assistance Listing Nos. 93.323, 93.847 Recommendation: Perform a review policies and procedures regarding proper monitoring of period of performance related to grant end dates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MURC will perform a review of policies and procedures to ensure recorded transactions are within the proper period of performance related to grant end dates. Name{s) of the contact person(s) responsible for corrective action: Jennifer Wood Planned completion date for corrective action plan: June 30, 2025

FINDING 2024-005 (Auditor Assigned Reference Number) Finding Subject: Special Education Cluster (IDEA)- Period of Performance Contact Person Responsible for Corrective Action: Julie Remschneider Contact Phone Number and Email Address: julie.r@nn.k12.in.us, 219-285-2228 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will ensure the Special Education Co-op will have controls in place to make sure payments are made within the period of performance. Anticipated Completion Date: September 30, 2025

Condition: Of the 40 samples included in our sample selected for testing in the Research and Development Cluster (R&D), the University included two invoices for a total of $2,618 that were incurred prior to the beginning of the grant period. Planned Corrective Action: The university has implemented a new grant financial and billing software that provides improved controls over operational transactions, including an Award Calendar control that recognizes the award end date in the invoice posting process. The costs described in this finding, which occurred before the new system was implemented have been removed from the existing grant and replaced by other allowable costs that were incurred within the proper award period. Contact person responsible for corrective action: Associate Controller, Brenda Lindberg Anticipated Completion Date: The new grants module, which includes grant billing and award calendar schedule became operational at July 1, 2024.

2024-001 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contacts: Regina Frazier Title: Payroll Manager Anticipated Completion Date: September 2025 Corrective Action: The Center is dedicated to maintaining compliance with federal regulations concerning allowable and unallowable activities and costs. In response to the recent audit finding, the Center’s payroll department will proactively engage with key stakeholders in high-risk areas prior to the start of the fiscal year. This engagement will involve reviewing payroll submission templates and ensuring that the rates align with the most current employment agreements. Status as of March 2025: All affected employees have been reimbursed, and key stakeholders in high-risk areas have been informed of the corrective action plan.

Reference Number: 2024-010 Prior Year Finding: 2023-008; 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: Admin 24A55UI000063 (10/1/2023-12/31/2026), DUA 23A60UD000013 (7/14/2023 - 7/14/2026) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the Department review and enhance its procedures and controls to ensure that prior to charging costs to the program, they are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department will review its procedures and internal controls and update as necessary to ensure that expenditures are incurred within the allowable period of performance for respective awards. It should be noted that during the period of performance for which this audit was conducted there were a large number of personnel changes and shifts. The position that was responsible for the majority of these duties retired in January 2024. We proactively hired for her replacement a year before she retired. Over the course of the year our replacement took over more and more duties. In the process of this replacement, we have completed a tremendous amount of evaluation of our assigned duties, processes, workflow, training, and documentation. Not only in this role, but we are also undergoing a division and business unit wide analysis of our internal controls and workflow. It should also be noted that the UI admin funds are considered ‘formula funds’ from the US DOL. We are expected to run this program year-round with no gaps in service or performance. The funding that we receive from US DOL is based on an antiquated formula that breaks down the amount that is budgeted by Congress between 52 state and territories. We generally do not receive enough funding for the entire year. Also, with the recent trend of Congress to utilize the tool of the Continuing Resolution our funding is often ambiguous until most of the program year is over. We have at times seen our funding cut once a budget had been passed by Congress even though there was only about 3 months left in the program year. We are still expected to run this program and ‘find other sources of funding’. This does make the adherence to the period of performance challenging. However, as we evaluate our internal controls and procedures over the coming months, we will make note of every opportunity to strengthen this function to ensure that all charges applied to program funds are relevant, within the period of performance of the award, and are correctly reviewed and signed. Scheduled Completion Date of Corrective Action Plan: April 1, 2025 Contacts for Corrective Action Plan: Chad Wawrzyniak, Financial Director II chad.wawrzyniak@vermont.gov

Reference Number: 2024-007 Prior Year Finding: No Federal Agency: U.S. Department of Defense State Agency: Vermont State Military Department Federal Program: National Guard Military Operations and Maintenance (O&M) Projects Assistance Listing Number: 12.401 Award Number and Period: W912LN2421001 (10/1/2023 – 9/20/2024) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Department should review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department agrees with this finding and will implement the following: • Update Accounts Payable Standard Operating Procedures to include instructions for determining the appropriate Federal Fiscal year for coding and paying vendor invoices. • Distribute updated procedures and train staff to ensure understanding of Period of Performance reporting requirements. • Update Vision query to include the Invoice Date field. Current reports used for preparing the SF-270 only include the Vision transaction date, therefore the preparer and reviewer are not able to determine the performance dates of individual transactions based on this report alone and rely on proper coding of the Class field during voucher entry. Adding the Invoice Date to the report will improve the department’s ability to QC the SF-270 for period of performance discrepancies prior to submission for reimbursement. • The Financial Director will perform quarterly audits of this Vision report to identify any improper reporting. Any errors identified will be corrected with a journal voucher and subsequently corrected on the next SF-270. Scheduled Completion Date of Corrective Action Plan: April 15, 2025 Contacts for Corrective Action Plan: Kim Fedele, Financial Director kimberly.fedele@vermont.gov

Corrective action plan: Social Services Block Grant (SSBG) Actions Taken: HHSC Fund Management worked with Chief Financial Officer (CFO) Operations Support to develop a query to identify journal transactions that post in the CAPPS Financials General Ledger module prior to the start date of the project. This query has been run monthly since May 2024, and it was fully implemented as of August 31, 2024. Planned: Additional training on the review process for Accounting and Budget staff, and revisions to the process to emphasize meeting deadlines while new federal grants and old federal grant close out transactions occur. An expenditure transfer voucher (ETV) to correct reconciliation issue will be completed by CFO Budget staff. Block Grants for Community Mental Health Services (MHBG) Actions Taken: HHSC Fund Management will run the monthly query and take corrective action on any resulting journals prior to the close of the fiscal year. In addition, HHSC Fund Management/Cash Management does not draw federal funds past the liquidation date. These dates are denoted in their draw ledgers. Cash Management also sends a semi_x0002_monthly email during the fiscal year and a weekly email from mid-June through the end of July to HHSC Budget identifying transactions by fund source that should be cleared from the draw down report prior to the close of the fiscal year. HHSC Cash Management will continue to send the draw down clean up report and start the weekly emails the first week of June. HHSC Budget will complete any ETVs resulting from the draw down clean up report to HHSC Fund Management General Ledger for processing by July 15 to ensure the draw down accurately reflects federal expenditures for the SEFA population. Planned: Budget Management will revise the coordination process with Behavioral Health Services program financial staff administering MHBG to prioritize addressing encumbered balances on expiring block grant years at the beginning of the liquidation period and set deadlines for Program input on required financial adjustments to ensure sufficient time for processing. ETV to correct reconciliation issue will be completed. Implementation dates: February 28, 2025 Responsible persons: SSBG: Heather Nevill, Fund Management Director, Fund Accounting Raymond Jasik, Budget Director, CFO Budget Heather Anderson, Budget Manager, CFO Budget MHBG: Marcie Ochoa-Gamez, Budget Manager, Budget Management

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.

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.

Finding: Special Tests and Provisions – Key Personnel Research and Development Cluster, Assistance Listing Number: 84.031S Federal Granting Agency: U.S. Department of Education Program Year 2023–2024 Type of Finding: Other Instance of Noncompliance and Deficiency Corrective Action: The University has a process in place for personnel charged to grants to complete personal activity reports to monitor their level of effort on the grants. We were not requiring key personnel that are providing in-kind services on grants to complete the personal activity reports, although the project directors are monitoring the involvement of all personnel working on grants to ensure we are providing an appropriate level of effort in the grant activities. The individual identified in this finding was providing in-kind services and was not paid from federal funds. The University will update its processes to ensure that that project activity reports are documented and reviewed for all key personnel assigned to grants, including in-kind personnel. Status: In-progress Person Responsible for Implementing: Edith Cogdell, Chief Financial Officer Implementation Date: 05/31/2025

OSU OKC and OSU Tulsa: The key personnel listed on the GAN will be responsible for completing the post-award training. Key personnel will also reconcile their federal grant budget on a monthly basis and a copy will be submitted to the Office of Institutional Grants and Compliance. The Director of Grants and Compliance will verify the purchases using the approved grant budget. Signed time and effort reports will also be submitted to the grants office at this time. OSU IT: A new PI will be appointed to the grant and ensure accurate reporting of time and effort. OSU IT will also implement a comprehensive training program for PI and grant-related staff, establish a monitoring system to ensure ongoing compliance, and designate a compliance officer to oversee this process. Will also implement a digital tracking system to streamline the reporting process and reduce the risk of errors.

Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately and completed by June 2025.

Views of Responsible Officials: Management has implemented mandatory on-boarding training and annual training of all staff on overall grant management, with a focus on compliant entry of time and effort. New budgeting and forecasting tools and processes have been implemented to allow more effective and timely monitoring of expenditures. In addition, CIPE has reviewed and revised relevant policies to ensure they align with best practices. CIPE worked closely with stakeholders on all these remedial efforts.

The Organization acknowledges this repeat finding and will take steps to address the deficiencies noted. Since the prior year's audit, management will implement updated procedures to strengthen internal controls around documentation of allowable costs charged to federal awards. These measures include the development of a formal time and effort reporting system, which requires all grant-funded employees to submit periodic certifications that reflect actual hours worked and funding source allocation. Supervisors are now required to review and approve these certifications to ensure alignment with actual program activities. Additionally, the Organization will reinforce its invoice documentation and review process. All expenditures charged to the Block Grant and Opioid STR programs must now be supported by detailed invoices and documentation that clearly demonstrate allocability, allowability, and consistency with the approved grant budget and period of performance. These requirements are monitored through monthly reviews by the finance department. The Organization has also adopted a document retention policy aligned with 2 CFR §200.334, and relevant staff have received training on documentation and compliance requirements for federal awards. These corrective actions are being actively monitored by the Director of Finance to ensure full implementation and ongoing compliance. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025

Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.

2023-007 Assistance Listing No. 96.001 , 96.006 and Social Security Disability lnsurance Cluster Type of Compliance Requirement: Period of Performance lnternal controls over period of performance were not consistentlv performed Response: Of the five instances noted in the auditor's "Period of Performance" test work, we concur with four. With one of the sample items, however, we argue that since the service was invoiced on a State Fiscal Year, it was impractical to further split the invoice into the various appropriate Federal periods of performance, especially given the way those specific invoices are allocated between other shared program areas within our agency, etc. Corrective Action Plan: Our agency takes these findings seraously and will continue to evaluate ways of improving controls. At a minimum, it is our intent to increase and provide additional training to the staff overseeing and approving these types of transactions so that they can accurately apply transactions to the appropriate periods. This was something we had already begun (i.e. provrding additional guidance and training to stafD during the current fiscal year. So, we hope our agency is already on a corrective path. But, we will continue to push for more training in the immediate future and strive for improvement in all other aspects. We also think it is important to note that, of the findings identifled by the auditors related to "Period of Performance," those items were discovered out of a total sample size oI 120 items (i.e. 60 sample items related to thejr "Period of Performance" test work and 60 sample items related to "General Disbursements" test work). So, a slightly larger sample size than that of the 60 referenced in the auditor's schedule of flndings. Additionally, the auditor's sample appeared to selectively target the specific periods and transactions that would have been most susceptible to these types of potential errors. And, although we are not objecting to the way in which the sample was selected, we would.just point out that this approach of sample selection may not be truly reflective of a purely random sample covering all transactions across the entire fiscal year. Therefore, although we ultimately concur with the findings here, we do not necessarily believe these results paint the fairest picture on the overall effectiveness of our agency's controls across the more than '100,000 transactions that would have been processed during the period of audit for this program. Again, we take these findings seriously. But, based on the audit test work and results, we feel the controls we have in place are ultimately working adequately enough to mitigate the potential for material misstatements. Regardless, we will continue to monitor and evaluate our controls to help further reduce the risk of these types of issues moving forward. Planned completion date for corrective action plan: lmmediately. But, additional training for managers to be provided by September 30, 2024.

All management will be educated on the procurement policy as well as the information noted from the CFR sections indicated in the findings by the Director of Finance. The Director of Finance will research and provide education to the Executive Leadership related to this finding during the Executive Leadership meeting. All Grants and cooperative agreements must be filed with the fiscal department. All expenditures must be approved prior to purchase / payment with sign off from Executive Director or Director of Finance.

This matter was investigated by both the AOS, the Allen County Auditor’s Office, and by board members of the RPC. GLCAP was met with and records from both RPC and GLCAP were scrutinized and matched. As a result, the duplicate payment made in the amount of $4,386 was returned by GLCAP to RPC and was deposited on 10/03/2024 into the Allen County Community Development Fund.

1. Implementation of Sage Accounting Software: We have since implemented a comprehensive financial accounting software system, Sage, which allows us to track expenditures more accurately and ensure compliance with federal grant requirements. The system includes built-in safeguards to flag non-compliant expenditures.

2. Review and Strengthening of Internal Controls: Life Source International Charter School will be implementing additional internal control systems & processes that include an additional review of back up documents before monthly reports are filed. A copy of all backup documents in support of all monthly reports will be kept at both Life Source International Charter School and the outside entities providing services and making reports on behalf of Life Source International Charter School.