Corrective Action Plans

Dear Mr. Waguespack, LSU Health Sciences Center in Shreveport (LSUHSC-S) is in receipt of your office's FYE2023 audit report for special tests and provisions requirements. LSUHSC-S concurs with the finding regarding documentation and agrees with the recommendations set forth by your staff. 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. Response with Corrective Action Plan: LSUHSC-S Office of Sponsored Programs (OSP) is the institution office of record that seeks written approval from the federal grantor if the level of effort is reduced by 25% or a disengagement from a project for more than three months for the PI or any senior/key personnel named in the notice of award. OSP has created a "Change in Senior/Key Personnel" Template for the Department Principal Investigators and Business Managers to complete for submission to OSP. This additional process requirement notice will be distributed through the weekly Research Matters newsletter, campus wide email, new award meetings, and research business manager meetings. The two audit exceptions identified reflected the time and effort certification form did not agree to the final effort reported to the federal grantor through the Research Performance Progress Report (RPPR) and there was no evidence of prior approval from the federal grantor for a change in key personnel. LSUHSC-S reviewed the documentation of the two audit exceptions and verified the effort reported on the RPPR for key personnel did not require written approval from the federal grantor. Name of Contact(s) Responsible for Action Plan Annella Nelson, Assistant Vice Chancellor for Research Development Valarie White, Director, Office of Sponsored Programs (OSP) Marcia Scarmardo, Senior Advisor to Chancellor Jen Katzman, Assistant Vice Chancellor for Administration and Finance Anticipated Completion Date: Continuous Recommendation: Management should revise the Time & Effort Certification policy or implement alternative controls designed to ensure compliance with Special Tests & Provisions requirements. Response with Corrective Action Plan: To strengthen the internal controls for special tests and provisions requirements LSUHSC-S is updating both the time & effort certification policy and the personnel action form (PER) for funding and % of effort changes. The personnel action documentation (PERs) will include the requirement for expanded explanations for the hiring process and/or current employee updates/changes. These anticipated document revisions will assist the department principal investigators and business managers in meeting compliance requirements. Anticipated Completion Date: June 2024 Name of Contact (s) Responsible for Action Plan: Marcia Scarmardo, Senior Advisor to Chancellor Jen Katzman, Assistant Vice Chancellor for Administration and Finance Annella Nelson, Assistant Vice Chancellor for Research Development Valarie White, Director, Office of Sponsored Programs If you have questions or need additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.

Dear Mr. Waguespack: Please find below our management response to the audit finding "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards.” The University concurs with the finding results. As you may recall, FY 22's finding prompted us to create an effort reporting policy and system in draft mode and tested it starting at the end of FY 22 and FY23. This audit has brought to the attention of the office of Sponsored Programs Finance Administration and Compliance (SPFAC) that there are deficiencies in our adopted system, particularly in the generation of effort reports, which regrettably missed some key personnel and required information. Your identification of these shortcomings underscores the urgency of our need to enhance our internal controls and procedures to ensure compliance with federal regulations. Regarding the draft policy calling for quarterly effort reports, we have carefully considered your recommendation and in light of our operational capacities have decided to proceed with an annual, calendar year (CY) reporting time frame. We believe that an annual reporting cycle aligns better with our current operational resources. We will ensure that this chosen reporting cycle is rigorously adhered to and supplemented with additional measures as needed to enhance accuracy and timeliness. Moving forward, we are committed to the following actions to address the identified deficiencies: 1. Enhancing Internal Controls: We will review and strengthen our internal control framework to ensure that all required information is captured accurately and comprehensively in our effort reports. 2. Annual Time & Effort Certification: We will revise our Time & Effort Certification policy to reflect the decision to adopt an annual reporting time frame. This will involve refining our processes to ensure that annual certifications provide a thorough and accurate reflection of personnel effort on federal awards as required by federal regulations. The annual reports will be processed on a calendar year (CY) basis. To allow for a fresh start for CY 2024, the next effort reporting cycle will cover July 1, 2023, through December 31, 2023. 3. Monitoring and Oversight: We will establish robust monitoring mechanisms to track changes in personnel effort and ensure that any deviations from approved thresholds are promptly identified and addressed. To further assist with correction of this finding, the University has engaged Ellucian Banner to apply the Effort Certification Module which is a systematic certification process for us to review, validate and certify the work effort performed by faculty and staff in support of sponsored research. The module is expected to go in test mode in 2024 and anticipated to go live in 2025. The director of SPFAC will oversee the implementation of this action plan.

2023-001 Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: We have controls in place to ensure that costs charged to a grant are incurred within the grant period of performance. This finding exposed a vulnerability that circumvented our controls. We will use this finding to pinpoint the cause(s) and make the necessary corrective adjustments. Name(s) of the contact person(s) responsible for corrective action: Deborah Grupp-Patrutz and Steve Simmons Planned completion date for corrective action plan: Prior to June 30, 2024

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

FINDING: 2023-004 Internal Control and Compliance over Period of Performance Recommendation: We recommend the Partnership establish procedures to ensure the funds are obligated and utilized in the proper period of performance. Action taken: Community Partnership is working with our state association, CAAP, to update internal controls and fiscal policies. Procedures to ensure that obligated funds are spent and utilized within the proper period of performance will be included in updated fiscal policies. Most of these issues resulted from the separation with our previous accounting/fiscal services provider who managed our fiscal and accounting services in the 2022 funding period. CP has worked to satisfy almost all outstanding obligations from this separation during the 2023 CSBG funding period, and currently has no outstanding obligations from the 2023 CSBG funding period. Moving forward, CP staff will work diligently with our selected vendor and board of directors to ensure that all funds are spent down within their designated funding periods.

Contacts: Alex Antkowiak, David Kilpatrick, and Katherine Robinson Titles: VP Accounting and Senior Director, Education Programs & Productions, and Payroll Manager, respectively Anticipated Completion Date: September 2024 Corrective Action: The Center is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding activities allowed or unallowed and allowable costs. In response to the audit finding, the Center is taking the following corrective actions to address the audit recommendations: • Accounting will convene meetings with Production and Operations Managers to communicate the Fiscal Year 2023 Federal Award Findings, study and strengthen internal controls in place, review the general criteria within 2 CFR Section 200.403 for manager awareness, and reinforce the importance of accuracy and timeliness of pay rates. • Production and Operations Managers will enact recommendations from Accounting Personnel to strengthen internal controls, proactively communicate with Unions throughout the year and prior to year-end to stay informed of any changes to rates established in Collective Bargaining Agreements and apply changes in pay rates prospectively from date of notice and retrospectively when required. • The Payroll Department, in collaboration with Accounting, will establish a schedule to sample support from managers for compliance with transparency initiatives. Status as of February 2024: The Theater for Young Audience Touring Production and Operations Manager in charge of payroll processing has updated processes to create an audit trail for pay rate calculation, update payroll submission form to include a PDF copy of the audit trail for Payroll Department’s inspection.

Finding Number: 2023-001 – Period of Performance Planned Corrective Action: The item in question was a deposit for an event that took place in August 2023. It was made in June 2023. While the $24k payment was a valid payment within the grant terms, it was inadvertently recorded as an expense item in our 2023 schedule of expenditures of federal awards instead of as a prepaid asset. Upon discovery we implemented new procedures whereby payments made at year end will be subjected to an additional review to ensure they are recorded in the proper period. Person Responsible: Stephen Mack, Chief Financial Officer Expected Completion Date: Immediately

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. Cameron Wood, UI Director, Cameron.Wood@vermont.gov Scheduled Completion Date of Corrective Action Plan: August 31, 2024

Action taken in response to finding: • Staff will verify that costs were incurred within the grant period. • Staff will verify that payroll costs are charged according to the period end date and not the pay date.

Corrective action plan: HHSC completed the correction of the rate prior to year-end close on August 25, 2023. General Ledger Cost Allocation Team will work with CFO Operations Support to develop a query to identify journal transactions that post in the CAPPS Financials general ledger module before the project start date. This query will be run monthly and any exceptions will be corrected. An additional review of the new fiscal year payroll projects will be performed by both Budget and the General Ledger Chartfield teams as part of annual fiscal year close coordination. Implementation date: August 31, 2024 Responsible person: Heather Nevill, Director, Fund Management

The Home contacted the Office of Refugee Resettlement (ORR) and was instructed to keep the funds and submit a carry-over request for these funds.

Finding: 2023-002: Questioned Cost – Material Weakness Costs for US Department of Transportation, Mobility Management Grant 20.507 Section 5307 included a $30,000 charge for use of the Data Management System (DMS). The charge is based on a contract rate charged to outside entities that varies depending on the number of users. Management stated the charge was to recoup costs for use of the DMS. Costs for the DMS consist of historical costs to get the system functioning, along with current personnel costs to operate the system and provide the contracted training. The historical costs occurred outside the period of performance and are thus unallowable. Personnel costs are already being charged to the grant through the allocated payroll and benefits of trainers and other personnel, and thus should not also be charged through the contract rate. In addition, if the contract rate includes a profit component this would also be unallowable to charge to the grant. Auditor Recommendation: We recommend that costs charged to federal grants be reviewed by an individual familiar with the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 as part of the SEFA review process. Contact Person Responsible for the Corrective Action: Lisa Cappellari, Chief Financial Officer, LisaC@paratransit.org Management Response and Corrective Action Plan: After the end of Fiscal Year 23-24 on 6/30/2024, Jody Wadley, Finance and Grants Manager, and Lisa Cappellari, Chief Financial Officer, will compile all expense to be charged to any federal grants. Tiffani Scott, Chief Executive Officer, will review the expense against the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 to make sure all expense is eligible.

Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the agency and are considered cost share for the grant as the work on the grant continued past the grant end date. We will review our grant close-out procedures to ensure that grants are closed out in a timely manner based on the grant end date preventing subsequent charges to the grant award. Anticipated Completion Date: March 1, 2024

Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made. On occasion, payment requests do not have an invoice number. To prevent duplicate payments, the Accounts Payable staff require original invoices and uses a system generated invoice number, or a will use a manual entry numbering convention to prevent duplicate invoice numbers. The invoice data is entered by an Accounts Payable specialist and reviewed by the Accounts Payable Manager. On occasion, A/P must request corrected invoices from vendors who try and reuse invoice numbers. The A/P Manager reviews invoice numbers during the check run for accuracy. Purchasing and A/P will also periodically review the vendor database for duplicate vendors. For construction projects that list a pay application number instead of an invoice number, A/P will implement a consistent invoice numbering convention to avoid duplicate payments. The A/P specialists will also review the PO payment history prior to processing. Responsible party(ies) for corrective action(s): Accounts Payable Manager Corrective action(s) timeline: December 1, 2023

Finding Number 2023-005 — Significant Deficiency in Internal Control/Non-Compliance — Appropriate Expense Period of Covid 19-ESSER II 23b — Credit Recovery Condition: During expense testing of ESSER funds, a journal entry that reclassed the cost of Edmentum, program licenses for Plato courses, had expensed the entire annual license fee. The period for eligible expenditures did not begin until October 1, 2022. This journal entry expensed the full cost of the invoice, $11,914.50, and the district did not prorate the costs to include only those expenses from October 1, 2022 through June 30, 2023. The District did not adhere to the proper period for expenditures. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop a summary of all federal grants. This summary will detail the fiscal year it is associated with but more importantly, it will provide the proper period of eligible expenditures for each federal funding source. This summary may be used and readily available at the time approvals are granted for expenditures. If an expense does not fall within the eligible time period, the expense can be rejected by the approver. This summary will be shared with all administrators and staff. In addition, the process for reclass journal entries will also include a pause to check that each invoice associated with a federal grant, is falling within the proper period of expenditures. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

This finding is caused by Human error in transcribing amounts from the general ledger to the proper Activities and Objects on the Final Expenditure Report. The completion date for the corrective action plan is immediate. The person responsible for the corrective action is Tina Mills, the Business Manager. The plan for monitoring adherence is the business manager will double check reports before submitting them to the State of Michigan.

Finding No.: 2022-035 AL Program: 93.767 - Children’s Health Insurance Program Area: Period of Performance Questioned Costs: $38,556 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

Finding No.: 2022-016 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Period of Performance Questioned Costs: $494,836 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1 (E. Cabrera): The Office of Grant Management (OGM) respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, OGM maintain all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Based on our records, grant award D20AP00005 remains active with a period of performance extending through September 30, 2025, while grant award D20AP00037 was closed on September 30, 2024. Both grants remained operational well beyond the originally prescribed September 30, 2022 deadline. Given the extended period of performance authorized by the awarding agency, all associated questioned costs ($494,660.00) are supported by active grant activity and should be deemed allowable. Accordingly, OGM respectfully requests that these questioned costs be removed, as they reflect legitimate expenditures incurred within the approved grant periods. Proposed Completion Date: Ongoing Condition 2 (N. Karakaya): CIP agrees with the finding. To address the finding and prevent recurrence, CIP will: - Revise and strengthen written financial management policies to clearly define documentation requirements to substantiate expenditures and ensure costs are within the award’s period of performance. - Incorporate federal regulation references, including 2 CFR 200.303 (Internal Controls) and 2 CFR 200.344 (Closeout). - Implement a standardized checklist for technical analyst and program managers to confirm that all expenditure documentation includes dates verifying that costs were incurred within the period of performance. - Require a secondary review and sign-off by the CIP Administrator prior to submission of documentation to auditors. - Conduct mandatory annual training for program on federal period of performance requirements and required supporting documentation standards. - Provide refresher sessions before each audit cycle. - Establish a quarterly self-audit of grant files to verify that documentation is complete and properly supports expenditures. - Document results of each review and address deficiencies immediately. The responsible official will report progress on corrective actions to the CNMI leadership and maintain documentation of all implemented changes. Evidence of compliance (updated policies, training records, and self-audit reports) will be provided to the auditors upon request. Proposed Completion Date: December 31, 2025

The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developing and implementing formal time and effort reporting procedures to ensure that personnel costs charged to federal grants are supported by actual activity records and certified by employees on a regular basis. This will include the adoption of time distribution systems that comply with 2 CFR Part 200 Subpart E and the requirement for supervisory approval of time reports. Additionally, the Organization will revise its expenditure review and approval processes to require that all costs charged to federal programs are supported by appropriate documentation, including vendor invoices and receipts. Staff involved in grant management and accounting will receive training on federal cost principles, documentation requirements, and period of performance compliance. A document retention policy in accordance with 2 CFR 200.334 will also be established to ensure that all supporting documentation is maintained and readily available for audit and program oversight. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any unobligated funds or, if applicable, seek authorization to retain the funds for use in other similar programs. This process will ensure proper financial management and compliance.

CORRECTIVE ACTION PLAN Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No.: 21.027 Federal Agency: Department of the Treasury ? Pass-through from the State of California Award No.: WWID 4SSO10370 & CA 1910156 Award Year: Fiscal year 2021-2022 Category of Finding: Activities Allowed or Unallowed, Allowable Costs Name responsible for correction action plan: Emily Armstrong, Revenue Services Manager The corrective action planned: Payments applied to the 93 water bills and 81 wastewater bills will be reversed on the customer?s accounts. A notice will be issued to customers via mail and email (where possible) of the discrepancy. The funds will be returned to the State pursuant to their outlined procedures. Moving forward, the City will ensure that there is a multi-layered approval process to review the eligibility period of any State funding to identify the correct eligible applicants prior to disbursement. For future funding related to water and/or waster bills, the list of eligible applicants will be compiled by an analyst within the department and will be reviewed by the Revenue Services Manager and Assistant Finance Director prior to disbursement. Anticipated completion date: March 24, 2023

Responsible: Thomas Hoover, CFO Corrective Actions: Update Finance policies to specify that documentation of review and approval of both the costs charged and the allocation methods of costs charged to federal grants be maintained. Completion Date: March 29, 2023 Explanation: Policies have been in place over the coding of costs allocated to federal grants in compliance with CFR 200 and were enhanced in 2023 in response to an OJJDP/OCFO recommendation. Review and approval of costs after being approved by an authorized signer takes place in multiple steps and concludes with preparation of reimbursements and financial grant reports (FFR). In order to further demonstrate compliance as recommended, Management has updated Finance policies to capture the documentation and maintenance of such documentation of Supervisory review and approval.

Invoices that are received will be scanned to “invoices”. This will direct them to our electronic software, Docuware. The item will then be forwarded to the appropriate Program Director for approval, and they will indicate the appropriate cost centers / allocations. Bookers will then review the approved coding and entered fiscal software. If there is a question or concern about approved coding by the bookkeeper they will speak with Director of Finance, Ethan Terrio. Once invoices are entered into fiscal software, checks will be printed. The check stub and invoice will be attached to each other and filed in the fiscal department. Paper documents will continue to be maintained in fiscal until we go 100% paperless, then all documents will be stored in Docuware.

FINDING # 2022-024No finding in prior yearThe New Jersey Department of Labor and Workforce Development (DLWD) has a policy in place for processing tuition reimbursements that are performed by the Department?s Accounts Payable unit. The policy was reviewed by the Office of Finance & Accounting (F&A) and internal control procedures were enhanced to ensure that fiscal cutoff measures were appropriately addressed. Tuition reimbursement procedures include having the requests forwarded to the responsible Supervising Analyst in the Appropriations/Accounting unit for final review and approval to ensure the proper fiscal period is charged. The correcting transactions were completed during the Single Audit timeframe to remediate the findings by charging and reimbursing the proper fiscal year accounts. The DLWD will continue its efforts to ensure compliance and that all charges applied to Federal awards are within the specified period of performance going forward.COMPLETION DATE/CONTACT PERSON December 31, 2023Ruslana Nagorniak(609) 984-7678Ruslana.Nagorniak@dol.nj.gov

FINDING # 2022-021No finding in prior yearThe Department of Children and Families (DCF) will review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within each grant award?s specified period of performance.Further, as the federal SSBG grant award cited has a period of performance that remains open through September 2023, DCF has adjusted the four transactions that were posted incorrectly to another available funding source and ensured that all transactions presently recorded are now in compliance and within the specified period of performance.COMPLETION DATE/CONTACT PERSON Fiscal Year 2024Steven M. Dodson(609) 888-7555Steven.Dodson@dcf.nj.gov