Corrective Action Plans

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.

Action Taken in Response to Finding: Budget-to-actual comparisons began in 2024 and were subsequently standardized and incorporated into Financial Policies and Procedures. As of 2026, budget-to-actual comparisons are performed on a monthly basis as part of the month-end (EOM) close, prior to the preparation and submission of Federal reimbursement requests. This ensures that: • Expenditures are reviewed against approved grant budgets prior to reimbursement • Variances are identified and evaluated • Costs charged to Federal awards align with approved budgets and allowable use requirements Additionally, Budget and Program Revisions and Allowable Use of Funds policies were incorporated into the Financial Policies and Procedures to formalize requirements for budget compliance and modification. Control Enhancement: A standardized budget-to-actual review has been implemented across all applicable Federal awards. This process: • Compares actual expenditures to approved grant budgets on a monthly basis • Identifies variances requiring review or correction • Ensures expenditures are aligned with budget categories and allowable cost requirements • Requires budget review prior to submission of reimbursement requests Monitoring & Review: • Budget-to-actual comparisons are performed monthly as part of EOM close • Initial review is completed by Finance • Secondary review is performed by the Director of Finance & Operations • Program staff are engaged as needed to validate alignment with program activities • Any required budget modifications are identified and addressed prior to reimbursement Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to validate that budget monitoring controls are operating effectively • Testing will confirm that: o Budget-to-actual reviews are completed consistently o Variances are appropriately identified and addressed o Reimbursements align with approved budgets Documentation & Evidence: • Budget-to-actual reports maintained in Teams / Sharepoint • Supporting documentation for budget revisions retained • Approval and review evidenced via email/workflow/sign-off Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Director of Finance & Operations, with executive oversight by the Chief Executive Officer Anticipated Completion Date: All corrective actions will be implemented by June 30, 2026. Ongoing monthly monitoring and quarterly validation will continue. Status: • Budget-to-actual comparisons (limited): Implemented 2024 • Standardized monthly workflow (EOM close): Implemented April 2026 • Policy integration into Financial Policies and Procedures: Completed May 2026 • Quarterly internal reviews will be conducted to validate that budget monitoring controls are operating effectively: June 2026

Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance

Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program agrees with this finding. To strengthen oversight and ensure adequate accountability over Federal awards, the CNMI CCDF Program has implemented a filing system Finding No.: 2023-041, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: where all documents relating to a federal award are properly maintained and labeled for accessibility. This system became effective on October 1, 2025. Proposed Completion Date: Completed Condition 2 & 3b: The CNMI CCDF Program agrees with this finding and acknowledges the need to strengthen internal controls to ensure that all expenditures are cleared by the bank before the end of the liquidation period. The CCDF Program will coordinate with the Department of Finance (DOF) Financial Services Division regarding the establishment of a monitoring log that tracks all checks issued and cleared by vendor and office. Once this log is implemented, the CCDF Program will request regular copies to allow responsible staff to verify whether payments have cleared and to follow up with vendors as needed to ensure timely bank reconciliation. To streamline payment processing and enhance compliance with federal cash management requirements, the CCDF Program is exploring a transition to a fully ACH based payment system. Moving to electronic payments will reduce delays associated with paper checks, improve tracking and reconciliation, and strengthen internal controls over disbursements. This corrective action is currently in progress. The CCDF Program anticipates full implementation of the monitoring process and/or ACH transition by October 1, 2026. Proposed Completion Date: October 1, 2026

It has been brought to our attention that we need an additional policy that covers conflict of interests and govern the performance of its employees engaged in the selection, award, and administration of contracts. We have taken this recommendation and are implementing the proper language, for all employees to acknowledge in our County Handbook. We will strengthen this control and add this be updated yearly, so that all conflict can be disclosed. Creek County prides itself in moving toward complete transparency and holding each employee accountable to disclose all information needed to make a proper selection of purchases. Creek County Clerk’s Office will work with the District Attorney’s Office for proper language.

FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding with reservations on a portion of the Finding. Description of Corrective Action Plan: \ This program is completed and the period of performance is over therefore there is not a need to formally adopt any Corrective Action Plan. The Subrecipient Contractor that administered the program has agreed that this finding was due to their internal error in submitting administration invoices too late to be properly processed and approved by the County. They will be reimbursing the ERA1 fund for the error in the amount of $154,812.56 that will be sent back to the US Treasury. Reservation: The US Treasury required the local grant recipient to prosecute ERA1 fraud activities. There were two fraud cases that were prosecuted by our local attorney. His fees were then deducted from the ERA1 fund as administration costs. The grant recipient should not be penalized for doing as directed to prosecute fraud cases without being able to pay for the services rendered. We do not control the timelines of the local courts nor the responses/actions of the defendants delaying the actions beyond the Period of Performance. Anticipated Completion Date: None, no corrective action plan is necessary.

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.

3. Staff Training and Capacity Building: Our staff has received training on federal grant compliance, including the specific criteria governing the period of performance and allowable costs under federal awards. Additionally, with the Sage system in place, staff are now better equipped to manage compliance and reporting accurately.

4. Commitment to Ongoing Compliance: We are committed to continually improving our internal control processes to ensure compliance with all federal regulations.

1. Cleveland UMADAOP will obtain written prior approval for any expenditure deviations from the originally approved budget. This topic will be covered when training occurs during the quarterly review of grant guidelines. 2. As part of its updated financial policies and procedures, Cleveland UMADAOP will seek to document all financial activity to ensure compliance with grant and federal guidelines. 3. As part of the updated financial policies and procedures, Cleveland UMADAOP will seek written confirmation from funders whenever there is a deviation from the terms outlined in the original award documentation. 4. As part of the updated financial policies Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

Finding 2023‐004 – Material Weakness, Material Noncompliance – Allowable Costs/Activities Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management will improve policies and procedures to record the purchase of gift cards as a prepaid transactions and expense the gift cards when all allowable cost criteria are met. We will also get input from our funders when necessary. Proposed Completion Date: October 31, 2024

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County review its procedures relative to allocating costs to Federal programs, and ensure only cost within the grant period are included. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements regarding period of performance. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

Management’s Corrective Action Plan For the Year Ended December 31, 2023 Contact Person(s): Sophia Hernandez, Chief Operations Officer Sophia.Hernandez@youthcare.org Amber Aman, Deputy Operations Office - Finance Amber.Aman@youthcare.org Finding Number: 2023 - 002 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action taken: • Develop a contract expenditure compliance review process created with final review and approval by Deputy Operations Officers. To be established by September 30th, 2024, and implemented in 2025 annual operating plan Anticipated completion date: In Process

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jessica Thome, Controller Contact Phone Number and Email Address: (812) 244-2360 and Jessica.thome@terrehaute.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Controller will review any previously entered contracts that are paid from our federal grants including ARP to ensure we are in compliance. Anticipated Completion Date: October 2024