Corrective Action Plans

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

Responsible: Thomas Hoover, Chief Financial Officer Corrective Actions: Updated Finance policies: Specify that documentation of review and approval of costs charged to federal grants be maintained and that costs are recorded in the appropriate grant funding period. Completion Date: July 10, 2024. 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 updated Finance policies to capture the documentation and approval of cost allocation methods and coding of costs to federal grants and maintenance of such documentation of Supervisory review and approval. Policies already in place specified that supporting and source documentation be maintained for at least 3 years, in compliance with federal grant requirements. In addition, the updated policy specifies that grant costs be recorded in the appropriate grant funding (fiscal) period. Four transactions sampled were partially or fully recorded in the incorrect funding (fiscal) period, though they were within the grant period.

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

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.

Boston Public Schools (BPS) has updated its’ training and guidance for timekeepers. Timekeepers participated in enhanced trainings during August of 2024 in preparation of the new school year. Anticipated Completion Date: August 31, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-004 Immunization Cooperative Agreements, ALN #93.268 Criteria: According to 2 CFR Section 200.308, all budget revisions over 10% must receive a budget revision from the grantee. Condition: Following a budget revision of over 10%, an approval was not received from the grantee. Cause: At direction from the pass-through agency, the Organization charged salary expenses to the contract services line items on its request reimbursement instead of getting budget revisions to reflect the change in the work performed. Effect: The costs billed on the vouchers for reimbursement, did not match the natural classification of the actual expenses incurred on the grant resulting in expenses reported being over budget on certain line items and under budget on others Auditor recommendation: We recommend that when there is a budget revision over 10%, the Organization works with the grantor to get formal documentation to support the revision to ensure amounts charged to the grants are in line with budget line items. Management response: Management will ensure a budget revision be done for any increase over 10% and submit that to the grantor to receive formal approval from the grantor.

To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. ● Ensure all documentation is easily accessible and systematically organized for audit purposes. ● Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and ONLY with written approval from the Federal awarding agency (as per 2 CFR 200.458). ● Establish a process for obtaining and documenting written approval for pre-award costs. ● Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. ● Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. ● Assign accountability for monitoring and reporting compliance to specific roles within the organization. This implementation of this plan shall be the responsibility of the Russ Kaubris, Business Manager. Starting with the Fiscal Year 2025 grant cycle, procedures to comply will be implemented.

DEPARTMENT OF ELEMENTARY PUBLIC HEALTH 2023-003 WIC Special Supplemental Nutrition Program for Women, Infants, and Children – Assistance Listing No. 10.557 Action taken in response to the finding: The Department and the WIC Nutrition Program will have all fiscal staff review the Operating Procedures to refresh themselves of the procedures surrounding Purchase Orders and Expenditures. (Excerpt from Operating Procedures) All Staff should complete a “Request for Purchase” form with all pertinent information such as quotes, renewal notices, conference registration, etc. and submit it to supervisor or Director for initial approval. Once the request is approved, the form is given to a fiscal staff to start the process of encumbering funds through MMARS and preparing a PURCHASE ORDER. At the very least, staff will identify that the service performed is correct and that funds are available and already encumbered to process the payment. All federal payments require a Program Code, and so the fiscal staff need to be sure the appropriate one is entered based on the dates of service or the date of the Purchase Order. Once all documents have been uploaded and submitted, then either the WIC State Director or the Fiscal Director will need to electronically approve the transaction in the Tracking System. The Fiscal Director and the State Director will more thoroughly review the assignment of Program Codes as they pertain to the Federal grant award dates before approving payment documents. This review will involve verifying: • The type of service • Date of service or receipt of item • Date of Purchase Order • Program Codes Name of the contact person responsible for corrective action: Beverly Andrew and Rachel Colchamiro Planned completion date for corrective action plan: April 30, 2024

Finding 2023-001 U.S. Department of Education Condition: Tuition invoices and payroll costs were charged to a 2023 grant that were for services rendered prior to the grant start date. Corrective Action Planned: The School will implement procedures to review all manual journal entries for period of performance compliance before posting to the general ledger. Anticipated Completion Date: Immediately Contact: Gilbert Lefort III, Director of Finance, North Attleborough Public Schools

We agree that the allocation being performed once annually does not create the most equitable allocation of costs between our individual programs. We will perform our indirect cost allocations more periodically during the course of the fiscal year to ensure that more appropriate times studies and applicable participant hours are being utilized to limit the potential of allocating unrelated indirect costs from the year to individual programs, including the federally funded programs.

Finding number: 2023-012 Federal agency: U.S. Department of Treasury Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance listing #: 21.027 Award year: 2023 Compliance requirement: Allowable Costs Corrective Action Plan: College Unbound has increased its administrative capacity and has implemented internal controls to properly track, account for and report on grant expenditures. CU hired the Vice President for Student and Institutional Sustainability in 2023 and subsequently a Controller and Bursar were hired in October 2023 to support the growing needs of the college. The Chief Development Officer, Program Staff and the Financial Team including the VP, Bursar, Financial Aid, and Controller have developed routines and procedures to ensure we are using grant funds as intended and have proper documentation. We are in the process of developing procurement protocols to align with federal grant expectations. Timeline for Implementation of Corrective Action Plan: Currently updating procedures to ensure compliance for FY25. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

American Diabetes Association (ADA) 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, ADA is taking the following corrective actions to address the audit recommendations: 1) Financial Services will communicate annual reminders of the existing policy relating toweekly completion and manager review of time records to all ADA team members. 2) Federal grant program management will perform weekly monitoring of all time recordsapplicable to federal awards to ensure that time is reviewed and approved by a manager with knowledge of staff activities so that ADA conforms to federal regulations regardingactivities allowed or unallowed and allowable costs. 3) Financial Services will execute a reimbursement request only once all time is reviewed and approved by a manager with knowledge of staff activities.

2023-003 – Period of Performance Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that expenditures are not charged to federal awards during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and Related services and the Portsmouth Finance department will monitor expenditures on an ongoing basis to ensure the funds are spent in accordance with the period of performance of the grant. The Finance department will review all purchases and notify the Office of Special Education if purchases are unallowable and do not follow the period of performance and have alternate suggestions on how the purchase can be made. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

2023-002 – Allowable Costs/Cost Principles Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that it retains documentation supporting time and effort on federal grants and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and related services, in collaboration with Portsmouth Schools Finance department will monitor that the certification of pay certifications are completed on a semi-annual basis. Finance will communicate via email, the list of personnel required to have the certification and also review once they are completed by the Office of Special Education. Finance will review all dates and signatures. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

Planned Corrective Action: To ensure grant funds are not utilized prior to final approval, grant application documents will be submitted to DESE by August 15th to ensure approval is given prior to costs being incurred. Additionally, we will identify alternative funding sources in the event grant approval is delayed and costs must be incurred.

Personnel Responsible for Corrective Action: Compliance with federal standards regarding key personnel change on federal grants will be supervised by COO, Tracie Thomas and coordinated by Grants Specialist, Westen Gehring Anticipated Completion Date: Policies and procedures will be implemented by the end of this fiscal year and reflected in the FY2024 audit. Corrective Action Plan: To ensure that key personnel changes on federal awards are in compliance with 2 CFR Section 200.308(c)(2) and (3), The Land Institute will draft and submit a request on letterhead to the pass-through entity for award 2020-68012-31934 specifying the cause for the disengagement of Rachel Stroer. Moving forward, all key personnel changes will be communicated beforehand for approval from the pass-through entity or awarding agency.

2023-003 - Allowable Costs/Cost Principles – Internal Control and Compliance over Allowable Costs/Cost Principles (Significant Deficiency) Condition: During our audit, we noted that three (3) out of forty (40) samples summed up to $39,055.50 had no proper source documents to support the transactions charged to the grant brought by lost official receipts, hence, identified as not adequately documented. Alternatively, the City created a memo to document the loss of receipts signed by the department head. Management concurs. Corrective Actions: The City has an existing purchasing policy and procedures requiring documentation of all purchases made. Finance department has already sent a reminder to all department heads regarding the policy and procedure and why they must comply. Implemented Name of Responsible Person: Manuel Carrillo Jr., Director of Recreation & Community Services

Action taken in response to finding: The finance department has taken action in response to the circumstances which led up to this finding. We have added an accountant position to the team whose primary responsibility is to organize and invoice all grants for the organization. The additional staff person allows a more thorough and detailed review of allowable grant costs, specifically prorated payroll charges. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Nelson, Accounting and Financial Analysis Director Planned completion date for corrective action plan: 9/30/2023

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