Corrective Action Plans

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

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