Corrective Action Plans

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.

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

Item 2022.007 - 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 FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

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

Dear Mr. Waguespack,Thank you for the opportunity to respond to your office's finding related to special tests and provisions requirements. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff and we concur with the finding.Recommendation:Management should continue to provide training for time and effort certifications.Response with Corrective Action Plan:LSUHSC-S will continue to offer training classes and educational meetings to address the Federal requirements and ensure compliance. The training classes include one-on-one departmental meetings held by the Office of Sponsored Programs on new awards, Department Business Manager and Administrative Staff monthly meetings and research personnel time and effort educational sessions.Name of Contact(s) Responsible for Action PlanAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentValarie White, Director, Office of Sponsored Programs (OSP)William Haacker, Assistant Director of Grants AccountingJen Katzman, Assistant Vice Chancellor for Administration and FinanceAnticipated Completion Date: ContinuousRecommendation:Management should also utilize the time and effort certifications and updated PER-3 forms to 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 will use both the time & effort certifications and personnel status change forms (PER-3s) to monitor effort percentages on federal grants. The monitoring review will include the departmental business staff and Principal Investigators (Pls).The new grant management software, Cayuse, that should be implemented now in FY2024, could be a source for the automation of time & effort tracking; however, until available, management is reviewing additional avenues to address this institutional internal control to include the re-initiation of the master tracking document reflecting the award's original personnel effort with changes as approved through the internal PER-3 form and/or written approval from federal grantor as necessary.Regarding prior approval for effort changes, 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 more for the PI or any senior/key personnel named in the notice of award per federal requirements. OSP is communicating with the Departmental PIs and Business Managers regarding effort changes throughout the grant year and reviews again with the PIs and Business Managers during annual progress reporting.With the implemented processes, LSUHSC-S should be able to ensure that the time & effort reporting during the grant year is reflective of the award document or if any approved changes from the federal grantor is required prior to annual progress report completion.Anticipated Completion Date: ContinuousName of Contact (s) Responsible for Action Plan:Sheila Faour, Chief Financial Officer, Business and ReimbursementsAnnella Nelson, Assistant Vice Chancellor for Research DevelopmentValarie White, Director, Office of Sponsored ProgramsWilliam Haacker, Assistant Director of Grants AccountingJen Katzman, Assistant Vice Chancellor for Administration and FinanceIf 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 does not concur that this is a second consecutive year finding, but in fact the same one from FY2021.The completion of FY2021 audit and the start of FY2022 audit did not allow the University time in between to correct the FY2021 finding.The following is timeline for the FY2021 finding.? Notification of potential finding was sent on 4/20/22.? Preliminary response request was sent on 5/26/22.? Preliminary finding response was submitted on 6/2/22.? Audit response request letter was sent on 6/6/22.? Audit response was submitted on 6/10/22.Sponsored Programs Finance Administration and Compliance (SPFAC) will continue the following corrective action provided in FY2021 and it will be overseen by Director of SPFAC.1. Update the current effort reporting and certification policy.2. Create and implement an internal user-friendly effort reporting system.3. Train faculty and staff on how to use the effort reporting and certification system.4. Track the effort certifications quarterly.5. For federal awards that follow CFR 200.201- Use of grant agreements (including fixed amount awards), cooperative agreements, and contracts, the University will internally track and certify the personnel effort cost separately as the billing is dictated by the issued task orders based on the estimated task order cost.

Finding Number: 2022-004Prior Year Finding: NoFederal Agency: U.S. Department of EducationFederal Program: COVID-19 - Elementary and Secondary Schools EmergencyRelief Fund (ESSER)Assistance Listing: 84.425C, D, U, WPass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:201787-01 (3/13/20 ? 9/30/22)Compliance Requirement: Allowable Costs/Cost PrinciplesType of Finding Significant Deficiency in Internal Control over Compliance,Other MattersRecommendation:We recommend that the Board review its policies and procedures to verify that controls are inplace to ensure expenditures are not reimbursed under more than one Federal Program.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding: ESSER funds will no longer be used for Food and NutritionServices.Name(s) of the contact person(s) responsible for corrective action: BCPS grant managers,and Fiscal Services staff.Planned completion date for corrective action plan: For immediate implementation andongoing

AUDIT FINDING REFERENCE: 2022-002FINDING SUMMARY:The District?s expenditures charged to grant award number 21-340-07000 occurred prior to the date of the sub-grantaward provided by the State of Nevada Department of Education.RESPONSIBLE PERSON:Dr. David Jensen, SuperintendentPLANNED CORRECTIVE ACTION:This finding was in relation to a pass-through grant of Supplemental Corona Virus Relief Funding provided to theDistrict in lieu of an error found in the PCFP funding formula for the bi-ennium. While the District?s expenditures forthe program are consistent with the March 1, 2020 through December 31, 2021 Period of Performance for thisfederal funding, the Period of Performance on the sub-grant Award was listed as December 10 through December 31,2021. Prior to acceptance, the District informed the pass-through entity that the funds would be used to reimbursecosts incurred during July through October, 2021, and the pass-through entity personnel verbally assured Districtmanagement that this would be acceptable. However, the pass-through entity did not amend the sub-grant awardperiod of performance, resulting in non-compliance with the sub-grant award.Humboldt County School District agrees with the audit finding that this was an isolated instance resulting from aunique situation that arose and was out of the District?s control, and is not the result of a systematic problem.However, the District will follow the recommendation and make every effort to obtain written documentation of anypromised revisions to sub-grant awards prior to expending funds from the pass-through entity in the future.ANTICIPATED COMPLETION DATE:January 31, 2023

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-006 – Period of Performance – Significant Deficiency Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all expenses include supporting documentation/invoice indicating period of performance. Grantee Response and Corrective Action Plan 2022-006: The Center for Black Women's Wellness has proactively updated our credit card policy in 2022. The CEO reviews the credit card statement monthly for discrepancies and allowable costs. Additionally, credit card holders are responsible for reviewing their credit card statements monthly for discrepancies and allowable costs. This measure aligns with our broader fiscal management improvements, which also involve the engagement of a Contractual CFO in April 2024 to oversee and refine our financial operations. These initiatives are part of our commitment to maintaining rigorous financial integrity and ensuring that all transactions are transparent and compliant with regulatory requirements. Additionally, we have resolved past documentation issues, such as those arising from the abrupt departure of an employee, by implementing robust procedures to avoid similar incidents in the future. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

The School System concurs with the auditor’s findings and recommendations. The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines.

We agree with the finding and observations and specifically note the following corrective actions will be implemented: - Develop policies and procedures to review employees’ timesheets charging federal grant and ensure changes in key personnel are identified timely - Monitoring of sub-recipient key personnel to identify discrepancies in a timely manner and take corrective action, with clear support documentation and retention - Training sessions for personnel assigned to manage the program and retain the records and succession. Responsible Official(s): * Director, Research/NYCAMH & Office of Sponsored Programs * Vice President of Financial Operations

FINDING 2022-010 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: June 2023

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (CHIP) Assistance Listing Number: 93.767 Award Number and Year: 2205DE5021 (10/1/2021 ? 9/30/2023) Compliance Requirement: Period of Performance Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DMMA will review reported expenditures based on the date of the federal draw to ensure that the expenditures occured within the period reported. Name(s) of the contact person(s) responsible for corrective action: Unkyong Goldie Planned completion date for corrective action plan: September 30, 2023

2022-002: Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact: Karina F. Alvarez Title: Senior Director of Total Rewards Anticipated Completion Date: September 2023 Corrective Action: The Center?s is committed to ensuring the appropriate documentation is in place in order 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: ? Management will review and update policies as needed to ensure employee compensation changes are documented sufficiently and verified through a quality control review; ? Implement additional functionality and security to minimize the potential for data entry error; and ? Design, develop, and implement a new Human Resource Information System (HRIS) that will provide a digital and modern platform to manage review and approval workflows surrounding compensation adjustments. Status as of February 2023: Management has informed the impacted employee and has updated their compensation documentation accordingly.

Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures for allocating expenses to grants to ensure only expenses incurred during the grant period are charged to grants. Completion Date: Immediately

Period of Performance ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by days worked within the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ? LMC staff will review all expense applied toward federal funds to ensure that all dates fall within the period of performance. ? CFO will work with grant management staff to further train and support review of all expenses allocated to grant funding. Name(s) of the contact person(s) responsible for corrective action: Melissa D?Onorio, CEO, and Emily Faricy, CFO. Planned completion date for corrective action plan: 1/31/2023