Corrective Action Plans

Views of Responsible Officials: Management acknowledges that prior approval must be received before allocating any cost to an award that is incurred outside of the period of performance. While in this case approval was ultimately not granted, the cost was returned to the original project and removed from the affected project and subsequent drawdowns adjusted accordingly. To avoid incurring costs outside the period of performance, the following actions will be implemented:  Update the Global Center procurement guidelines to explicitly emphasize period of performance requirements when incurring expenses on grants and contracts.  Systematically confirm all purchase requests, vendor contracts, consulting agreements and subawards fall within the period of performance by including the start and end date of the grant or contract on all associated documentation. Responsible Officials: Daniel Grimshaw, Director of Finance Anticipated Completion Date: December 31, 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

Material Weakness in Internal Controls over Compliance Condition: Time and effort certifications were not maintained for grant employees’ whose salaries and wages were not supported by detailed time records. Corrective Action Planned: The School Business Office is working with the SPED department to implement a system for completion and maintenance of time and effort certifications for federally funded grants salaries, based on the recommendations of the Town auditors. Anticipated Completion Date: September 30, 2024 Contact: Liz Latoria, School Business Manager

Condition: Invoices were charged for services performed prior to the award approval dates by the pass-through agency. Corrective Action Planned: At the recommendation of the Town auditors, the business office keeps its own records of grant revenues and expenses and verifies the accuracy of those entered by the Town Accountant's office. These records also contain the period of performance for each grant, which has helped to ensure spending is kept within the correct dates. The School Business Manager reviews all requisitions for accuracy to verify expenses are being charged to the correct grants or funding sources. Anticipated Completion Date: Spring of 2024 Contact: Liz Latoria, School Business Manager

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

Finding 2023-002: Overcharge of Indirect Costs Federal Grant – ALN 93.959 Condition – During testing it was noted that indirect costs were overcharged for ALN 93.959 by an immaterial amount. Corrective Action – The HealthWest grants policies and procedures have been updated and will follow the de minimis indirect rate. All HealthWest staff will be required to review the policy annually. Contact Person – Brandy Carlson, Chief Financial Officer Anticipated Completion Date – June 30, 2024

Finding 2023-001: Overcharge of FICA Expenses Federal Grant – ALN 93.958 and ALN 93.959 Condition – During testing it was noted that FICA costs were overcharged for ALN 93.958 by $6,663 and for ALN 93.959 by $458. Corrective Action – HealthWest is implementing Attendance on Demand (AOD). AOD is a timekeeping system that will allow staff to account for times worked under grant funding. HealthWest will update the grants policies and procedures accordingly and will review expenses monthly for accuracy and compliance. HealthWest will also create a Timekeeping policy and procedure for AOD. All HealthWest staff will be required to review the policy annually. Contract Person – Brandy Carlson, Chief Financial Officer Anticipated Completion Date – October 1, 2024

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.

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

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.

Department of Health and Human Services 2023-005 Value-Based Medical Student Education Training Program – Assistance Listing No. 93.680 Condition: Indirect cost expense was improperly calculated. Auditors’ Recommendation: We recommend the institution strengthen its internal controls to ensure that calculations are reviewed and adjusted for, if necessary, in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: UMMC’s transition to Workday resulted in the need for multiple F&A bases to be created in Workday to accommodate our DHHS negotiated agreement. However, since our go-live we have only been using one modified total direct cost base to calculate F&A. UMMC is in the process of engaging a Workday Certified consulting firm to review the operational efficiency of Workday for Post-Award Accounting. The scope of this engagement will be to align our usage of Workday to industry best practices, including best practices for F&A calculation. During the scope of this project, we will review these established bases to ensure they meet the needs of our negotiated rate agreement provisions. In the meantime, we are reviewing the F&A calculations on existing projects when an invoice or financial report is prepared to ensure accuracy. F&A will be recalculated with each invoice and/or financial report and any necessary adjustments will be made before the invoice or financial report is submitted to the sponsor. Name(s) of the contact person(s) responsible for corrective action: Julie Schwindt, Director, Post-Award Accounting Planned completion date for corrective action plan: June 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Julie Schwindt at 601-984-1058.

Views of Responsible Officials: Grant funds received pursuant to a period of performance or an approved drawdown or reimbursement request will be expended as specified in the request. When Federal grants are funded in advance, rather than on a reimbursement basis, the Foundation will minimize the time elapsing between the receipt of Federal grant funds and disbursement of such funds for their approved purpose. We will implement procedures to ensure that expenses are recorded or accrued properly.

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