Corrective Action Plans

Reference Number: 2024-007 Prior Year Finding: No Federal Agency: U.S. Department of Defense State Agency: Vermont State Military Department Federal Program: National Guard Military Operations and Maintenance (O&M) Projects Assistance Listing Number: 12.401 Award Number and Period: W912LN2421001 (10/1/2023 – 9/20/2024) Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Department should review and enhance its procedures and internal controls to ensure that it charges expenditures to the program that are incurred within an award’s allowable period of performance. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The Department agrees with this finding and will implement the following: • Update Accounts Payable Standard Operating Procedures to include instructions for determining the appropriate Federal Fiscal year for coding and paying vendor invoices. • Distribute updated procedures and train staff to ensure understanding of Period of Performance reporting requirements. • Update Vision query to include the Invoice Date field. Current reports used for preparing the SF-270 only include the Vision transaction date, therefore the preparer and reviewer are not able to determine the performance dates of individual transactions based on this report alone and rely on proper coding of the Class field during voucher entry. Adding the Invoice Date to the report will improve the department’s ability to QC the SF-270 for period of performance discrepancies prior to submission for reimbursement. • The Financial Director will perform quarterly audits of this Vision report to identify any improper reporting. Any errors identified will be corrected with a journal voucher and subsequently corrected on the next SF-270. Scheduled Completion Date of Corrective Action Plan: April 15, 2025 Contacts for Corrective Action Plan: Kim Fedele, Financial Director kimberly.fedele@vermont.gov

Condition: Costs were charged to the grants for payroll and related benefits earned prior to the start of the grant period. Corrective Action Planned: We had budgeted the full cost of one teacher and four teaching assistances in the IDEA 240 grant for 2024. The approval process for the grant took longer than expected, our intent was always to comply, but we do realize we should have waited for the approval to be in place prior to charging the costs of these employees to the grant. In the future we will wait for the approval process to be complete and will then charge the employees there. Anticipated Completion Date: July 1, 2025 Contact: Martin Anguelov, Chief Financial Officer for Nantucket Public Schools and Deb Gately, Director of Special Education for Nantucket Public Schools

Condition: Costs were liquidated after 120 calendar days after the end of the grant period. Corrective Action Planned: The Sandwich Public Schools will implement the following procedures to ensure that the 120 liquidation finding doesn’t happen again. 1. We will make sure that all costs are liquidated within the 120 day window after the end of the grant period. 2. If we see we are approaching the 120 day limit on a certain expense, we will reach out to DESE to ask for an extension to the 120 day liquidation requirement. 3. We will add these procedures to our Federal Grant Manual so that all are aware of these requirements. Anticipated Completion Date: June 30, 2025 Contact: Michelle Austin, Director of Finance and Business Operations

3.1.Ensure that the inventory expenses charged to the federal program are allowable within the period of performance. Responsible Official: Head of Operations, Supply Chain Managers, DRD Operations, SCM RTAs, Completion Date: September 30, 2025

2.1 Ensure timely reconciliation of inventory distributions in order to record the transactions in the correct accounting period. Responsible Official: Head of Operations, Supply Chain Managers, DRD Operations, SCM RTAs, Completion Date: September 30, 2025

Context: The School Corporation pays one hundred percent of its Special Education Cluster funding to one service provider. From review of the expense population, we noted 2 payments to the service provider where the service provider was not paid until after liquidation date of December 29, 2023. The School Corporation did not pay the service provider until April 30, 2024 for $258,488 for the services provided. Contact Person Responsible for Corrective Action: Abigail Lindsey Contact Phone Number: 765-853-5464 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Corporation will have all Special Ed funds paid before liquidation date. Anticipated Completion Date: 12/29/25

Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately and completed by June 2025.

Finding 2024-004 Period of Performance Finding Summary: During the course of the engagement, one instance was noted of a fiscal year 2023 expenditure recorded during fiscal year 2024 and therefore not allowable under the terms of the grant. Responsible Individuals: Michelle Bethke-Kaliher, Director Corrective Action Plan: A thorough review of expenditures should be performed to ensure expenditures are being properly recorded in the appropriate grant periods. Anticipated Completion Date: June 30, 2025

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

Summary of Findings During testing of program expenditures, one of thirty-seven expenditures (2.7%) tested was determined to be an unallowable cost under the grant. The amount identified totaled $13,247. This instance was identified as noncompliance with Allowable Costs/Cost Principles requirements. The finding is not considered a repeated finding. Statistical sampling was not used in making sample selections. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-005. The administrative agent that administers the organization’s health insurance changed their name. As a result, the health insurance bill ($13,247.02) was coded to the wrong GL code. Instead of being posted to the health insurance expense code, this was erroneously posted to the GL code for other consultants. Corrective Action A. Immediate Corrective Action Taken 1. Management reviewed the specific expenditure and confirmed that it was erroneously assigned the wrong GL code. 2. The unallowable cost of $13,247 was removed from the federal award, and properly reclassified. 3. Supporting documentation of correction was retained. Completion Date: Completed prior to issuance of audited financial statements. B. Long-Term Corrective Actions The organization will develop a Vendor Change Monitoring Procedure that will require documentation and review when a vendor changes name, ownership, or payment structure. This will Include verification that the vendor is mapped to the correct GL account before payment is processed. Responsible Parties: Executive Director and Contractual Bookkeeper Completion Date: Within 60 days of the date of this memo.

Summary of Findings Testing identified one expenditure out of seven sampled (14.3%) totaling $3,300 that was not recorded in the proper fiscal year. This was determined to be an instance of noncompliance in internal control over compliance related to Period of Performance requirements. The finding is not considered a repeated finding. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-008. The organization failed to accurately review an expenditure that was billed in the audited fiscal year but was actually a prepay for services in the following fiscal year. The expenditure did appropriately fall within the correct grant award period as the grant spanned both fiscal years. This oversight was due to human error. Corrective Action A. Immediate Corrective Action Taken 1.Management reviewed the transaction in question and verified the correct period of performance. 2.The expenditure was reclassified to the appropriate fiscal year. 3.A review of expenditures recorded near the fiscal year-end for all federal awards was conducted to identify any additional cutoff errors. 4.Supporting documentation for corrections was retained. Completion Date: Completed prior to issuance of audited financial statements. B. Long-Term Corrective Actions The organization will implement enhanced year-end closing procedures that will include review of all invoices for the period of service to ensure that expenditures recorded near the start or end of a fiscal year are aligned with the proper fiscal year. Prepaid service expenditures will be recorded as accruals. Responsible Party: Executive Director and Contractual Bookkeeper Implementation Date: Beginning current fiscal year-end and ongoing.

Corrective Action Plan Action Item Responsible Party Monitoring Require that federal grant expenditures be tracked by program and period of performance to ensure costs are incurred within approved timeframes. CFO / Grants Accounting Monthly review Maintain supporting documentation to substantiate the timing of costs incurred and the liquidation of obligations in accordance with federal requirements. CFO / Accounting Staff Periodic internal review Reconcile grant expense records to the SEFA to ensure a complete and reliable population for compliance testing. CFO Documented reconciliation In FY 2026, management developed and implemented a formal Records Retention Policy to ensure that accounting records, supporting documentation, and organizational records are properly maintained and retained in accordance with applicable regulatory and audit requirements. CFO Management oversight Implement supervisory review of grant expenditures to confirm compliance with performance requirements. CFO / Board Finance Committee Quarterly review ________________________________________ Management Response Management notes that no additional federal grants, other than the HRSA Section 330 program grant (Assistance Listing 93.224), were received in FY2025 or FY2026. Prior management did not provide a reconciled SEFA schedule for earlier reporting periods, which contributed to the documentation limitations identified during the audit. Beginning in FY2026, management has developed a detailed SEFA tracking schedule for the HRSA Section 330 grant that identifies the date federal funds were drawn down, the amount received, the related expenditures, and the corresponding disbursement dates. This schedule is maintained to improve reconciliation between drawdowns, expenditures, and the general ledger and to ensure documentation is readily available for audit and compliance purposes. In FY2026, management implemented an updated and comprehensive set of policies and procedures designed to strengthen internal controls and promote consistent, standardized accounting and administrative practices. These updates establish clearer documentation requirements, defined responsibilities, and improved oversight to ensure compliance with applicable regulations and the safeguarding of organizational records and financial information. ________________________________________ Responsible Official: Chief Financial Officer Expected Completion Date: FY 2026

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Establish an indirect cost policy to standardize the evaluation and approval for subrecipient. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

The Organization acknowledges this repeat finding and will take steps to address the deficiencies noted. Since the prior year's audit, management will implement updated procedures to strengthen internal controls around documentation of allowable costs charged to federal awards. These measures include the development of a formal time and effort reporting system, which requires all grant-funded employees to submit periodic certifications that reflect actual hours worked and funding source allocation. Supervisors are now required to review and approve these certifications to ensure alignment with actual program activities. Additionally, the Organization will reinforce its invoice documentation and review process. All expenditures charged to the Block Grant and Opioid STR programs must now be supported by detailed invoices and documentation that clearly demonstrate allocability, allowability, and consistency with the approved grant budget and period of performance. These requirements are monitored through monthly reviews by the finance department. The Organization has also adopted a document retention policy aligned with 2 CFR §200.334, and relevant staff have received training on documentation and compliance requirements for federal awards. These corrective actions are being actively monitored by the Director of Finance to ensure full implementation and ongoing compliance. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025

The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control process to monitor and review additional invoice samples from Branches after they have been processed and reviewed by Branch Program Technicians and Branch Auditors. Additionally, the DDSD Central Support Services Branch implemented a secondary audit process and created a new Auditor role to routinely sample additional Medical Evidence of Record (MER) and Consultative Examination (CE) contracts. Findings are provided to branches to reinforce accuracy and assure compliance. The DDSD, also transitioned from MIDAS to DCPS, which provides more sophisticated fiscal controls. To remediate any inaccuracies, DDSD’s centralized auditor will assess findings and develop an action plan to prevent erroneous invoices. The CDSS ensures that all necessary controls are in place to verify the accuracy and proper documentation of invoices. The CDSS concludes that the sample size of 15 MER cases does not provide sufficient audit evidence that controls are not operating effectively resulting in a calculated $54,398 in potential costs. However, CDSS agrees with the finding and is committed to the control and mitigation of risk related to the audit recommendation. Estimated Implementation Date: Implemented Contact: Bernice Stanfield, Fiscal and Procurement Section Chief Central Support Services Branch Disability Determination Service Division California Department of Social Services

Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.

2023-007 Assistance Listing No. 96.001 , 96.006 and Social Security Disability lnsurance Cluster Type of Compliance Requirement: Period of Performance lnternal controls over period of performance were not consistentlv performed Response: Of the five instances noted in the auditor's "Period of Performance" test work, we concur with four. With one of the sample items, however, we argue that since the service was invoiced on a State Fiscal Year, it was impractical to further split the invoice into the various appropriate Federal periods of performance, especially given the way those specific invoices are allocated between other shared program areas within our agency, etc. Corrective Action Plan: Our agency takes these findings seraously and will continue to evaluate ways of improving controls. At a minimum, it is our intent to increase and provide additional training to the staff overseeing and approving these types of transactions so that they can accurately apply transactions to the appropriate periods. This was something we had already begun (i.e. provrding additional guidance and training to stafD during the current fiscal year. So, we hope our agency is already on a corrective path. But, we will continue to push for more training in the immediate future and strive for improvement in all other aspects. We also think it is important to note that, of the findings identifled by the auditors related to "Period of Performance," those items were discovered out of a total sample size oI 120 items (i.e. 60 sample items related to thejr "Period of Performance" test work and 60 sample items related to "General Disbursements" test work). So, a slightly larger sample size than that of the 60 referenced in the auditor's schedule of flndings. Additionally, the auditor's sample appeared to selectively target the specific periods and transactions that would have been most susceptible to these types of potential errors. And, although we are not objecting to the way in which the sample was selected, we would.just point out that this approach of sample selection may not be truly reflective of a purely random sample covering all transactions across the entire fiscal year. Therefore, although we ultimately concur with the findings here, we do not necessarily believe these results paint the fairest picture on the overall effectiveness of our agency's controls across the more than '100,000 transactions that would have been processed during the period of audit for this program. Again, we take these findings seriously. But, based on the audit test work and results, we feel the controls we have in place are ultimately working adequately enough to mitigate the potential for material misstatements. Regardless, we will continue to monitor and evaluate our controls to help further reduce the risk of these types of issues moving forward. Planned completion date for corrective action plan: lmmediately. But, additional training for managers to be provided by September 30, 2024.

All management will be educated on the procurement policy as well as the information noted from the CFR sections indicated in the findings by the Director of Finance. The Director of Finance will research and provide education to the Executive Leadership related to this finding during the Executive Leadership meeting. All Grants and cooperative agreements must be filed with the fiscal department. All expenditures must be approved prior to purchase / payment with sign off from Executive Director or Director of Finance.

This matter was investigated by both the AOS, the Allen County Auditor’s Office, and by board members of the RPC. GLCAP was met with and records from both RPC and GLCAP were scrutinized and matched. As a result, the duplicate payment made in the amount of $4,386 was returned by GLCAP to RPC and was deposited on 10/03/2024 into the Allen County Community Development Fund.

1. Implementation of Sage Accounting Software: We have since implemented a comprehensive financial accounting software system, Sage, which allows us to track expenditures more accurately and ensure compliance with federal grant requirements. The system includes built-in safeguards to flag non-compliant expenditures.

2. Review and Strengthening of Internal Controls: Life Source International Charter School will be implementing additional internal control systems & processes that include an additional review of back up documents before monthly reports are filed. A copy of all backup documents in support of all monthly reports will be kept at both Life Source International Charter School and the outside entities providing services and making reports on behalf of Life Source International Charter School.

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

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

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