Corrective Action Plans

SECTION III – FINDINGS – FEDERAL AWARD FINDINGS Finding 2023-001 – Activities Allowed/Unallowed, Costs Principles, and Period of Performance (Internal Controls Over Compliance) Significant Deficiency Criteria: Uniform Guidance 2 CFR, Part §200.313(a) requires that non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our review of the Coalition’s disbursements related to the Title V major program, we examined 40 transactions for internal controls over compliance. 2 of the 40 transactions examined did not contain sufficient evidence that a review and approval process was completed prior to payment being processed. Questioned Costs: None Cause: The Coalition does not have sufficiently established control policies and procedures to ensure proper approvals are obtained prior to the disbursement transactions being processed. Effect: Disbursements are being processed without proper approval, resulting in the possibility of disallowed expenditures. SECTION III – FINDINGS – FEDERAL AWARD FINDINGS Finding 2023-001 – Activities Allowed/Unallowed, Costs Principles, and Period of Performance (Internal Controls Over Compliance), continued Recommendation: We recommend the Coalition becomes familiar with requirements of 2 CFR, Part §200.313(a) and establishes appropriate internal control policies and procedures and that all staff be trained on those policies and procedures, so they are familiar with the requirements. We further recommend the Coalition does not process payment for disbursements that do not contain necessary approvals. Responsible Official: Carlett Gregory, CFO Corrective Action: In response to the finding regarding insufficient internal controls over compliance for disbursements related to the Title V major program, the Coalition will take the following corrective actions: 1. Review and Revise Policies and Procedures: o The Coalition will conduct a thorough review of our current internal control policies and procedures related to disbursements to ensure they align with the requirements of 2 CFR, Part §200.313(a). o We will revise and update our policies and procedures as necessary to ensure they are comprehensive and robust, providing clear guidelines for review and approval processes. 2. Training and Education: o We will provide additional training to all staff involved in the procurement process to ensure they are fully aware of the updated policies and procedures. o The training will cover the importance of obtaining proper approvals prior to processing payments and the specific requirements of 2 CFR, Part §200.313(a). 3. Implementation of Approval Controls: o We have implemented a standardized approval process for all disbursements, ensuring that each transaction is reviewed and approved by the designated authority before payment is processed. o We currently have in place a checklist to document the review and approval process for each transaction, ensuring that evidence of compliance is retained. 4. Monitoring and Compliance Checks: o We will establish regular monitoring and compliance checks to ensure adherence to the updated policies and procedures. o Quarterly internal audits will be conducted to verify that all disbursements are properly reviewed and approved according to the established guidelines. Timeline for Implementation: The corrective actions outlined above have been implemented. Training sessions will be part of the onboarding process and existing programs. It will also be reviewed as needed to address any changes.

May 28th, 2024 Christy White, Inc. 348 Olive Street San Diego, CA 92103 Response to Find in #2023-003: The Business Office, in coordination with the Purchasing Department, is developing a process to ensure that the appropriate approvals are obtained in the event that capital expenditures are charged to federal programs. The corrective action is expected to be implemented by June 30, 2023.

Lifespan agrees with the finding as departments did not consistently follow its equipment tracking, storage, and disposal policies and procedures related to equipment purchased with federal funding. The following steps will be taken to address the finding: All departments of Lifespan will receive a notice from the Office of Research Administration that equipment tags, proper storage, and timely disposal of equipment are an integral part of the internal control process for capital assets. The Office of Research Administration communication will be sent to all impacted departments by July 15, 2024 and office hours will be made available for any departments that have questions. Contact: Lifespan Office of Research Administration: Daniel Bryant, Director Research Operations 401-444-6893. DBryant@lifespan.org Mindy Marshall, Director Grants and Contracts 401-444-4487. MMarshall6@lifespan.org Leslie Simone, Research Information Systems 401-444-8696. LVarone@lifespan.org. Expected Implementation: July 15, 2024

Item 2023-002- Equipment and Real Property Management Recommendation: 2 CFR 200.303 requires the non-Federal entity to "(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non­ Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award." 2 CFR 200.313 and 2 CFR 200.439 requires that the following rules of allow ability must apply to equipment and other capital expenditures "Capital expenditures for special purpose equipment are allowable as direct costs, provided that items with a unit cost of $5,000 or more have the prior written approval of the Federal awarding agency or pass-through entity. The Chief School Financial Officer, Jessica Pettway, should review documentation for proper approval of equipment and real property prior to encumbrance. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.13 and CFR 200.439 relating to capital expenditures and agrees with the recommendation. Effective July 1, 2024, the Chief School Financial Officer, Jessica Pettway, will review for proper approval of equipment and real property prior to encumbrance.

The District of Columbia Public Schools (DCPS) agrees with the conditions and recommendations of this finding. Starting October 1, 2024, DCPS will conduct a districtwide physical inventory of assets and the results reconciled with the existing records at least once a year per the DCPS Technology Asset Management Policy. Contact - Cyrus Verrani, Chief of Data and Technology Estimated Completion Date - September 30, 2025 See Corrective Action Plan for chart/table

Federal Aid Policies Finding 2023-002 Auditor Description of Condition and Effect: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. As a result, the Authority is noncompliant with 2 CFR 200. Auditor Recommendation: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Corrective Action Plan: The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

Finding 2023-025 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626 - Inaccurate Inventory of Equipment Management Views DNR agrees with the finding. Planned Corrective Action DNR sent an email communication on May 7, 2024, to the Department Budget Control Team as a reminder to all divisions that the division inventory liaison will ensure that all capitalized equipment assets or special memo assets acquired have been tagged and recorded in the department inventory system. On a quarterly basis, the “Purchased Equipment Report” in BI will be used to identify purchases of equipment and verify that they have been recorded in the inventory system. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Houle, DNR

To address the discrepancy and ensure accurate capital asset records, the technology director will do a: 1. Physical Re-inventory: Conduct a comprehensive physical re-inventory of all capital assets, focusing on areas where misplaced items are suspected. 2. Records Reconciliation: Compare physical inventory findings with existing records. Identify and rectify any errors in location data, descriptions, or asset status. 3. Asset Tracking Improvement: Implement measures to improve asset tracking, such as: Updating asset tags with clear and accurate identification information; doing a major search to retire all old devices still in inventory; and cleaning out storage areas for all outdated assets. 4. Investigation: If theft or damage is found on any of these missing devices, an official investigation per the district's policies will occur.

Finding 2023-002 – Preparation and Maintenance of Equipment Population The single audit report included the following recommendation: To address the Condition identified above, we recommend Amtrak to continue integration of the systems in such a way that appropriate funding source would be tagged to each asset automatically and that required property records would automatically be consolidated into one system of record and updated in that system. Ensure that adequate IT interface and business process application controls over the completeness, accuracy, validity, confidentiality, and availability of transactions and data during application processing (input, processing, output, etc.) are in place. Additionally, management should consider breaking out large purchase orders containing multiple items of equipment and tools under one purchase request, by creating separate level 2 WBSE codes in order to distinguish between different types of items being acquired, in order to be able to provide more appropriate classification. Identification as a repeat finding: Not a repeat finding Management Response/Status of Action Plans: Amtrak will implement the following to mitigate the finding related to the equipment population. 1. To prevent errors regarding the mapping of grant funding to equipment, the Capital Accounting Department will be implementing additional procedures and validations in the preparation and approval of the equipment review population file. This will include additional cross checks to validate mappings from fund sources to equipment and an additional review by EAMDT. The additional review and approval steps will be formalized with documented steps before September 2024. 2. To prevent errors related to missing asset numbers, the Capital Accounting Department, in coordination with EAMDT, has implemented an additional review of the single audit eligible indicator and inclusion of an asset unit number at the time the equipment asset is recorded in the fixed asset ledger. Additionally, EAMDT and Capital Accounting are now utilizing automated reporting that allows real time review of single audit equipment additions and data fields from the Company’s systems. This reporting allows for a timely view of key data fields from the related systems including Asset Equipment Description, Asset Unit Number, Single Audit Flag, Last Audit Date and Conditions. All equipment with missing asset unit numbers will be investigated and corrected. If any equipment marked as single audit eligible appears as not being eligible, Capital Accounting will investigate and resolve. The contacts for this item are Carol Hanna, VP Controller and Michele Millsaps, Assistant Controller, Capital and Inventory Accounting. Amtrak anticipates that changes above will remediate this finding in the fiscal year ending September 30, 2024 and beyond.

Finding 2023-001 – Equipment and Real Property Management The single audit report included the following recommendation: We recommend that Amtrak continue to work toward a full integration or reconciliation between Amtrak’s fixed asset system of record and the different equipment-tracking systems. We recommend that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs. For example, Amtrak should consider an automated system report that would flag an asset proactively when a 2-year inventory deadline is approaching. During the observation process, management should ensure there is a review control within the process to validate that the asset is accurately tagged and such identifying information matches the equipment-tracking system. Additionally, this review control should also be performed when the asset is first logged into the equipment-tracking system. In the interim, until such processes are fully implemented, Amtrak should enhance the current control procedures surrounding the asset documentation and ensure that field personnel are aware of and are consistently and carefully updating the asset records such that clerical/human errors are minimized and that the asset records contain the necessary asset details in order to properly track equipment by federal requirements. This would include enhancing the asset chain of custody recordkeeping so that such changes are identified and reported timely. Additionally, management should consider requiring the serial number and model number to be documented in the system of record at set up in addition to the asset tag number. This will help ensure that the equipment has a unique ID number that can help it be identified and matched to the system record should an asset number not get added timely. Finally, as it relates to condition #4 above, management should investigate the root cause of the asset that could not be located and determine if additional control changes or modifications need to be made in order to prevent reoccurrence. Identification as a repeat finding: This finding was identified as a repeat finding in the immediate prior year as Finding 2022-001. This finding was reported in prior years as well, beginning in at least FY2012. Management Response/Status of Action Plans: Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Amtrak continues to progress on a multi-year effort to remediate this finding. Amtrak created the EAMDT which has been tasked to improve equipment record keeping which will resolve this finding. 1. In April 2024, Amtrak completed an engagement with an outside consulting firm that delivered three items: an updated Equipment Control Policy (ECP), standard operating procedures (SOPs) for equipment management based on the accountable property system of record, and a one-hour eLearning course that reinforces the importance of good equipment management practices and the need to follow the equipment tracking requirements of 2 CFR Part 200. These deliverables will improve policies and corporate governance over assets by providing training to the employees and improving the processes needed for oversight of equipment management, as well as to help ensure that assets are not capitalized without a complete record, which would include a unique asset identifier and the condition and location of the asset. The ECP was approved and published in the Amtrak Policy and Instruction Manual in May 2024. Amtrak will communicate the updated policy to all relevant personnel by the end of June 2024. The EAMDT is working with the Learning and Development team to identify the employees who will need to take the eLearning course, and these employees will be required to take the eLearning material beginning in the first quarter of FY25. 2. The EAMDT is implementing controls throughout the equipment lifecycle as it identifies improvement opportunities. For example, EAMDT has been added as an approver to the purchase requisition workflow for equipment purchases, and EAMDT is working with Capital Accounting to ensure that assets are recorded completely before being capitalized, which would include a unique asset identifier, condition, and location of the asset. EAMDT is reviewing assets currently in the system that do not have assigned asset IDs. EAMDT’s goal is to resolve and update existing records that are missing IDs and other information by the end of April 2025. Additionally, in August 2023, the Asset Disposition group began reporting into EAMDT which enables centralization of a more complete oversight of Amtrak’s assets. EAMDT is working to improve the record keeping for asset dispositions. 3. EAMDT is working with Amtrak’s Digital Technology (DT) Department to find ways to track equipment electronically. This includes installing location tracking technology on yard and Engineering Maintenance of Way equipment to better track and locate Amtrak assets. As of the end of April 2024, location tracking technology has been installed on over 1,500 pieces of equipment with the goal of having location tracking technology installed on approximately 2,400 assets by the end of June 2024. EAMDT is also coordinating with DT on an application accessible via a mobile device (e.g., cell phone, tablet) used by field personnel to perform audits and update equipment records. 4. EAMDT has developed trend reporting and operational reporting to help EAMDT and the departments track their compliance progress and identify assets that are out of compliance or soon-to-be out of compliance to both bring assets back into compliance, as well as to ensure an inventory is done and recorded within the two-year period. As of September 2023, two primary dashboards have been developed and can be used by all departments to help identify assets that are out of compliance and/or need to be audited. 5. EAMDT performs site visits to assist the equipment managers in performing equipment and vehicle audits. During these visits, equipment managers are educated on their responsibilities and tools available for performing audits. The contacts for this item are Ian Hinke, AVP Supply Chain Management and Robert Hoban, Director Asset Management. Amtrak anticipates the implementation of the above procedures, along with continual process monitoring and refinement, will fully remediate this finding by June 2026.

2023-002 – Equipment and Real Property Management Policy Planned Corrective Action: Management is working on creating and implementing policies and procedures surrounding equipment and real property management. Name of Contact Persons: Darla Burkett, Executive Director, Angie Warren, Finance Manager and Teri Ortiz, Grants Specialist Anticipated completion date: June 30, 2024

11-087-0040-26 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-_ 001__ Condition: The District's property records did not include all equipment purchased with Education Stabilization Funding. Plan: The District will assign an employee independent of the preparer, preferably with knowledge of applicable federal grant expenditures, to review the District's property records on a periodic basis to ensure the listing is complete and meets the requirements of 2 CFR section 200.313(d)(1). Anticipated Date of Completion: 06/30/2024 Name of Contact Person: Shane Schuricht Management Response: Management will implement the corrective action plan for the year ended June 30, 2024.

Health Center Infrastructure Support Equipment Physical Inventory Management’s Views and Corrective Action Plan Management’s View and Opinion Sunset Park agrees to establish a process, as required by OMB Uniform Guidance 2 CFR 200.313(d), to conduct a physical inventory of equipment and reconcile the results with the property records at least once every two years. Sunset Park is strongly committed to rectifying the oversight and will improve the internal control processes to prevent future occurrences. Corrective Action Plan Each year, between April and July, Sunset Park will conduct a physical inventory of equipment purchased with federal funding. The inventory listing will contain equipment records such as description, location, manufacturer's serial number, source of funding, purchase order/requisition information, cost, equipment condition, and disposition data. The Site Directors of Sunset Park will conduct and reconcile the results of the physical inspection with the inventory listing provided to them by the Grants Fiscal Department. Subsequently, the Site Directors will provide a dated and signed attestation to the Grants Fiscal Department and Director of Grants as evidence of the inventory. Any discrepancies will be further investigated and reported to the Director of Grants, the Site Director, and the Vice President of Finance for resolution. Timeline for Action Plan Date of Completion: 08/31/2024 Responsible Individual Leonardo Arias Email: Leonardo.Arias@nyulangone.org

The National Trail Local School District will be updating the School District’s inventory system to properly account for all property and equipment purchased using federal funds.

Personnel Responsible for Corrective Action: Policies and procedures will be supervised by Senior Accounting Specialist, Laura Froese, Facilities Operations Manager, Tiffany Durr, Grants Specialist, Westen Gehring Anticipated Completion Date: Equipment inventory listing of federally covered purchases will be completed by July 1, 2024 and reflected in the 2024 audit. Integration into Limble will start this fiscal year, but full installation of the new system has an anticipated completion date of January 1, 2025. Corrective Action Plan: The Land Institute will review grant expenses in the previous years and cross reference with existing equipment inventory to create a complete listing of equipment purchased with federal funds. Documentation demonstrating proper equipment procurement practices will be housed in the federal award folders for the grant covering the purchase cost. Additionally, The Land Institute is currently modernizing equipment tracking and inventory practices using Limble and will ensure that federal procurement tracking in compliance with uniform guidance standards is included in this practice. TLI purchased Limble on 10/20/2023 after a competitive review of similar CMMS’s (Computerized Maintenance Management Systems). Setup of the system will be completed by June 30, 2024. Beginning July 1, 2024 TLI will start implementation and training of new system with full adoption of the system tentatively planned for January 1, 2025.

Finding Number: 2023-001 Planned Corrective Action: The Emergency Prepardness Program Manager position has been turned over twice in the two-year period in which the physical inventory was to be performed. This last vacancy was four months and filled near the end of the two-year inventory cycle. During the audit it was discovered the physical inventory was i nthe planning stages but due to transition, the inventory was not completed. The schedule for completion did not get transferred to the new program manager. When it was discovered that the physical inventory had not been completed, plans were made to complete the physical inventory. To ensure ongoing compliance, the program manager has created an inventory calendar and plans to perform half the physical inventories in year one and the second half in the second year. The calendar is published in the ASPR Grant Teams site. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Christina Fozio, Emergency Preparedness Program Manager

Condition - The District did not maintain the proper property records as required under CFR Title 2, part 200.313(d). Plan - The District's Inventory Control sheet will be updated to include all of the required elements related to the Equipment and Real Property Management compliance requirements. Anticipated Date of Completion - 6/30/2024. Name of Contact Person - Tony Shinall, Superintendent. Management Response - There is no disagreement with this finding and the District will update the invenory control sheet to include all of the required elements to ensure the District is complying with the Equipment and Real Property compliance requirements.

51-084-0150-26 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-_ 002__ Condition: The District is not maintaining property records required by 2 CFR section 200.313(d)(1). Plan: The District will assign an employee, preferably with knowledge of applicable federal grant expenditures, to prepare and maintain the District's property records and ensure the listing is complete and meets the requirements of 2 CFR section 200.313(d)(1). Anticipated Date of Completion: 06/30/2024 Name of Contact Person: Tip Reedy Management Response: Management will implement the corrective action plan for the year ended June 30, 2024.

The School District will add the renovations to the health center to the inventory records.

Response: The District concurs with this finding. Deficiencies in the internal control activities adversely affected the District’s ability to record program expenditures in the District’s equipment subsidiary ledger. District management recognizes the importance of recording such expenditures so that these assets can accurately be tracked over time.

Corrective Action Taken: Corrective action has been implemented by the District to establish an internal control process for recording such assets. The Business Manager ensures that items are coded correctly upon purchase and that related documentation is forwarded to the District’s fixed asset supervisor, who then records the items to the equipment subsidiary ledger in a timely manner. Periodic reports are run by the Business Manager to verify that all required items have been entered.

Finding No.: 2023 – 005 Condition: The District does not currently maintain a detailed accounting/list of its capital assets, including Federal assets. The District does not have a recent replacement cost valuation for insurance purposes. Plan: The district has allocated internal business office resources to perform a detailed inventory and accounting of capital assets and Federal assets. Anticipated Date of Completion: May 31, 2024 Name of Contact Person: Christopher Blomquist, CSBO Management Response: See plan above

Finding Number: 2023-002 Planned Corrective Action: Management will update the District’s inventory records to include the six new school buses. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Dan Russomanno, Treasurer

CORRECTIVE ACTION PLAN December 7, 2023 Kansas State Department of Education and Kansas State Department of Administration Unified School District Number 214 respectfully submits the following corrective action plan for the year ended June 30, 2023. Dirks, Anthony & Duncan, LLC Po Box 885 Ulysses, KS 67880 Audit Period: June 30, 2023 FINDINGS – FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Education Passed Through Kansas State Department of Education Program Name: Education Stabilization Fund Cluster Federal Assistance Listing Numbers: 84.425W, 84.425U, 84.425D Finding 2023-001 Recommendations: The Board of Directors, the Director and key positions of management should adequately document internal control procedures for equipment inventory, log maintenance, and dispositions requirements consistent with 2 CFR sections 200.313(c) through (e). Board should then periodically check that all procedures agreed upon are operational and effective, and adjust procedures as needed. Action Taken: We agree with the recommendation. Our targeted implementation date is March 2024. If the Kansas State Department of Education and/or Kansas State Department of Administration has questions regarding this plan, please call Corey Burton at 620-356-3655. Sincerely yours, Corey Burton Superintendent

Finding 2023-002. Inventory Management Corrective Action: Due to staff turnover at the school, this task was not completed. Management will undertake the inventory of fixed assets. Responsible Person/Position: Rod Iberg/COO