Corrective Action Plans

2023-002 – Equipment Management Cluster: Research and Development Cluster (“R&D Cluster”) Grantor: Various - All R&D Cluster awards with equipment Award Name: Various - All R&D Cluster awards with equipment Award Year: FY2023 Assistance Listing Number: Various – All R&D Cluster awards with equipment. Pass-through entities and ID Number: Various - All R&D Cluster awards with equipment Management acknowledges that, while a physical inventory of equipment is performed at least every two years, reconciliation procedures and documentation of such reconciliation can be improved. Specifically, by June 30, 2024, an aggregated listing of federally funded equipment will be maintained and reconciled to the results of the third-party equipment inventory and will ensure that all federally funded equipment has been counted within the last two years. Further, follow-up inquiries related to assets included in the University’s aggregated listing, but not identified during the third-party inventory observation will be documented and aggregated as well. Lastly, new equipment identified during the third-party inventory observation which is not included on the University’s aggregated listing of federally funded equipment, potentially because it is below the capitalization threshold or is not federally funded, will be investigated to ensure proper exclusion with results documented. These updated processes will be implemented jointly by the Capital Asset Administrator and Associate Director of Research Administration Compliance.

Finding 2023-003 Recommendation: We recommend that management resume the inventory counting every two years View of Responsible Officials and Planned Corrective Actions: The University will immediately resume biannual physical inventory review and count on a regular schedule. Individual Responsible for Corrective Action: Thomas Kaeo, Director, Office of Research Services, 610-660-1206, tkaeo@sju.edu Anticipated Completion Date for Corrective Action: The Planned Corrective Actions will be immediately implemented

CORRECTIVE ACTION PLAN AUDITOR FINDING: 2023-001 AREA: Equipment Compliance It was noted that (1) equipment records were not maintained in accordance to 2 CFR 200.313, in which equipment is not identifiable with serial numbers or tags; (2) internal controls were not in place to safeguard equipment at various locations. It is recommended for the Organization to tag all equipment and perform a physical inventory count in order to create a complete equipment listing within its asset management system. In addition, it is advised for the client to create an agreement between Organization and location/holder of property that clarifies ownership as well as compliance requirements for equipment purchased with federal funds with respect to safeguarding and maintaining such equipment. Lastly, for the Organization to establish an equipment policy and train grant managers in the requirements associated with equipment management and federal compliance requirements. CLIENT PLANNED ACTION: The Organization agrees with the finding. All equipment will be tagged in order to specifically identify it and alert that it was purchased with federal funds, and to aid in inventory control. A subaward document has been created that clarifies ownership, compliance requirements, and the need to safeguard and maintain equipment received. This will be presented to and signed by each organization who receives equipment purchased with federal funds through Billings Clinic. Grant managers that are in charge of purchasing equipment for other sites under the conditions of a federal grant, will be trained in the requirements associated with equipment management and federal compliance requirements. The grant manager will maintain an equipment list of all items with required information, including identifying number, location placed, etc. CLIENT RESPONSIBLE PARTY: Stephanie Fitch, Grant Manager COMPLETION DATE: October 1, 2023

Finding 2022-011 Fixed Asset Inventory Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Michelle Thomas, Acting Executive Director; Program Directors; Enterprise Managers; and Rona Johnson-Murillo, Accounting Director. Action: Compile inventory listing by July 1st of each fiscal year. Anticipated Completion Date: March 2026.

2022-003—EQUIPMENT MANAGEMENT (EQUIPMENT IDENTIFICATION/TAGGING) Response: Management concurs with the finding. Corrective Action Plan: Management will update written property and equipment procedures to require tagging of all federally funded equipment upon receipt. The Innovation Program Manager will be responsible for tagging equipment, maintaining property records, and performing at least annual inventory and tagging reviews. All existing federally funded equipment currently in use, including the TVAC machine, will be reviewed and appropriately tagged. Designation of Employee Position Responsible for Meeting Deadline: Innovation Program Manager — by January 31, 2023.

Recommendation: We recommend the College implement policies and procedures to ensure all property and equipment purchased with federal funds includes such information in the property records to comply with the requirement, and physical inventory be taken every two years. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has begun to explore the Asset Module in the Jenzabar platform, with the goal that Procurement is the first stage of our property tracking. Work continues to be a challenge in this area as we are short staffed. The Business Office Staff will continue to work with the Purchasing staff to identify how best to proceed with this requirement. The College currently has Policies that speak to Assets and the recording of such. The College will strengthen the specifics of what an Asset listing is to include. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Charles Roberts, Purchasing Manager, and Paul Roberts, Fiscal Technician/Receiving Planned completion date for corrective action plan: March 31, 2025

Finding No.: 2022-015 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Equipment and Real Property Management Questioned Costs: Unknown Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Geraldine Cruz, Procurement Services Director Corrective Action Plan: The Procurement Services Division agrees with this finding. The CNMI has recently implemented the MUNIS Financial Management System to improve recordkeeping and compliance processes. All equipment and real property records acquired with federal funds will now be entered, tracked, and maintained within MUNIS. Supporting documentation will also be filed in accordance with standardized retention procedures to ensure that accurate and sufficient audit evidence is readily available. Current staff are undergoing formal training on the use of the MUNIS system, with particular emphasis on modules related to asset and property management. This training will ensure staff are fully capable of inputting, maintaining, and retrieving compliance-related records to support audit readiness. The CNMI is actively working on completing the FAIR (Federal Asset Inventory & Reconciliation) project, which aims to reconcile all existing federal property records. Upon completion of this project, a random physical inventory of federal property assets will be conducted to verify accuracy and completeness of records within the system. Results will be documented and used to address any discrepancies. Corrective Action Plan: To support sustained compliance, CNMI will develop internal procedures that align with federal property management regulations. These procedures will define roles and responsibilities, documentation requirements, and timelines for conducting regular physical inventories and system updates. Proposed Completion Date: June 30, 2026

Equipment and Real Property Management College of the Marshall Islands acknowledges the finding and confirms that a new system has been put in place to transition from manual to automated processes for improved recordkeeping and monitoring. The College has implemented the MIP Fixed Asset Module to maintain complete and accurate capital asset records, conduct timely reconciliations, and strengthen asset safeguarding controls. Internal procedures have been enhanced to ensure periodic physical inventory, prompt updates, and independent reviews of capital asset records. The full reconciliation and migration of all capital asset data into the new system is actively ongoing and scheduled to be completed by December 2025. These measures will ensure compliance with federal property management requirements and prevent recurrence of similar issues in the future.

The Government concurs with the auditor's findings and recommendations. The Epidemiology Division has established robust procedures to manage and monitor property and equipment effectively, adhering to Property and Procurement guidelines. All equipment is meticulously inventoried, and employees sign acknowledgment forms listing the items assigned to them, such as laptops or cell phones, with serial numbers clearly documented and safeguarded. However, DOH recognize the need for improved coordination between the Epidemiology Division and Property and Procurement. To enhance asset management, the Department of Health will update our Fixed Asset SOP to require that each division shares its asset inventory with Property and Procurement on a quarterly basis, ensuring more accurate and up-to-date records.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the finding regarding the management and documentation of federally funded equipment. VIDE will ensure the reliability of its asset tracking system and ensure the maintenance of a centralized record of all assets acquired with federal funds, to include property description, serial number or other identification number, source of property, titleholder, acquisition date, cost of the property, percentage of Federal participation, location, use and condition of the property, and disposition information. The Procurement Division will schedule quarterly inventory audits and reconciliation processes to ensure all federal program assets are accounted for and that records align with actual inventory. Any discrepancies identified during these audits will be resolved promptly. The Fixed Asset Director will create a protocol to facilitate regular communication and updates among Programs/Divisions responsible for asset acquisition, maintenance, and recordkeeping. Monthly status reports on federal asset records will be required from each Program/Division to ensure data accuracy and timely updates.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the finding regarding the management and documentation of federally funded equipment. VIDE will ensure the reliability of its asset tracking system and ensure the maintenance of a centralized record of all assets acquired with federal funds, to include property description, serial number or other identification number, source of property, titleholder, acquisition date, cost of the property, percentage of Federal participation, location, use and condition of the property, and disposition information. The Procurement Division will schedule quarterly inventory audits and reconciliation processes to ensure all federal program assets are accounted for and that records align with actual inventory. Any discrepancies identified during these audits will be resolved promptly. The Fixed Asset Director will create a protocol to facilitate regular communication and updates among Programs/Divisions responsible for asset acquisition, maintenance, and recordkeeping. Monthly status reports on federal asset records will be required from each Program/Division to ensure data accuracy and timely updates.

The Government concurs with the auditor's findings and recommendations. The Asset Management Division (AMD) has consistently followed Federal equipment and maintenance guidelines. Assets are tagged, and records are created using the Tyler Munis Resource Planning system (ERP). The serial numbers, model numbers, acquisition dates, cost of equipment, and agency that received the items are included. In 2022, AMD conducted inventory for four agencies, ensuring that all assets were accounted for and managed according to Federal regulations. Additionally, AMD have completed the Standard Operation Policies and Procedures (SOPP), which is currently in the approval process. Implementing SOPP is essential to enhancing internal controls and ensuring compliance with Federal regulations. Training sessions will be conducted for fixed assets employees across all Government agencies to provide detailed insights and updates on the processes. It has been identified that additional staff will be required to support this initiative effectively.

Finding Reference Number: SA 2022-006 Equipment Management AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-15-MC-06-0037, B-16-MC-06-0037, B-17-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037, B-21-MC-06-0037 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Jennifer Block, Management Analyst Kiranjeet Sanghera, Finance Manager • Corrective Action Plan: The City will update its capital assets records to specify funding source. Procedures will be developed to meet physical inventory requirements. • Anticipated Completion Date: October 2025

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compliance Requirements: Equipment and Real Property Management Audit Findings: Significant Deficiency Condition: An effective internal control system was not in place at the City to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The City did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the capital asset listing is maintained throughout the year and CIP is tracked. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

RECOMMENDATION: Create a property management system and adopted written policies and procedures. These procedures should be reviewed and updated to, at a minimum, adhere to the newest federal guidelines under OMB Uniform Guidance. Physical inventories should be performed periodically and reconciled to the property management records. Property management records should also include copies of the original asset purchase documentation. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

January 31, 2025 To Whom it May Concern: The City of Harrisburg, Pennsylvania respectfully submits the following summarized corrective action plan for the Fiscal year ending December 31, 2022. The Audit Report was prepared by Boyer & Ritter LLC, Certified Public Accountants and Consultants, 211 House Avenue Camp Hill, PA 17011. Related findings are described in detail as contained within the City’s Single Audit Report, schedule of findings and questioned costs, and such are numbered in the corrective action plan in accordance with that assigned in the schedule. Any questions regarding this plan can be directed to Bryan McCutcheon, Accounting Manager at bmccutcheon@harrisburgpa.gov. Bryan McCutcheon, Accounting Manager City of Harrisburg Building and Housing Development Director of Housing and Economic Development, and Accounting Manager By or before 12/31/20025 Expenditures of CDBG grant funding for capital outlays on equipment and real property are readily identifiable within the City’s fixed assets module of the accounting system, including subsequent retirements of any such capital assets. The Department acknowledges related physical inventory observations to identify these assets have not been consistently performed and will work to formalize such inventory procedures. The City will look to complete such process as soon as is feasibly possible.

2022 – 009: Activities Allowed and Unallowed, Allowable Costs, Period of Availability (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008 and 2021-007) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 15.030 Indian Law Enforcement ALN 93.575 Child Care and Development Block Grant ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, we selected 120 transactions for testing from each major program. The following number of transactions were not provided for our review during the audit: ALN 93.441 – Indian Self Determination – 47 transactions ALN 20.205 – Highway Planning and Construction - 11 transactions ALN 15.030 – Indian Law Enforcement – 8 transactions ALN 93.575 – Child Care and Development Block Grant – 22 transactions ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds – 9 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year.

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will update its property records to include all required information. Additionally, the Organization plans to complete a physical inventory count and related reconciliation on an annual basis. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date October 31, 2024

Management will assign personnel responsible for the monitoring of all Federal funded equipments and establish internal control policies and procedures to perform the required physical inventory and reconciliation of all equipment and real properties acquired from Federal funds at least every year.

Procedures and policies surrounding equipment and real property management, physical inventory and data retention are being reviewed and updated to ensure requirements under Uniform Guidance are met.

We are currently working on a project to integrate the accounting system in the warehouse and Receiving module with the property module that will significantly improve the accuracy of asset management. With this action we will establish a communication protocol between these systems and ensures that equipment and property are meticulously tracked and reconciled. This seamless integration will not only streamline the recording process, but also provide a reliable method for maintaining the integrity of the general ledger. We expect to have this integration by the end of 2024.

Finding 2022-013 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will work to achieve compliance with the requirements outlined in 2 CRF Sections 200.313. Specifically, Management will enhance controls over the review and disposal of equipment and real property and enhance supervisory reviews over this accounting function. Anticipated Completion Date: December 31, 2024

Finding 2022-012 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Further, staff will perform regular reconciliations for the equipment and real property listing to ensure that its accuracy is maintained. Anticipated Completion Date: December 31, 2024

Finding 2022-011 Equipment and Real Property Management - Material Noncompliance and Material Weakness in Internal Controls Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Further, staff will perform regular reconciliations for the equipment and real property listing to ensure that its accuracy is maintained. Anticipated Completion Date: December 31, 2024