Corrective Action Plans

2023-005 – Equipment and Real Property Management Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will immediately conduct a physical inventory of all items listed on its capital asset listing. • Once a physical inventory has been taken, CBNHC will create an effective property record which includes the description of the property, a CBNHC serial number, the funding source for the acquisition of the property (including the Assistance Listing Number), and the relevant title information, acquisition date and cost. • CBNHC will thereafter assign department managers responsible for the custodianship of the said equipment/property. • At the end of each fiscal year, CBNHC will conduct a physical inventory and maintain evidence in its accounting files. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Accounting Technician (Charlotte Sandoval) – Is responsible for scheduling and performing the physical inventory inspection. • Accounting Supervisor (Candyce Guerro) – Is responsible for coordinating the custodial assignment of the CBNHC’s property and equipment. • Interim Finance Director/Chief Operations Officer (Volelle Zamora) – Is responsible for ensuring the completion of the physical inventory on an annual basis. Completion Date: CBNHC will perform its physical inventory immediately, with completion by September 30, 2024. Thereafter, the physical inventory count will be performed annually before the last day of the calendar year.

Corrective Action: Monroe County Schools will take the following corrective actions to improve the equipment and real property management – ESSER: • The Board will develop a policy with guidelines detailing proper inventory of real property and equipment. This policy will include maintaining inventory of items purchased with federal funds. • A detailed inventory listing for all real property and equipment, including those acquired under the COVID-19 American Rescue Plan ESSER program will be developed. • The listing will be updated through annual physical inventory. Effective Date: November 30, 2024 Person(s) Responsible: CSBO & Director of Federal Programs, Monroe County Schools

Recommendation: We recommend the Entity enhance the design of its control activities and policies and procedures should be developed to ensure physical inventories are taken at least once every two years. Action Taken: The Organization understands the importance of regular physical inventories and will implement this control activity for the June 30, 2023 fiscal year end. Responsible Person: John Clemons, Chief Financial Officer Timelines for implementation: July 31, 2023

The District will communicate with the team at DESE to determine what is needed to bring all files current.

The District understands fully that all state and federal spending must follow guidelines set forth in the grant or amount allocated.

Accounts payable will not release funds until all guidelines and documents are secured and attached to the Purchase Card of Purchase Order form. The district has appointed a different Federal Program Coordinator and this action has been practiced since January 2, 2024.

The District will conduct a training to inform supervisors what forms and guidelines are required prior to the release of any monies by the end of July 2024.

ALN: 20.509, Corrective Action Plan: Noncompliance with Federal Procurement Requirements - MDT - The Montana Department of Transportation has hired new leadership for the Transit Section, who are actively working with the Federal Transit Administration (FTA) and the subrecipients to formalize procedures, document oversight measures, and correct the deficiencies. Person(s) Responsible for Corrective Measures: Rob Stapley, Administrator, Montana Department of Transportation, Target Date: 06/30/2025

ALN: Various R&D, Corrective Action Plan: Equipment Inventory Controls - MSU - Montana State University - Bozeman will enhance the internal controls surrounding the capital asset inventory and tagging process, including accessing research space to count and tag new assets. The university had a difficult time over the pandemic in retaining employees and hiring replacements. There were also difficulties accessing space on campus due to social distancing requirements. The university has been able to hire employees in Property Management and expects the pandemic-related challenges to be minimal moving forward. Person(s) Responsible for Corrective Measures: Aaron Mitchell, Associate Vice President for Financial Services, Montana State University, Target Date: 12/31/2024

ALN: Various R&D, Corrective Action Plan: Equipment Inventory Controls - UM - The University of Montana - Missoula has strengthened internal controls by hiring an Account Analyst to manage asset tagging and to conduct comprehensive reviews to ensure all assets are tagged and accounted. The Account Analyst will be assisted by an intern to conduct a thorough review to verify and update the status of all assets. Person(s) Responsible for Corrective Measures: Rachel Buswell, Controller, University of Montana - Missoula, Target Date: 09/30/2024

Response to "2023 - 003 Finding: Activities Allowed/Unallowed and Cost Principles (Compliance; Internal Controls Over Compliance)" Yankton Transit will become familiar with the requirements of 2 CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on those policies and procedures.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – COVID-19 – EDUCATION STABILIZATION FUND (FEDERAL ALN 84.425) 2023-003 Internal Control Over Compliance With Equipment and Real Property Management Requirements Finding Summary 2 CFR § 200.313(d)(1) requires the Academy to designate fixed assets purchased under federal programs and to maintain related property records, including a description of the property, a serial number or other unique identification number, the source of funding for the property (including the federal Assistance Listing Number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use, and condition of the property, and any ultimate disposition data, including the date of disposal and sale price of the property. During our audit, we noted that the Academy did not have sufficient controls in place within the COVID-19 – Education Stabilization Fund federal program to specifically identify federally-funded fixed assets and maintain the required records as noted above to assure compliance with federal equipment and real property management requirements. Corrective Action Plan Actions Planned – The Academy plans to review its internal control procedures to ensure future compliance with the federal compliance requirements specific to equipment and real property management for the COVID-19 – Education Stabilization Fund federal program. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will ensure that federally-funded fixed assets are distinguishable within the Academy’s finance system. The Academy also intends to review its control procedures relating to equipment and real property management requirements to ensure compliance for future federal awards expenditures.

Name of Auditee: Town of Alexander, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: David Miller, Supervisor Phone: 585-591-2455 (2) Audit Finding 2023-002 - The Town did not have accurate capital asset records. (a) Implementation Plan of Actions - The Town is looking into capital asset software and is having a physical inventory performed. (b) Implementation Date - This will be implemented for the year ended December 31, 2024. (c) Persons Responsible for Implementation - The Town Board and Supervisor of the Town of Alexander.

Recommendation: The auditor recommends the City enhance the design of its control activities and create a tool to assist in tracking and maintaining equipment purchased with federal funds. Additionally, the employees responsible for the inventory count should be trained to ensure understanding of the Uniform Guidance requirements relevant to equipment and real property management. Periodic review should also be designed to evaluate compliance with the relevant requirements. Action Taken: The City agrees with this finding. In November 2022 (about 5 months into FY23) the City hired a new Airport Manager with substantial experience managing municipal airports and overseeing federal funding for airports. During FY23 the long‐time Administrative Manager at the Airport separated without notice from the City and other staff were unable to access needed files which included equipment records. In FY24 the Airport Manager hired a heavy equipment mechanic. This position is responsible for tracking, maintaining, and repairing Airport equipment. Logbooks are now being kept for all equipment. In CY24 the Finance Director and the Accounting Officer will work with the Airport staff to improve internal controls over equipment purchased with federal funds. Policies and procedures will be developed to ensure that an accurate physical inventory is conducted timely, and that assets are removed from the asset listing when they are disposed of. Tools will be developed to facilitate tracking and maintaining equipment purchased with federal funds. In CY24 the City will provide Uniform Guidance training to staff which will include capital assets and equipment information. The City is in the process of identifying a vendor to contract with Airport to assist with federal compliance and provide training to Airport staff on relevant Uniform Guidance requirements. The vendor’s scope of work will also include helping with developing and documenting standard opera􀆟ng procedures related to equipment and real property management. Due Date of Completion: December 31, 2024 Responsible Official: Emily Oster - Finance Director, James Harries - Airport Manager, Jerome Sanchez - Airport Heavy Equipment Mechanic, Matthew Bonifer - Accounting Officer, Grants Manager (in recruitment)

Planned Corrective Action: The District confirms the audit finding and will implement policies and procedures, as well as staff training, to ensure compliance with the ES fund. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Matthew Bryant, Director of Facilities

Research and Development – Assistance Listing No. Various Recommendation: We recommend the University ensure that a physical inventory over equipment is completed at least every two years. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Langston will strengthen its equipment inventory practices ensuring that a physical count is completed at least every two years. Name(s) of the contact person(s) responsible for corrective action: Mr. Chris Kuwitzky, Vice President for Fiscal and Administrative Affairs. Planned completion date for corrective action plan: June 2024

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.