Corrective Action Plans

Noncompliant Fixed-Amount Subawards - Immunization - DPHHS - The Montana Department of Public Health and Human Services does not concur. All subawards, including those referenced in the finding, were explicitly listed in the federally approved budget documents and the Notice of Award (NOA). These materials contained the subaward amounts that the auditors questioned and were formally reviewed and approved by the Centers for Disease Control and Prevention (CDC). The approval included the fixed-amount subaward methodology and the department’s planned use of funds. In addition, the CDC conducted a technical review during the same period and identified no findings or compliance issues, including none related to fixed-amount subawards or internal controls. In September 2025, the department consulted program officials at the CDC, who reaffirmed that the approved NOAs and budgets are sufficient evidence of federal approval and compliance. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - N/A

The Partnership will develop and implement comprehensive written subrecipient monitoring and procurement policies aligned with Uniform Guidance. Procedures will include verification of suspension and debarment status (e.g., SAM.gov), incorporation of required compliance terms in subaward agreements, tracking of subrecipient funding by program, implementation of a risk-based monitoring framework, and documentation of monitoring activities including financial and programmatic reviews. Staff will be trained on these updated procedures, and compliance reviews will be centralized within the finance and administrative function.

Recommendation: We recommend the SNP reviews its internal controls and policies to ensure all students receiving benefits have an application, or other supporting documentation, on file to support their eligibility. Action taken in response to finding: Management acknowledges the finding and will revise and formalize internal controls as follows: • Eligibility Documentation Procedures: Develop a standardized checklist to confirm required documentation is obtained, reviewed and retained prior to approval. • Centralize Review and Approval Process: A designated reviewer will be responsible for verifying completeness and accuracy of all eligibility determinations. Approval will be formally documented. • Record Retention Controls: Management will establish controls to ensure that all eligibility documentation is: Properly maintained, readily accessible for audit or review and retained in accordance with federal, state and organization-wide policy. • Personnel Training: Training will be conducted annually and upon onboarding new personnel. Name of the contact person responsible for corrective action: Sean Jernigan, Chief of Operational Vitality, Department of Catholic Schools, Archdiocese of Los Angeles Planned completion date for corrective action plan: • Procedure and checklist implementation: Within 30 days of financial statement issuance • Staff training: Within 60 days of financial statement issuance • Full implementation and evidence of operation: 90 days of financial statement issuance

The organization has developed and implemented a standardized documentation process to ensure that all data submitted is fully supported and traceable to source documentation. Responsible staff have been trained to retain and reference appropriate supporting records for each data element prior to submission. A supervisory review step has been added to verify that documentation is complete, accurate, and clearly tied to the reported data before final submission.

Finding 2025-006 Subrecipient Monitoring Federal Agency Name: Department of Health and Human Services Pass-Through En􀆟ty: Iowa Department of Health and Human Services Assistance Lis􀆟ng Number: 93.069 Program Name: Public Health Emergency Preparedness Finding Summary: The County did not formally communicate the required informa􀆟on to the subrecipient. No subrecipient agreement was executed. In addi􀆟on, no monitoring ac􀆟vi􀆟es were documented. Responsible Individuals: Amber Shepard, Budget Director Correc􀆟ve Ac􀆟on Plan: Clinton County is working with Genesis Health System on implemen􀆟ng a subrecipient agreement and will put a control process in place to monitor An􀆟cipated Comple􀆟on Date: June 30, 2026

The District agrees with this finding and will implement the following:  Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling.  Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of the population used to calculate and select samples.  Internal Review Process o Establish manual review process to confirm all required documentation and applications are retained and accurately represent the population.

Finding Number 2024-111 Subject Heading (Financial) or AL no. and program name (Federal) 93.323: Epidemiology and Laboratory Capacity for Infectious Diseases Planned Corrective Action Management agrees with this finding. To mitigate this issue going forward, the established network drive for FFR supporting documentation retention will now be reviewed at closeout of each FFR to ensure all detailed schedules are centrally retained and accessible prior to certification. Anticipated Completion Date 6/30/2026 Responsible Contact Person Kimberly Courtney, Director of Accounting

Finding Number 2024-110 Subject Heading (Financial) or AL no. and program name (Federal) 93.268: Immunizations Cooperative Agreements Planned Corrective Action Management agrees with this finding. To mitigate this issue going forward, the established network drive for FFR supporting documentation retention will now be reviewed at closeout of each FFR to ensure all detailed schedules are centrally retained and accessible prior to certification. Anticipated Completion Date 6/30/2026 Responsible Contact Person Kimberly Courtney, Director of Accounting

Finding 2024-005: Reporting (Title V, CFDA 93.U01) Material Weakness (Repeat Finding: 2021-005, 2022-005, 2023-005) Condition: The Organization could not provide required Title Vreports, including the financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards report, and property inventory. Corrective Action: • Build a federal reportingcalendar listing every required Title Vreport, its due date, data source, and responsible preparer. • Assign a designated preparer and a second-level reviewer for each report prior to submission. • Retain a copy of each submitted report, with the submission confirmation, in a centralized compliance file. • Provide staff training on Title V reporting obligations and the underlying contract requirements. Responsible Party: Chief Financial Officer/ Grant Director Anticipated Completion Date: Reporting calendar in place by October 15, 2026; first fully compliant reporting cycle Q1 2027

Finding 2024-004: Procurement and Suspension and Debarment (Title V, CFDA 93.U01) Material Weakness (Repeat Finding: 2021-004, 2022-004, 2023-004)Condition: Because Title V expenditures lacked transaction-level detail, the auditor could not select procurement transactions for testing or verify that vendors were screened for suspension/debarment prior to contract award. Corrective Action: • Adopt a written procurement policy aligned with Uniform Guidance thresholds (micro-purchase, simplified acquisition, formalprocurement); this policy is in progress and pendingboard approval. • Require and document a System for Award Management (SAM.gov) check, or an equivalent vendor certification, before anyfederally funded contract or purchase order is issued. • Retain SAM.gov screening printouts/certifications with the procurement file for each Title V vendor. • Apply the GLrestructuring from Finding 2024-003 so procurement transactions are individually identifiable for testing. Responsible Party: Chief Financial Officer Anticipated Completion Date: Procurement policy adopted by November 15, 2026; SAM screening process in effect for all new Title V vendors by December 1, 2026

Finding 2024-003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Title V, C FDA 93. U0 1) Material Weakness (Repeat Finding: 2021-003, 2022-003, 2023-003) Condition: Title V expenditures were recorded through summary journal entries without transactionlevel detail, preventing the auditor from selecting a valid sample or testing compliance. A disclaimed opinion on compliance was issued for this major program. Questioned costs are undetermined due to scope limitation. Corrective Action: • Restructure the chart of accounts/ GL coding so every Title V transaction is individually recorded and traceable to source documentation, rather than aggregated into journal entries. • Require program/grant coding at the point of transaction entry (accounts payable, payroll allocation, purchasing) rather than after the fact. • Implement a quarterly internal review reconciling Title V ledger detail to the approved Title V budget and contract terms. • Provide finance staff training on Uniform Guidance recordkeeping requirements (2 CFR §200.302, §200.333) specific to federal award transactions. Responsible Party: Chief Financial Officer Anticipated Completion Date: GL restructuring to be implemented concurrent with the Organization's new fund accounting system (Blackbaud Financial Edge NXT), implementation kickoff August 13, 2026; complete by March 31, 2027, with the first fully traceable Title V transaction month in April 2027

Finding #2024-002 – Lack of Subrecipient Monitoring Description of Finding: The Town passed through approximately $1,650,000 in federal funds to a local electric Co-op for broadband infrastructure installation. The Town did not perform subrecipient monitoring specific to this award by identifying applicable requirements for the award after the disbursement of these funds. Statement of Concurrence of Nonconcurrence: The Town concurs that applicable requirements for the award were not identified for the subrecipient, however the Town did monitor activities of the subrecipient. The Town monitored activities to ensure funds were used for allowable activities. Contact Person: Courtney Delaney, Town Administrator Planned Corrective Action: Establish and implement a formal subrecipient monitoring process for all federal funds passed through to other entities. Seek guidance from the awarding agency if responsibilities are unclear. Anticipated Completion Date: The Town has been in regular communication with the awarding agency and established clarity as to applicable terms and conditions as of this date. The Town is working to establish and implement a formal monitoring process and anticipates completion no later than December 31, 2025.

Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount transposed with the amount of another federal program. This resulted in an over-request of a material amount on the Ryan White Program. Duplicate Invoice Reimbursement: An invoice was requested and received for reimbursement on a prior drawdown and was subsequently included again in a draw after year-end, resulting in a duplicate reimbursement. Incomplete Expenditure Tracking: The entity did not have a complete system for tracking all expenditures eligible for reimbursement. The drawdown process was limited to cash disbursement and payroll transactions and excluded expenditures incurred and recorded by journal entries. This resulted in the entity having unreimbursed expenditures that could have offset the over-requests noted above. Corrective Action Plan: To correct the deficiency, we are implementing a plan focused on establishing a review and approval process for all drawdown requests and revising our policies to ensure that all eligible incurred expenditures are properly captured and reconciled, thereby assuring strict compliance with federal cash management regulations and preventing federal funds from exceeding our immediate needs. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.

2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.

FINDING 2024-001 Finding Subject: 20.205 Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Commissioner Ron Jarman, Auditor Tammy Justice Contact Phone Number and Email Address: 765.745.0013, rjarman@rushcounty.in.gov; 765.932.2077, auditor@rushcounty.in.gov Views of Responsible Officials: Rush County concurs with the finding. Description of Corrective Action Plan: The Commissioners will create a Procurement, Suspension & Debarment Policy with all necessary requirements. Anticipated Completion Date: September 2025

The District will aggregate and reconcile all application documentation and scan all supporting documentation and place in a secured central location electronically and/or physically.

The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. Condition #1 - All FFRs and corresponding programmatic and financial reports will be reviewed by the Accountant, the Accounting Officer, the Agency Fiscal Officer, the Budget staff, and the Grants Program Manager prior to submission to the Federal government. OCFO will utilize a grants matrix that will reflect the respective grants due dates to ensure timely filing of FFRs. The matrix will be reviewed to ensure compliance monthly with each Accountant during the monthly analysis and review process. Condition #2 -DBH will save the SOR tracking sheet that is used to calculate the earmarked amounts for administrative and data costs for the Federal programmatic reports. This will be retained in a central location. Condition #3 - Prior to the submission of the SEFA, the grant expenditures will be reviewed with the Accounting Officer, the AFO, and the Grants program manager for a detailed review of the SEFA to confirm expenditures are correctly categorized by fund and grant, reconciles to the financial system and reflects the amount expended for sub-recipients. Contact: FFR (SF-425) and SEFA: Barbara S. Roberson, Accounting Officer, Human Support Services Cluster PPR Reporting: Sharon Hunt, State Opioid Treatment Authority, DBH Estimated Completion Date: September 2025 See Corrective Action Plan for chart/table

The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are issued promptly after the drawdown is made.

The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written internal procedures to ensure that payments are issued promptly after the drawdown is made.

The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are issued promptly after the drawdown is made.

Contact Person Responsible for Corrective Action: Dr. Tammy Rowshandel, Chief Accountability Officer Contact Phone Number: 812-462-4224 Views of Responsible Official: The School Corporation's management will establish an effective system of internal control to ensure compliance and comply with the grant agreement and the Special Tests and Provisions - Annual Report Card, High School Graduation Rate compliance requirement. Description of Corrective Action Plan: A system will be put in place that ensures compliance with the Special Tests and Provisions-Annual Report Card, High School Graduation Rate requirements. Records will be retained for audit so that appropriate documentation is available to substantiate all future reporting. Building registrars will enter state exit codes for students and upload documentation to substantiate the exit codes that are chosen. Once the documents are uploaded, the registrars will place the word “AUDIT” in the withdrawal comments. This indicates the exit is now audit ready. Schools will conduct regular internal cohort audits. Comparisons of IDOE cohort data and withdrawal information in Skyward will be done. The registrar, assistant principal, and data counselor in each building will work together to check the original uploads of documentation done by the registrar and keep record of this work. One final internal audit will take place at the school level by head counselors and assistant principals to indicate all graduates are correctly identified and all exits have proper documentation on file. The CFO and superintendent will digitally sign off on these records during IDOE July certification. Anticipated Completion Date: March 1, 2025

Finding #2024-001 – Inability to Produce Supporting Report to Confirms the Accuracy of the Verification Report Sample Contact for corrective action: Dr. Gregg Klinginsmith, Superintendent District’s response: Concur Anticipated completion date: December 31, 2024 Corrective Action: The District agrees with this finding and will implement the following: • Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling. • Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of reports produced by the software used to select samples. o Obtain training from the software provider to understand how the software pulls reports, ensuring sample accuracy. • Internal Review Process o Establish periodic reviews to confirm all required documentation is retained and accurately represents the population.

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.

2023 – 005: Reporting (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-005 and 2022-005) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory. Without these reports, we were unable to perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. Management has implemented procedures and training to assure financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory are completed and retained.