Corrective Action Plans

ACDJFS will strengthen its internal controls and documentation practices related to the allocation of direct expenses and the completion of Random Moment Sampling (RMS) observations, particularly for programs serving both eligible and non eligible participants. 1. Strengthening Cost Allocation Controls ACDJFS will revise and reinforce its cost allocation procedures to ensure all direct expenses are properly assigned, consistently treated, and supported by clear documentation. Updated procedures will include supervisory review checkpoints and periodic reconciliation to ensure costs are charged in proportion to the benefit received by each program. 2. RMS Compliance and Documentation Standards ACDJFS provides a dedicated RMS Coordinator to maintain clear RMS compliance and documentation standards to ensure activities are coded accurately, consistently, and in accordance with state and federal requirements. Staff are expected to provide complete and accurate RMS responses that clearly describe the activity performed, its purpose, and the population served. Attention will be given to activities that support both eligible and non-eligible populations to ensure proper classification and allocation of costs. Allocation errors will be corrected promptly and documented. Incorrect RMS responses will be corrected and retrained immediately. All RMS responses are currently being reviewed. Supporting documentation must be maintained and readily available to substantiate RMS activities and demonstrate compliance during monitoring, audit, or review processes. Supervisors and management will routinely review RMS documentation and coding practices to ensure consistency, identify areas requiring clarification, and maintain the integrity of the agency's cost allocation methodology. The coding of direct expenses are reviewed prior to the processing month end to ensure that they are coded correctly. These standards help ensure RMS results accurately reflect agency operations and support the appropriate claiming of administrative costs. 3. Staff Training and Capacity Building ACDJFS will conduct targeted training for program and fiscal staff to ensure a consistent understanding of cost allocation principles, RMS documentation requirements, and compliance standards for programs serving mixed-eligibility populations. Annual refresher training will be incorporated into ongoing professional development efforts to reinforce expectations, maintain compliance, and support accurate coding practices. The RMS Coordinator will work closely with agency leadership and the Ohio Department of Job and Family Services (ODJFS) to monitor policy updates, guidance, and best practices related to Random Moment Sampling. The coordinator will obtain and disseminate updated information as quickly as possible to ensure staff receive timely communication, training, and technical assistance when changes occur. In addition, the RMS Coordinator will provide weekly reviews and updates to agency management, creating multiple levels of oversight and accountability. This ongoing review process allows leadership to identify trends, address potential concerns early, verify compliance, and ensure consistent application of RMS requirements across all programs. Through training, communication, and regular management review, ACDJFS strengthens internal controls and promotes the accuracy and integrity of its RMS activities. 4. Monitoring and Continuous Improvement ACDJFS leadership will conduct quarterly monitoring of allocation patterns, RMS samples, and documentation quality. Findings will be used to make timely corrections and guide additional staff training. Monitoring results will be retained and used to support continuous improvement. 5. Implementation Timeline All corrective actions, including updated procedures, training, and monitoring mechanisms—will be implemented within 90 days and maintained on an ongoing basis. Annual RMS training was completed in July 2025. ODJFS provided RMS training to all staff in December of 2025. ODJFS will provide annual RMS training scheduled for September 2, 2026. ODJFS will provide RMS Coordinator training on August 6, 2026. RMS training for Management/Fiscal is scheduled for July 7, 2026. Written documentation of fiscal procedures and policies is being reviewed and will be implemented by September 1, 2026.

Management Response and Corrective Action Plan Finding 2025-001 – Allowability Federal Agency: United States Department of Health and Human Services Program Name: Research and Development (R&D) Assistance Listing Number: 93.859 Responsible Individual: BIDMC – Jarod Kohr, Director, Research Finance or The Center - Roy Bourne, Director, Research Finance and Operations Contact Information: BIDMC - jkohr@bidmc.harvard.edu; 617-216-7479 The Center - rbourne2@joslin.harvard.edu; 617-309-5741 A review of Beth Israel Deaconess Medical Center’s (BIDMC) salary allocation process revealed 53 instances out of approximately 11,000 records of allocation in excess of NIH Salary Cap limits (0.04%). BIDMC acknowledges discovery of system limitations that will correct future instances. Accordingly, management has concluded that controls are operating as intended, but will be enhanced to limit human errors. Corrective Action Plan: - Management will implement a calculation control that will prevent the ability to save changes to salary allocation that exceeds the salary cap for the respective period. (Completed) - Management will implement a calculation control that will prevent the ability to reflect a percent salary higher than the percent effort for any salary cap controlled grant. (Completed) - Management will monitor monthly changes to effort/salary allocations in the Time and Effort system for calculated variances. (Ongoing) Expected Completion Date: October 1, 2026 Status of Completion: In process The Center’s management acknowledges that an invoice was incorrectly matched to a purchase order; however, this was not reflective of the overall control environment. The Center maintains established controls over purchase order invoice processing, including system-generated duplicate invoice detection, cost matching tolerances, and restrictions preventing matching to closed purchase orders. Transactions outside established parameters are automatically flagged for manual review. Management performed a targeted review of these transactions, noting expenditures were properly allocated with the exception of the item noted in this finding. Accordingly, management has concluded that controls are operating effectively overall, Accordingly, management has concluded that controls are operating effectively overall, while continuing to evaluate and enhance processes to further mitigate the risk of recurrence. Corrective Action Plan: - Management will reinforce matching requirements through targeted training and communication with Accounts Payable and Purchasing (Completed) - Periodic reconciliation reviews will be performed to identify and correct any misallocated costs as necessary (Completed) - The Center’s planned implementation of a new ERP system on October 1, 2026 will introduce enhanced automated matching controls, further reducing the likelihood of recurrence Expected Completion Date: October 1, 2026 Status of Completion: In process

April 1, 2026 U.S. Department of Justice Green River Regional Rape Vicitm’s Services, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Alexander & Company CPAs PSC 2707 Breckenridge St., Suite 1 Owensboro, Kentucky Audit period: Fiscal year ending June 30, 2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF JUSTICE 2025-001 16.575 Crime Victims Assistance Recommendation: Management should review all grant agreements for CFDA numbers and pass-through identification information. Management should reconcile the SEFA to the general ledger periodically throughout the year. Action Taken: Management has updated the SEFA process to incorporate safeguards. If the Department of Justice has questions regarding this plan, please call Karla Ward at 270-926-7273. Sincerely yours, Karla Ward Executive Director

Condition: The Organization lacked effective controls over the review of the SEFA to ensure that only federal expenditures were included for fiscal year 2025 and to ensure that expenditures were appropriately tracked and recorded to the correct grant period. Planned Corrective Action: The Organization will enhance its reviews around SEFA preparation and federal expenditure tracking to accommodate the lack of an integrated system as well as to ensure cut-off, completeness, and classification of federal expenditures. Contact person responsible for corrective action: David Anderson Anticipated Completion Date: September 30, 2026

2025-002 Corrective Action: We will correct the application of indirect costs and reduce the very next future request for reimbursement by the overcharged indirect costs. We have also changed the circumstances that caused the limitation to be overlooked related to this specific contract.

Condition: Expenditures for the Child and Adult Care Food Program were incorrectly reported as expenditures to other nutrition programs. Recommendation: The auditors recommend that the School properly identify and report nutrition program expenditures by program. Contact Name: Anastacia Europa Ruiz, Chief Operating Officer Corrective Action Planned: The School Management will identify nutrition program expenditures by each separately funded program and report such expenditures by each separately funded program. Anticipated Completion Date: June 30, 2026

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. We believe this finding to be the result of an isolated incident that was reported to SBOA and Title. Description of Corrective Action Plan: The Business Manager/Treasurer provides to the corporation grant administrator monthly grant reports, as well as a grant tracking spreadsheet. The appropriations for each grant are entered into Komputrol, according to the budget located in the approved grant documents. The appropriations are presented to the Grant Administrator for approval. All spending from each grant is approved by the corporation grant administrator. Any wages paid via the corporation payroll that is charged to grant funds is approved by the business manager/treasurer and the corporation grant administrator. The Payroll Specialist/Deputy Treasurer completes the payroll and sends the distribution account records to the Business Manager/Treasurer and Grant Administrator. Any payroll claims for payment via grant funds is required to have three signatures for approval. We believe the system of internal control in place has been strong and in compliance since March 2025. Anticipated Completion Date: March 1, 2025 and ongoing

FINDING 2025-004 Finding Subject: Child Nutrition Cluster, Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Since January 2025, the internal controls that resulted in this finding have been corrected. The finding stated that “The lack of internal controls and noncompliance over Allowable Activities and Allowable Costs/Cost Principles is an isolated incident.” The Food Service Director and the Business Manager/Treasurer meet monthly to review the school lunch accounts and to concur with the month end balances. The Deputy Treasurer approves all monthly fund transfers completed by the Business Manager. Anticipated Completion Date: January 1, 2025 and ongoing

The formal policy was written, incorporated in to our comprehensive accounting policies manual, and approved by the board of directors on February 25, 2026.

The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.

Westminster College Corrective Action Plan (CAP) Federal Program: Economic Adjustment Assistance Program, Assistance Listing Number 11.307 Finding 2025-001: Questioned Costs – Allowable Costs/Costs Principles (material weakness) Name of Contact Person: Gerald J. Ganz, Jr., Vice President, CFO Specific Corrective Action: To prevent recurrence, the College is implementing the following measures: 1. Enhanced Funding Source Review Procedures: The College will develop and enforce a standardized review process requiring staff to verify and document the original funding source for any expenditure prior to charging it to a federal award. This process will include mandatory cross-checking between project accounting records, bond expenditures logs, and grant reimbursement requests. 2. Strengthened Internal Controls Over Capital Project Accounting: The College will implement additional controls within the accounting system to ensure expenditures tied to capital projects are flagged and reviews for potential dual funding before being charged to any federal program. 3. Training and Guidance for Staff: All personnel involved in grant management, accounting, and capital project administration will receive updated training on Cost Principles under 2 CFR 200.400-200.406, with emphasis on allocability, reasonableness, and the proper handling of applicable credits. 4. Ongoing Monitoring and Review: Quarterly internal compliance reviews will be conducted to confirm adherence to the new procedures, and corrective measures will be taken immediately if discrepancies are identified. The College is committed to ensuring full compliance with federal regulations and strengthening internal controls to safeguard all funding sources. We appreciate the opportunity to improve our processes and will implement the recommended procedures to ensure the integrity of future federal program expenditures. Anticipated Completion Date: June 30, 2026

Indirect Cost Rate Review Auditor Description of Condition and Effect. The University does not have a formal review process related to indirect cost rate automated entries. As a result of this condition, there is an increased risk of unallowable charges to the grants, inaccurate financial reporting, and other potential noncompliance with federal regulations. Auditor Recommendation. We recommend the University implement procedures to review the indirect cost rate input and automated entries by responsible individual on a monthly or quarterly basis. Corrective Action. The University will establish formal procedures to review the indirect cost rate input and automated entries by additional individual on a monthly or quarterly basis. Responsible Person. Yah-Sheba Jenkins, Controller Anticipated Completion Date. June 30, 2026

Finding 2025-002 Lack of Internal Controls over Activities Allowed and or Unallowed and Allowable Costs/Activities – Cash Disbursements Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD will modify the written credit card policy that details rules for using the card, which includes employees taking responsibility for the use of the credit card and for the safekeeping of the credit card. Credit cards will be limited to the Superintendent, BOE President and the Academic Director. The cardholder will follow the general purchasing processes that begin with approval to purchase. Procedures for reporting credit card use with monthly reconciliations with receipts will be shared with cardholders. DocuSign will be used for electronic signature approval. Proposed Completion Date: Implemented July 1, 2025.

Finding 2025-006 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Activities Name of Contact Person: Tamara VanderPool, Payroll Director and Lisa Pearce, Business Manager Root Cause: **Insufficient staffing level. Inconsistent application of the personnel action forms and required documentation for changes to payroll details. Corrective Action Plan: • Clarify roles and responsibilities regarding payroll processing. • Establish a review process of all payroll transactions and documentation. Proposed Completion Date: Fall of 2025.

The Boys and Girls Clubs of Southcentral Alaska has contracted with a national accounting firm, Fohrman and Fohrman, to reconcile the 2025 books and implement a simpler accounting structure. There will still be significant findings in 2025 as the organization ultimately closed due to financial instability. The new system will be implemented in 2026. Fohrman and Fohrman will continue on contract to ensure adequate grant reporting and compliance with reporting requirements.

The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.

Airport management will implement written policies and procedures for the administration of federal awards.

Finding Number: 2024-018 Finding Name: Improper Calculation of Qualified Incentive Payments Claimed under the Medicaid Cluster Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) incorrectly calculated qualified incentive payments charged to the Medicaid Cluster program using the enhanced federal medical assistance percentage (FMAP) rate applicable to payments under the Affordable Care Act (ACA) rather than its regular FMAP rate. Additionally, the auditors noted the supervisory review procedures related to the calculation of the qualified incentive payments were not designed to and did not operate at a level of precision to identify an error of this nature. Name of Contact Person(s): Rene Corso, Senior Public Service Administrator - Illinois Department of Healthcare and Family Services, Long Term Care (LTC) Rate Setting Unit Corrective Action(s): The LTC Rate Setting Unit has updated the spreadsheet for calculating the Quality Incentive Payment (QIP) to ensure the percentages for the ACA and the FMAP are distinguishable. Peer checking has also been implemented to ensure amounts are correct before processing Proposed Completion Date: April 16, 2025

The Authority concurs with the Auditor’s recommendation. The Authority has made a number of employee changes as well as administrative and accounting-related improvements. The Authority will continue its efforts to further strengthen its administration of the federal programs/funds. The Executive Director will continue to oversee the process of updating the Authority’s policies and procedures. The Executive Director will oversee the correction by September 30, 2025.

As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final agreement, the budgeted requested salaries were not updated. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 in April 2024. Implementation Date – April 2025

Audit Finding: 2024-001 – Lack of Documentation of Review and Approval Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures were formally adopted in 2025 and implementation began immediately. Standardized review documentation is now required for payroll, expenses, and financial reporting, and oversight by the external accounting firm is ongoing to ensure compliance with 2 CFR Part 200. Anticipated Completion Date ● Implemented in 2025 (Monitoring ongoing) Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

Review and update the Accounting Manual as needed • Re-train employees in the need for proper use of purchase orders, needed documentation to support charges to federal awards, and detailed receipts to show taxes paid (if any) according to the Accounting Manual

FINDING 2024-012 Finding Subject: Title I Grants to Local Educational Agencies - Level of Effort – Maintenance of Effort, Earmarking Contact Person Responsible for Corrective Action: Tricia Hudson, Curriculum Director & Federal Grants Administrator Contact Phone Number and Email Address: 812.279.3521, ext. 16242; hudsont@nlcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The school district will document all parent involvement expenditures with the object code 661 and all homeless set-aside funds with the object code 660 to ensure that Matching, Level of Effort, and Earmarking compliance requirements are consistently met. Any funds not expended will be carried over under the same Earmarking for the following grant period. The school corporation will properly document all Title I grant expenditures from accounts payable vouchers to payroll and fringe benefits. This documentation will ensure that we can calculate and substantiate that we met earmarking requirements for the grant prior to the closing of the allowable period. Anticipated Completion Date: The school district will comply with this plan for the FY25 Title I grant and for all Title grants moving forward. This corrective action will be fully completed by June 30, 2026.

We have conducted a thorough review of our existing procedures for managing Title III funds to identify gaps and areas of improvement. Management hired a Title III consultant to assist with proper accountability and to establish clear guidelines for fund allocation, monitoring, and reporting. Management will conduct periodic internal reviews to verify adherence to established controls and address discrepancies promptly.

If ED has questions regarding this plan, please contact Dr. Douglas Allen, Vice President for Finance and Administration, Talladega College at (256) 761-6100.