Corrective Action Plans

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2024 AUDITOR FINDING: 2024‐001 Finding: Allowable Costs and Allowable Activities Certain cost principles were not consistently applied to all expenses. The Organization received a grant for the purpose of expanding electronic health record systems, which ended in February of 2024; however, the contracted vendor had not completed work for which the grant funds had been appropriated within the 120 day grant close out period. The Organization did not have adequate internal controls in place to ensure cost principles under Uniform Guidance were consistently applied. The Organization should coordinate with HRSA to determine allowability of expenditures incurred. The Organization should add internal controls to monitor that cost principles under Uniform Guidance are consistently applied. PLANNED ACTION: The project period for the HRSA Optimizing Virtual Care (OVC) grant ended on February 28, 2024. The project in question relied heavily on a contract agreement to implement a new Electronic Health Record (EHR) system. The original timeline called for implementation to be complete by January 1, 2024, well within the project period. Due to unforeseen circumstances, the EHR launch date was delayed several times until a confirmed completion date of January 28, 2025 was established. The project scope was fully defined by the contract in place and that contract was paid in full prior to the end of the project period with the OVC funds. The organization has worked with HRSA to determine the best course of action. In addition, training was conducted with the responsible staff to ensure adequate knowledge of federal contract compliance requirements and the appropriate application of “no‐cost extension” requests. Modifications to the internal control procedures regarding federal grant expenditures are under review and will be updated no later than January 31, 2025. RESPONSIBLE PARTY: Ryan Pierce, VP of Finance COMPLETION DATE: January 31, 2025

Finding 2024-002 Lack of Internal Control / Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is made. The Business manager and the Superintendent will conduct a review of claims to determine whether they are proper and valid charges. Once reviewed, all transactions will be authorized. DocuSign will be used for electronic signature approval. The accounts payable clerk will ensure that all transactions include copies of receipts for the goods or services purchased. Finally, the Finance department will work with the program directors to ensure that expenses are coded accurately and within a reasonable timeframe to allow for timely submission of grant reports. Proposed Completion Date: Fiscal Year 2025

Recommendation We recommend a verification process be established to ensure accuracy in manual journal entries and to prevent the occurrence of duplicate recordings. Regular reconciliations should be enhanced and additional review steps should be incorporated during the financial close process to identify and correct errors promptly. Furthermore, future Federal Financial Report should take this error into account to accurately reflect cumulative expenditures. Management Response Corrective Action: Four Corners REC has added additional verification processes to ensure the accuracy of manual journal entries to prevent duplicate entries. Reconciliations will be done timely and accurately with added steps. Additional reviews will be done during financial closing and future federal expenditure reporting has been corrected. Due Date of Completion: Completed as of September 9, 2024 Responsible Party(ies): Finance Director

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Human resources manager will collaborate with both a business manager and a grant manager to ensure that employees’ time is being charged to the correct programs and grants in accordance with approved budgets. The human resource manager will prepare a payroll action form that will list available and applicable funding sources to cover the payroll expenses of an employee. The independent payroll contractor will maintain payroll action notices (PAN) for employees who are covered by multiple funding sources or funding sources other than general fund. In addition, she would update payroll distribution coding in the accounting software to match PAN. She would also match coding on timesheets with coding on PAN and in the accounting software. In case of a discrepancy, she would reach out to a business manager and/or a grant manager on how to resolve it. The Superintendent will review account coding each payroll while performing a review of the payroll check register. In addition, budgeted account codes will be compared to the actual codes being used in payroll on a periodic basis. Proposed Completion Date: Implemented July 1, 2024

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Human resources manager will collaborate with both a business manager and a grant manager to ensure that employees’ time is being charged to the correct programs and grants in accordance with approved budgets. The human resource manager will prepare a payroll action form that will list available and applicable funding sources to cover the payroll expenses of an employee. The independent payroll contractor will maintain payroll action notices (PAN) for employees who are covered by multiple funding sources or funding sources other than general fund. In addition, she would update payroll distribution coding in the accounting software to match PAN. She would also match coding on timesheets with coding on PAN and in the accounting software. In case of a discrepancy, she would reach out to a business manager and/or a grant manager on how to resolve it. The Superintendent will review account coding each payroll while performing a review of the payroll check register. In addition, budgeted account codes will be compared to the actual codes being used in payroll on a periodic basis. Proposed Completion Date: Implemented July 1, 2024

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is made. The Business manager and the Superintendent will conduct a review of claims to determine whether they are proper and valid charges. Once reviewed, all transactions will be authorized. DocuSign will be used for electronic signature approval. Accounts payable clerk will ensure that all transactions include copies of receipts for the goods or services purchased. Finally, reasonable timeframe to allow for timely submission of grant reports. Proposed Completion Date: Implemented July 1, 2024

Audit Finding: 2023-002 – 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 adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

Juel Fairbanks Chemical Dependency Services will implement signature approval of all timecards and invoices before the payroll and invoices are printed. Changes made to payroll and monthly reports being actual expenses started in Quarter 4 in 2023.

2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on file for the following reasons: (I) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request or maintain support before payment was made. Known questioned costs associated with the 23 exceptions noted in our testing were $9,867. Based on the projection of the sampling results to the remaining population, we project additional likely questioned costs of approximately $173,400. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP. Current Status of Corrective Action Plan The Authority has resolved this finding. An additional review was added at the close of each case.

Finding: 2023-004: Significant Deficiency - Payroll Allocations Description of Finding: Payroll costs were allocated to grant programs using manual spreadsheets rather than an entity-wide time-tracking system, making it difficult to clearly demonstrate the proportional benefit required. This manual approach increased the risk of allocation inconsistencies and made documentation less robust than needed. Cause: The use of manual spreadsheet-based timekeeping did not provide an auditable system for allocating payroll costs to grants. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian acknowledges the significance of this finding and the potential for misstating staff expense and has taken steps to strengthen its time-tracking and payroll allocation processes. Beginning January 1, 2025, SacAsian implemented a new accounting system that includes electronic timesheets for staff to track their time daily to specific grant activity. Timesheet training has been performed and timesheet completion is required for all employees each day, providing support for hours worked/billed, as well as documentation of the certification and approvals that all staff time entered is accurate and in compliance with contract requirements, and providing proper support for all grant direct labor and indirect costs. Monthly reviews by the Project Directors/Managers, with secondary review by the accounting team are performed, ensuring ongoing compliance with federal requirements. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: January 2025

Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unrestricted. As a result, the ledger detail did not clearly demonstrate the grant claim support without additional reconciliation. Cause: A comprehensive system for allocating and documenting grant-related costs had not yet been implemented. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands and acknowledges the significance of this finding and the potential that it creates for documentation gaps. The Controller and Director of Finance have implemented an ERP system which allows for better cost reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. While the general ledger details do not align, SacAsian did provide full documentation to substantiate the expenses claimed in each billing. Moving forward, all expenditures that have been billed will be reconciled to the general ledger monthly by the Director of Finance, Controller, and external CFO firm to ensure that billings match to expenditure detail and have been correctly allocated. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: October 2025

Finding Reference Number: 2023-004 Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Controller and Director of Finance have implemented an ERP system which allows for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation.We also understand these findings are repetitive from the 2021 and 2022 audits; however, due to catch-up of the prior year audits, we were unable to address these issues prior to completion of the 2023 audit. This delay was caused by a change in auditors as our previous auditor did not have the capacity to retain us as clients due to staff shortages related to COVID. The implemented ERP system includes electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. Timesheet training has been performed and timesheet completion is required for all employees each day. This began effective January 1, 2025 and provides support for hours worked/billed, as well as documentation of the certification and approvals that all staff time entered is accurate and in compliance with contract requirements and provides proper support for all grant labor costs and indirect costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Susan Wright, Controller, 256-689-7055, swright@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: January 2025

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: As a measure of corrective action, I will be implementing a check sheet that will be attached to every claim sheet. This new procedure requires that you go through the check sheet and initial each item to ensure that all procedures have been followed correctly before submission. Additionally, I will also maintain a check sheet in my office since I am the last person to review each claim. This will help to ensure thoroughness and accuracy in our claims processing. Furthermore, moving forward, any grant funds will be placed into their own individual funds and distributed through an individual account. This approach will allow us to track payments for any expenses associated with these funds more effectively. Additionally, the BOT expenditure is done and in the future we will do a better job. Anticipated Completion Date: October 31,2025

Finding Number 2023-105 Subject Heading (Financial) or AL no. and program name (Federal) 10.542 - Pandemic EBT – Food Benefits Planned Corrective Action The P-EBT program is no longer issuing benefits. Should a similar program be required in the future, the DHS will ensure internal controls are in place to avoid duplicate or erroneous payments. Anticipated Completion Date N/A Responsible Contact Person Sondra Shelby

Corrective Action Plan (CAP) – FY 2023 Single Audit Finding 1: Material Adjustments to Recognize Balances in Accordance with U.S. GAAP Planned Corrective Action / Views of Responsible Officials: Management acknowledges the need for a formalized process to ensure that all general ledger balances are reviewed and accurate prior to audit. A third-party accounting firm has been engaged to conduct quarterly reviews and reconciliations of the general ledger to ensure proper documentation and recognition in accordance with U.S. GAAP. Management plans to develop and implement a structured internal review process before submitting the General Ledger balance for audit to ensure alignment with U.S. GAAP. We recognize that this may continue as a finding in the FY 2024 audit; however, the corrective action is in place as of this Single Audit in July 2025. Expected Completion Date: In progress with full implementation as of October 2025 or expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 2: Completeness of SEFA and Data Collection Form Filing Timeliness Planned Corrective Action / Views of Responsible Officials: We recognize the deficiencies in our prior SEFA submission process. As of July 2025, the organization has engaged a third-party accounting firm to conduct quarterly reconciliations of federal grant activity and maintain a rolling SEFA throughout the fiscal year. Management turnover has stabilized, and processes are now in place to maintain an up-to-date general ledger with accuracy to support a complete and timely SEFA. A documented checklist and timeline have been implemented to ensure timely and accurate reporting. Expected Completion Date: In progress, with full implementation expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 3: Employee Loan Documentation Planned Corrective Action / Views of Responsible Officials: New leadership has implemented a strict no-loan policy. Any loan or advance to staff must now receive prior written approval from the Executive Board. A formal Employee Loan and Advance Policy is being adopted to ensure any future considerations are properly documented, authorized, and compliant with internal controls. Payment-processing staff will be trained to enforce the new policy and ensure all reimbursements and advances meet approval requirements. Expected Completion Date: September 30, 2025 or expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 4: Internal Controls Over Compliance – Timesheet Approval and Allowable Costs Planned Corrective Action / Views of Responsible Officials: As of April 2024, the organization implemented a new electronic timekeeping system (SwipeClock) in partnership with a third-party payroll provider. This system includes: • Supervisor approval of all time entries. • A final review by a member of the executive team (CEO, Operations Manager, or Accounting Coordinator). This three-tiered approval process ensures accuracy and accountability in payroll allocation to federal grants. Expected Completion Date: Fully implemented as of April 2024 Responsible Official: Amee Ivie, MSW Chief Executive Officer, AmeeI@cssnv.org

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. We will attempt to have the sponsoring office of the federal program to retroactively amend the Assistance Agreement to remove the compensation limitation. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 April 2024.

2023-026 Strengthen Controls to Ensure Compliance with Federal Monitoring Requirements ALN #21.023 We acknowledge the finding. The Mississippi Department of Finance and Administration was not appropriated funds for this program nor was the agency given any authority for the administration for the program. As such, DFA was not in a position to assess eligibility determinations or perform monitoring. DFA drew down funds on behalf of Mississippi Home Corp in light of an impending federal deadline. Mississippi Home Corporation had eligibility and fraud prevention policies in place for the ARPA programs. These policies included, but are not limited to, contracting with a third-party law firm to review all applications with a three-tier review system, monitoring with random sample selections for every 10% completed, employing an internal, qualitycontrol auditor, and reviewing any applications submitted that were greater than $10,000. As a result of their monitoring, MHC was able to identify suspicious applications and report them to the Mississippi Attorney General for investigation. MHC continues to report all expenditures directly to U.S. Treasury on a quarterly basis. It is also worth noting that the program stopped taking applications in September of 2022 which was prior to the issuance of the 2022 Single Audit Report that was released on July 31, 2023. Thus, policies and controls in place could not be changed for this. DFA is taking the position that corrective action is no longer necessary for these funds. Corrective Action: A. The Mississippi Department of Finance and Administration is taking the position that corrective action is no longer necessary. The program stopped taking applications in September of 2022, which is prior to the current 2023 single audit report dated November 21, 2024. Policies and controls in place could not be changed for this. B. N/A C. N/A D. The Emergency Rental Assistance program stopped taking applications September of 2022.

Finding 2023-003 Condition: The organization did not properly maintain documentation to support the pay rate authorization. Corrective Action Plan: Management will conduct internal audits to randomly select pay statements and verify there are pay rate authorization documents to support the pay rate in the pay statements. Person responsible: Finance Director and Human Resources Manager Completion date: Starting 4th quarter of 2024 and through 2025 until management is satisfied the problem is resolved.

Historic Hudson Valley will adopt written policies and procedures, and standards of conduct as required by 2 CFR 200, Subparts D and E.

Pioneer Works Art Foundation will adopt written policies and procedures, and standards of conduct as required by 2 CFR 200, Subparts D and E.

Recommendation: We recommend the Annex Teen Clinic, Inc. document the authorization of expenditures charged to federal awards and ensure documentation is available to support such expenditures. Planned Action: We have implement a new Accounts Payable Automation Sofware called Continia, which will make reimbursement, invoicing, and credit card submission processes more efficient and advanced. With this new software, we will be able to streamline our accounts payable processes and save a significant amount of time. Continia will allow everyone to submit their expenses and mileage trips on the Continia Expense Portal. It will also automate the approval process.

Condition: A duplicate expense was recorded to the program and expenses were recorded to the program prior to the period of performance. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has instituted procedures to provide a review of journal entries to reclass expenses to grant funded programs and promptly record. As well, Finance staff have been added to oversee the accounting function for the grant. Contact person responsible for corrective action: Mary Lawrence, Director of Financial Analysis and Special Initiatives Anticipated Completion Date: 5/15/2024

Finding 2023-005 Lack of Internal Control / Noncompliance over Subrecipient Monitoring Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: HCSD established a Subrecipient Monitoring Checklist as a monitoring tool to ensure that subrecipients are successful and compliant and the subawards are used in accordance with federal statutes, regulations, and the terms and conditions of the federal and state awards. Proposed Completion Date: Fiscal Year 2024

Federal Award Findings and Questioned Costs Finding 2023-004 Lack of Internal Control / Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: Management will ensure that the system of internal controls over cash disbursements is designed appropriately and operates effectively to ensure all transactions are coded, reviewed, and approved before payment is made. The Business manager and the Superintendent will conduct a review of claims to determine whether they are proper and valid charges. Once reviewed, all transactions will be authorized. DocuSign will be used for electronic signature approval. Accounts payable clerk will ensure that all transactions include copies of receipts for the goods or services purchased. Finally, the Finance department will work with the program directors to ensure that expenses are coded accurately and within reasonable timeframe to allow for timely submission of grant reports. Proposed Completion Date: Fiscal Year 2024

2023-024 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program MANAGEMENT RESPONSE: We agree with this recommendation. The ODHS Office of Facilities Management coordinates care of a 168-building portfolio. Part of this work is coordination of furniture reconfiguration, minor and major remodels of office spaces and other building maintenance work. For these projects we rely on program staff with understanding of their funding sources to provide us with accurate coding to support the project related costs. Our office does not work directly with funding source management only coding and billing. To better track who is providing us the coding and maintain a record of payment approval we have revised our workorder form to include who from the program is providing the coding and what authority they have to provide the coding. This will allow us to assure that important details are captured regarding funding application and coding for billing and protect from funds being drawn from sources that do not support and/or are not appropriate for a given project. The questioned costs of $3,849 were corrected and refunded to CMS using document BTCL1485 with a April 17, 2024 effective date. The refund will be reported on the Q3 FFY 2024 CMS 64 which will be submitted by June 30, 2024. Anticipated Completion Date: June 30, 2024 Contact person: Karuna Thompson, Construction and Facilities Maintenance Manager; Travis Labrum, Grant Accounting Manager