Corrective Action Plans

The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control process to monitor and review additional invoice samples from Branches after they have been processed and reviewed by Branch Program Technicians and Branch Auditors. Additionally, the DDSD Central Support Services Branch implemented a secondary audit process and created a new Auditor role to routinely sample additional Medical Evidence of Record (MER) and Consultative Examination (CE) contracts. Findings are provided to branches to reinforce accuracy and assure compliance. The DDSD, also transitioned from MIDAS to DCPS, which provides more sophisticated fiscal controls. To remediate any inaccuracies, DDSD’s centralized auditor will assess findings and develop an action plan to prevent erroneous invoices. The CDSS ensures that all necessary controls are in place to verify the accuracy and proper documentation of invoices. The CDSS concludes that the sample size of 15 MER cases does not provide sufficient audit evidence that controls are not operating effectively resulting in a calculated $54,398 in potential costs. However, CDSS agrees with the finding and is committed to the control and mitigation of risk related to the audit recommendation. Estimated Implementation Date: Implemented Contact: Bernice Stanfield, Fiscal and Procurement Section Chief Central Support Services Branch Disability Determination Service Division California Department of Social Services

The deficiency occurred due to such documentation not received or forwarded from former personnel, and perhaps inadequate training by former personnel on compliance requirements. Mana Maoli plans to facilitate increased training for all personnel using debit cards to increase competency and compliance under 2 CFR § 200.302(b)(3) and 2 CFR § 200.403(g). Prior to and during the course of the FY2023 audit, Mana Maoli has already taken steps to train our personnel before issuing debit cards to better ensure staff understand the importance of receipt retention. Staff training focuses on how to implement and comply with federal documentation retention policies. As our new training protocols continue to be implemented, we will monitor for more comprehensive receipt retention and approvals. Mana Maoli’s management will evaluate and monitor the training’s effectiveness in producing more timely receipt retention. The responsible persons for training staff are Ruth Faioso Leau, Finance Manager, and Erik Yoshimoto, Office Manager. We will assess, monitor, and verify ongoing compliance for the second half of FY2025 and will have the new training protocol fully implemented by the first half of FY2026. Each quarter, the Finance Director will review a sample of federal disbursements that supporting documentation is maintained. The results will be reported to senior management. In conclusion, we will be taking steps immediately to address the findings in the audit. If additional information is needed, please contact Ruth Faioso Leau, Finance Director at faioso@manamaoli.org or 808-753-8746.

Finding Number: 2023-006 Planned Corrective Action: The corrective action in 2023-005 will assist in providing accurate financial information when completing the Schedule of Expenditures of Federal Awards. Anticipated Completion Date: March 1, 2025 Responsible Contact Person: Ashley Miller

The Sheriff’s Department separated from the individual that handled the grant funding as of the first of 2025. We have worked diligently to get these reports correct as of December 31, 2024.

Views of Responsible Officials and Planned Corrective Actions: The Organization will update policy to ensure that all payments made in any form have appropriate documentation. Additionally, policy on review of invoices prior to payment will be reviewed by Executive Director and Business Manager. Monique Johnson, Executive Director of Allen County Drug & Alcohol Consortium, is responsible for this corrective action. The anticipated completion date is May 31, 2025.

Finding: 2023-006 • Condition: We identified costs incurred in 2022 that were incorrectly recorded as 2023 costs and charged to federal awards. • Planned Corrective Action: Corrected during the process of the audit and new policies implemented moving forward. Contact Person: Katherine Jaeger Anticipated Date of Completion: 2/21/2025

Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.

Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost Principles, Cash Management, and Matching, Level of Effort, and Earmarking Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

No payments will be made for purchases until the proper documentation is received and attached to the purchase order

Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated employee responsible for receiving deliveries will be tasked with ensuring that all receipts and receiving reports are accurately matched with the corresponding invoices. This process will enhance our internal controls and improve the tracking and accountability of all deliveries. Recommendation 2: Comment: We will implement a policy requiring Unit Directors to submit daily "End of Day Reports" using a standardized template. This template will capture essential information, including activities conducted, materials distributed, and deliveries received. We will also establish a policy for maintaining and utilizing sign-in sheets at each Unit, outlining the required information such as the activity or event description, number of children involved, materials distributed, and the names of the Unit Director and Assistant Director. These sign-in sheets will be submitted to the appropriate parties promptly and saved in an online repository, organized by Unit and grant year. Additionally, supporting documentation will be collected and stored as part of the overall documentation process. We are committed to enforcing these policies to ensure timely submission and proper maintenance of all required documentation, further reinforcing our dedication to transparency, accountability, and effective use of grant funds.

FA 2023-002 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021) S425U210012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: $98,807 Repeat of Prior Year Finding: FA 2022-002 Description: A review of expenditures charged to the Elementary and Secondary Emergency Relief Fund program revealed that the School District's internal control procedures were not operating to ensure that expenditures were appropriately documented to support allowability. Corrective Action Plans: District office will review payroll process and develop a procedure to ensure proper documentation is kept in an orderly manner. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2023-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010-21A (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: $6,942 Repeat of Prior Year Finding: FA 2022-001 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawbacks are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will included detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2023-002 Strengthen Budgetary Controls over Expenditures Internal Control Impact: Significant Deficiency Compliance Impact: Activities Allowed or Unallowed Allowable Costs/Cost Principle Prior Year Finding: None Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed instances in which expenditures has not been properly approved by the pass- through entity. Corrective Action Plans: the School District will work with all entities to confirm that all existing controls are adhered to by developing and implementing an improved monitoring process. This process will ensure that all expenditures comply with all applicable policies and regulations. Estimated Completion Date: June 30, 2024 Contact Person: Daisy M. Prather, Finance Director Telephone: (478) 836-3131 extension 106 Email: daisy.prather@crawfordschools.org

CONDITION: The Regional Office of Education No. 39 did not ensure costs or expenditures were adequately documented, reviewed, and approved to ensure allowability under the federal award. PLAN: Although procedures were put into place in March 2023 to ensure that all expenditures were signed by the Program Directors, or Assistant/Regional Superintendent the previous Business Office Manager and Accounts Payable employee were not consistent on ensuring that all receipts/invoices were reviewed if a PO was created and approved or if it was approved with prior requisition form. A new purchasing process will be implemented that will document all expenditures have been reviewed, approved, and ensured that they are allowable under the federal and state award. This process will be consistent across all purchases to ensure that all approvals and reviews are conducted and documented. ANTICIPATED DATE OF COMPLETION: Implemented May 2024 CONTACT PERSON: Jill Reedy, Regional Superintendent

2023-007 Assistance Listing No. 96.001 , 96.006 and Social Security Disability lnsurance Cluster Type of Compliance Requirement: Period of Performance lnternal controls over period of performance were not consistentlv performed Response: Of the five instances noted in the auditor's "Period of Performance" test work, we concur with four. With one of the sample items, however, we argue that since the service was invoiced on a State Fiscal Year, it was impractical to further split the invoice into the various appropriate Federal periods of performance, especially given the way those specific invoices are allocated between other shared program areas within our agency, etc. Corrective Action Plan: Our agency takes these findings seraously and will continue to evaluate ways of improving controls. At a minimum, it is our intent to increase and provide additional training to the staff overseeing and approving these types of transactions so that they can accurately apply transactions to the appropriate periods. This was something we had already begun (i.e. provrding additional guidance and training to stafD during the current fiscal year. So, we hope our agency is already on a corrective path. But, we will continue to push for more training in the immediate future and strive for improvement in all other aspects. We also think it is important to note that, of the findings identifled by the auditors related to "Period of Performance," those items were discovered out of a total sample size oI 120 items (i.e. 60 sample items related to thejr "Period of Performance" test work and 60 sample items related to "General Disbursements" test work). So, a slightly larger sample size than that of the 60 referenced in the auditor's schedule of flndings. Additionally, the auditor's sample appeared to selectively target the specific periods and transactions that would have been most susceptible to these types of potential errors. And, although we are not objecting to the way in which the sample was selected, we would.just point out that this approach of sample selection may not be truly reflective of a purely random sample covering all transactions across the entire fiscal year. Therefore, although we ultimately concur with the findings here, we do not necessarily believe these results paint the fairest picture on the overall effectiveness of our agency's controls across the more than '100,000 transactions that would have been processed during the period of audit for this program. Again, we take these findings seriously. But, based on the audit test work and results, we feel the controls we have in place are ultimately working adequately enough to mitigate the potential for material misstatements. Regardless, we will continue to monitor and evaluate our controls to help further reduce the risk of these types of issues moving forward. Planned completion date for corrective action plan: lmmediately. But, additional training for managers to be provided by September 30, 2024.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

The contracted executive director will document time spent on federal awards with date, hours, and purpose. The contracted accountant will allocate the indirect expenses. Both the executive director wage expenses and the indirect allocations will be reviewed and approved by the contracted grant administrator.

Catholic Charities of Central and Northern Missouri agrees with this finding and as of July 1, 2024 has altered procedures so that invoices and documentation related to expenditure of federal funds are now scanned and attached to the accounting entry recording the payable.

We will maintain a schedule that details all salary and benefit expenses charged against each Federal award and ensure that these totals are reconciled back to the general ledger and the Final Expenditure Report. We take some exception with this finding, as we believe the audit sample was pulled and formatted in a cumbersome manner and did not facilitate the process of clearly identifying all of the expenditures cited, which often represented portions of benefit costs paid for personnel and reflected in total on related insurance invoices, etc. The Director of Federal Programs and the Payroll Coordinator will be charged with ensuring the accuracy of this information and the related processes moving forward.

Finding 2023-002: Internal Control Deficiency and Noncompliance over Activities Allowed/Allowable Costs Principles, Period of Performance Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: Management did not have adequately designed internal controls in place over expenses charged to the federal program. Management also did not consistently retain evidence to support the existence of certain expenditures and thus the expenses were not adequately documented. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-01 finding, to ensure expenditures are appropriately reviewed and approved prior to entering into the expenditure or requesting reimbursement from the federal program. Documentation will be maintained to support that expenditures were reviewed for appropriate period of performance. Management will ensure all duties are appropriately segregated. In addition, following the October 2023 implementation, care will be taken to ensure that invoices for vendors using electronic invoicing systems will be downloaded in a timelier manner to ensure electronic invoices do not expire within those systems. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

CONDITION: The District did not comply with the laws and regulations related to its participation in it’s various federal grant program reporting requirements. Personnel did not complete and submit the required ‘quarterly cash on hand reports’ and ‘final expenditure report’ (FER) for the grant programs based on supporting accurate general ledger expenditures as required by Section 2 CFR 200.403(g) of the Uniform Guidance. CRITERIA: The PA Department of Education (PDE) and Section 2 CFR 200.403(g) of the Uniform Guidance requires the completion and submission of a ‘quarterly cash on hand report’ quarterly as needed and a ‘final expenditure report’ (FER) at the conclusion of each grant program year (including any carryover period) based on information contained in the School District’s financial management system and supported by all underlying documentation. MANAGEMENT’S CORRECTIVE ACTION PLAN: The School District concurs with the above noted finding. The School District has employed a new Business Manager whose responsibilities include the oversight of accounting records and preparation of all required financial reports related to PDE federal grant programs in a timely manner, and to ensure that the information reported to PDE is supported by the underlying documentation contained in the District’s general ledger. Procedures will be put into place during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for ensuring federal program reports are prepared accurately and agree with the financial management system and supported by all underlying documentation.

Assistance Listing 14.267 Continuum of Care Program Views of the Responsible Officials and Corrective Action Plan: OHS agrees with the issues outlined, which stem from the delayed processing of invoices and untimely payments. These challenges are largely the result of longstanding issues with over-allocations and the need to catch up on processing a backlog of documents. We appreciate you bringing this to our attention, as it provides an opportunity to refine our procedures and put in place measures to prevent these issues from recurring in the future. This feedback will be valuable as we work to improve our processes and enhance our ability to manage workloads more effectively. Contact Person: Jerome R. Hill, Director of Compliance, Office of Homeless Services, 215-686-0371, 215-520-3556

This matter was investigated by both the AOS, the Allen County Auditor’s Office, and by board members of the RPC. GLCAP was met with and records from both RPC and GLCAP were scrutinized and matched. As a result, the duplicate payment made in the amount of $4,386 was returned by GLCAP to RPC and was deposited on 10/03/2024 into the Allen County Community Development Fund.