Corrective Action Plans

Condition: As a precondition to receive federal awards, prospective recipients must have effective internal controls over the federal award. As described in 2 CFR, Part 200.303, nonfederal entities must have certain written policies and procedures surrounding the management of their federal awards. Such policies should include procedures for collecting payments of federal funds per 2 CRF 200.305, cash management (i.e., minimizing the time between draws and actual disbursing of federal awards) per 2 CFR 200.302(b)(6), allowable cost per 2 CFR 200.403, and conflict of interest per 2 CFR 200.318. Per 2 CFR 200.319(d), the non-Federal entity must have written procedures for procurement transactions. Recommendation: The Authority should adopt written policies and procedures over cash management and allowable costs required under the Uniform Guidance. Planned Corrective Action: The Authority implemented these policies during the FY 2024 (BA054 Cash Management Policy and BA059 Authorization of Purchases). Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

Name of Responsible Individual: Bruce Jones, Vice President of Research, Marchon Jackson, Associate Vice President of Research, Dana Hector, Assistant Vice President, Sponsored Grants & Programs Corrective Action: The process to review subrecipient invoices will be improved by requiring the review of supporting documents to ensure expenses are allowable by the newly established Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, reasonable and recorded in the proper period according to university policies and grant terms. Invoices will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. The Director of Compliance will conduct spot checks on all sponsored transactional activity, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO post-award office. The Director of Post Award Compliance will be hired by March 2025. Anticipated Completion Date: March 31, 2025

FINDING 2023-005 Finding Subject: COVID-19 – Education Stabilization Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles. Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements. Across-the-board stipends were paid without documentation or justification for additional duties or work performed on which to base the stipends. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We disagree with this finding. We did not offer an across the board stipend with ESSER II. We paid it to employees who had met certain length of employment requirements and effectiveness requirements. The IDOE guidance states that staff may be paid extra for added COVID-related work. However, this list is not exhaustive and we believe there are other reasons that allowed us to proceed. a. Incentives paid with federal funds must comply with 200.430(f). The federal regulations explicitly state that the bonus is allowed for efficient performance, which was our criteria. Explanation and Reasons for Disagreement: The USDOE gave what we did as a recommended best practice and example for others, of addressing staffing shortages and offering premium pay. In regards to Cafeteria workers please see this research brief released by USDOE regarding pandemic funds (ARP but also other federal pandemic funds, which would include ESSER II) State and Local Practices for Cafeteria and Custodial Staff • Waco Independent School District in Texas will give custodians and cafeteria workers up to $1,000 in bonuses, based on years served with the district. Those who have worked for 10 or more years will receive $1,000, divided in three payments beginning in December 2022. Those who have worked for five to nine years will get $750, and those with the district fewer than five years will get $500. The district expects $500 in bonuses to go to custodians and cafeteria workers. INDIANA STATE BOARD OF ACCOUNTS 46 • North Carolina is using ESSER funds to help local school nutrition operations across􀀃North􀀃Carolina􀀃 recruit􀀃and􀀃retain􀀃needed􀀃staff.􀀃 ESSER states, any activity authorized by the ESEA of 1965 (Titles I, II, III, IV IC Migrant, ID Neglected and Delinquent, 21st Century Community Learning Centers, and Rural and Low-Income Schools Grant) is allowable. Title II has explicit language about paying teachers and admin (but not cafeteria) more as a recruitment or retention bonus

1. Implementation of Sage Accounting Software: We have since implemented a comprehensive financial accounting software system, Sage, which allows us to track expenditures more accurately and ensure compliance with federal grant requirements. The system includes built-in safeguards to flag non-compliant expenditures.

2. Review and Strengthening of Internal Controls: Life Source International Charter School will be implementing additional internal control systems & processes that include an additional review of back up documents before monthly reports are filed. A copy of all backup documents in support of all monthly reports will be kept at both Life Source International Charter School and the outside entities providing services and making reports on behalf of Life Source International Charter School.

3. Staff Training and Capacity Building: Our staff has received training on federal grant compliance, including the specific criteria governing the period of performance and allowable costs under federal awards. Additionally, with the Sage system in place, staff are now better equipped to manage compliance and reporting accurately.

4. Commitment to Ongoing Compliance: We are committed to continually improving our internal control processes to ensure compliance with all federal regulations.

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over non-payroll transactions such that all expenditures can be properly explained with supporting documentation, and all expenditures are reviewed and approved prior to payment. Additionally, the Organization only submits expenditures for reimbursement that have been paid. While the Office of Management and Budget allows the reimbursement of expenditures that have been incurred, the pass-through entity will only reimburse expenditures that have been paid. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Already implemented.

Views of Responsible Officials and Planned Corrective Action - The County will create a documented process in the new policy and procedures manual for federal guidelines and charging of administrative costs for documented time spent on grants with supporting calculations will be documented for clarity and consistency. Responsible Official - Andrea Montoya, Deputy County Manager and Robert Placencio, Finance Director Timeline and Estimated Completion Date -November 2024.

We are aware of the findings from the report and we will take the necessary steps to mitigate the issues.

Action taken in response to finding: 1. Create a standard procedure for tracking grant expenses: Completed 2. Train staff on procedures: Completed 3. Create an independent review process for all grant tracking: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

1. Cleveland UMADAOP will obtain written prior approval for any expenditure deviations from the originally approved budget. This topic will be covered when training occurs during the quarterly review of grant guidelines. 2. As part of its updated financial policies and procedures, Cleveland UMADAOP will seek to document all financial activity to ensure compliance with grant and federal guidelines. 3. As part of the updated financial policies and procedures, Cleveland UMADAOP will seek written confirmation from funders whenever there is a deviation from the terms outlined in the original award documentation. 4. As part of the updated financial policies Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

Finding 2023‐004 – Material Weakness, Material Noncompliance – Allowable Costs/Activities Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management will improve policies and procedures to record the purchase of gift cards as a prepaid transactions and expense the gift cards when all allowable cost criteria are met. We will also get input from our funders when necessary. Proposed Completion Date: October 31, 2024

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County review its procedures relative to allocating costs to Federal programs, and ensure only cost within the grant period are included. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements regarding period of performance. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

Apart from the audit observation that the work from home environment has impacted existing processes and retention of information, the issues with staff retention and turnover have presented multiples challenges in relation to continuity of knowledge base and consistent work routines. A key vacancy in the Budget & Compliance area is impacting the ability to move forward on several planned initiatives including i) develop a comprehensive key-data repository, easily accessible to parties requiring this information, ii) centralized accounting records i.e., journal entries, directly related to Federal contracts tracking and bookkeeping and iii) digitalization of underlying legal grant contracts, documents and files, as well as other important data. We are targeting full staffing no later than March 31, 2025, and these items will form part of this new hire’s cri􀆟cal path in the first 90 days at JVS.

We will implement procedures to ensure that our policies and procedures requiring the maintenance of documentation to support expenditures claimed under federal awards be followed consistently for all claimed expenditures in October 2024.

2023-009- Significant Deficiency in Internal Control and Non-material Noncompliance - Supporting Documentation for Expenses Incurred during the Year WPHW understands this finding and has already taken steps to ensure this issue does not come back up for FY24. WPHW keeps an extensive filing system which is mostly paper and not electronic. Our initial plan was utilized in NetSuite program as part of the electronic filing keeping system. After the transition away from NetSuite, we recognized the need for electronic filing keeping. In FY24 we did transition utilizing our share file to keep electronic copies of everything that we have paper copy. This includes AP items, AR items along with journal entries, bank reconciliations anything else deemed necessary. We understand the importance of having all documentation readily at hand for our monthly review’s yearly reviews and especially for the audit. Our process includes the following: 1) As items are entered into the vendor center of our accounting software, they are then scanned into the following system labeled by the individual in which it's entering the information into the system. 2) Invoices are prepared within the accounting software printed and then scanned with all supporting documentation into this electronic filing system. 3) Journal entries once prepared are printed attached with supporting documentation and then scan it to the electronic filing system. 4) Other items in which we keep electronic documentation following similar process these include bank reconciliations, contracts, and other pertinent files. All documentation is also kept within a filing system here within our department. Each group of documented items are labeled and filed chronologically in a centralized location. As we move through FY24 into FY25 we will continue to review and improve this internal process.

Management’s Corrective Action Plan For the Year Ended December 31, 2023 Contact Person(s): Sophia Hernandez, Chief Operations Officer Sophia.Hernandez@youthcare.org Amber Aman, Deputy Operations Office - Finance Amber.Aman@youthcare.org Finding Number: 2023 - 002 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action taken: • Develop a contract expenditure compliance review process created with final review and approval by Deputy Operations Officers. To be established by September 30th, 2024, and implemented in 2025 annual operating plan Anticipated completion date: In Process

Corrective Action: ABHS plans to optimize technology to improve the month-end closing process and allow for reconciliations to be performed on a consistent basis. Person Responsible: Alethea Velasquez, Chief Financial Officer, and CLA Estimated Completion Date: December 31, 2024

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Grantor no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

Audit Finding Number: 2023-002 Responsible Person: Carrie Smith, AVP of Regulatory Response to Findings: The Accounting Team performed an internal review and agrees with the Uniform Guidance audit findings. An adjustment was recorded as of 12/31/2023. In addition, the finding was communicated to the State auditors. Corrective Action to be Taken: 1. VillageCare will continue to utilize project ID when recording grants revenue and grants expenses. 2. Only appropriate, non-duplicative, and verified invoices will be submitted by the Accounts Payable Department for reimbursement. The AVP of Regulatory will receive and review all invoices from AP prior to submission to the funding source. 3. For material reimbursement, the Procurement Department will ensure the goods are received. 4. The Accounting Team will maintain all potential reimbursement schedules and cross check against current and past grants to ensure no prior approved expenditures are resubmitted for reimbursement. 5. The Director of Accounting and Finance and/or Controller will only approve grants receivable accrual based on allowable, confirmed, and validated invoices. Completion Date or Anticipated Completion Date of the Action to be Taken: September 1, 2024.

Over the past year, we have made significant improvements, reducing the occurrence of these findings compared to 2022. To continue to improve on and address this, we implemented a new HR solution, Rippling, in 2024, which will ensure all future agreements and rate changes are properly tracked and documented. This system will enhance our document retention process and ensure compliance with federal regulations moving forward.