Corrective Action Plans

2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.

Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with Uniform Guidance requirements for indirect costs, the following actions will be implemented: 1. Establish Written Indirect Cost Procedures – Develop and document procedures to ensure indirect costs are consistently calculated at the approved de minimis rate per the federal grant award on total direct costs during the performance period. 2. Implement Pre-Posting Review – Require a supervisory review of indirect cost calculations before charges are recorded to the general ledger and before grant reimbursements are submitted. We have implemented new procedures to ensure that indirect costs are included in each invoice for reimbursement. 3. Staff Training – Provide training for grants and finance staff on indirect cost requirements, the proper application of the de minimis rate, and reconciliation processes in accordance with 2 CFR 200.414(f). 4. Quarterly Reconciliations – Implement quarterly reconciliations of indirect costs applied to grants to confirm rates are applied correctly and consistently throughout the fiscal year. 5. Continuity Controls – Assign responsibility for indirect cost oversight to both a primary and a backup staff member to ensure consistency during periods of management turnover. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • New procedures: June 15, 2025 • Written procedures in place: December 31, 2025 • Staff training completed: January 31, 2026 • Supervisory review and reconciliations implemented: Beginning with January 2026 close

Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with 2 CFR 200.403(e), the following actions will be implemented: 1. Establish Written Cutoff Procedures – Formal written procedures will be developed for reviewing service dates and supporting documentation prior to posting expenditures in the general ledger. These procedures will specifically address Uniform Guidance period-of-performance requirements. 2. Implement Supervisory Review – All expenditures charged to federal awards will undergo supervisory review at period-end. The review will confirm that expenses are recorded in the proper performance period before submission for reimbursement. Effective June 2025, the Vice President of Finance and the Controller performed a retrospective review of 2024 expenses to confirm that they were allocated to the correct reporting period. This supervisory review has continued into the current reporting period with no exceptions noted. 3. Staff Training – Grants and finance staff will receive focused training on Uniform Guidance cost principles, proper expenditure cutoff, and documentation standards to ensure consistent application. Staff training will include review of the finding and leadership will highlight the importance of verifying the correct reporting period for each entry. 4. Continuity Controls – To address turnover risk, responsibility for cutoff procedures will be assigned to both a primary and a backup staff member to provide coverage and reduce errors caused by staff changes. 5. Ongoing Monitoring – The VP of Finance will review quarterly grant compliance checklists and provide updates to senior leadership and the Finance Committee. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • Management supervisory review procedures: June 15, 2025 • Written cutoff procedures in place: December 31, 2025 • Staff training completed: January 31, 2026

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.

Management will evaluate systems and processes to ensure time tracking procedures meet the standards outlined in the Uniform Guidance.

Management concurs with the recommendation and is committed to strengthening internal controls over the grant reporting process to similar overcharges in the future. To address the identified issues, FWCRC will implement the following corrective actions: - Draw Submission Reviews: We will establish a formal review protocol for all draw submissions to verify that expenses have not been previously reimbursed. This will include cross-referencing prior draws and maintaining detailed tracking logs. - Staff Training: Targeted training sessions will be provided to accounting and grants management personnel. These sessions will focus on federal cost principles, allowable costs, and proper drawdown procedures to ensure compliance and consistency. - Oversight and Reconciliation: Supervisory review procedures will be enhanced to include reconciliation of all funding sources prior to draw submission. This will help ensure accuracy and prevent duplication of reimbursements.

Management concurs with the finding. External experts were engaged to assist in preparing the indirect cost rate calculation, which is currently under internal review. The College plans to submit the finalized rate to the pass-through entity in 2025 and will take all necessary actions resulting from this submission to ensure compliance. Upon completion of this process, management will update internal procedures and provide comprehensive staff training to ensure the accurate preparation of the indirect cost rate and full compliance with 2 CFR Part 200. To strengthen ongoing compliance and accountability, management will implement an annual review and recalculation of the indirect cost recovery rate. The Controller will oversee the annual recalculation, while the Technical and Internal Controls Accountant will review the indirect cost pool to confirm the allowability and allocability of expenses. These measures will reinforce accuracy, transparency, and integrity in the administration of federal awards.

2024-002 – Allowable Costs/Cost Principles Corrective Action: ABHS has implemented a new accounting and payroll system which allows the organization to reconcile employee benefit expenditures monthly. These systems were implemented in March and April of 2025 and management expects this finding to be resolved in 2025. Person Responsible: Alethea Velasquez, Chief Financial Officer Estimated Completion Date: December 31, 2025

Corrective Action Plan: Management is in the process of working with HHS to renew the Provisional Rate agreements. The anticipation is that the agreement will be completed by the end of 2025. Anticipated Completion Date: December 31, 2025

Management agrees with the finding and in the summer of 2024, contracted with a third party accounting company to provide services.

Finding 2024-002 – Material Weakness – Inadequate Documentation Condition We selected a sample of both payroll and nonpayroll related expenditures for controls and compliance. During our testing of payroll expenditures, there were five instances out of 11 in which a timesheet or other documentation could not be located to support a payment made to an employee. During our testing of nonpayroll related expenditures, there were three instances out of 18 in which an invoice for the selected expenditure lacked proper documented approvals. Recommendation All employees in the Finance Department and associated with any federal program must be adequately trained in overall federal regulations and guidance as well as other requirements associated with each federal award. All such employees must read the grant-related policies and internal control policies. Management should check to ensure all federal grant expenditures are properly approved and have supporting documentation. Management’s Corrective Action Plan The Corporation has experienced staff turnover which resulted in process challenges. Nevertheless, the Corporation will take this recommendation and implement revised procedures to ensure that the Finance Department and other pertinent Corporation resources receive federal regulations and guidance training, incorporate available systems and technology capabilities available from the technology service providers, and adopt best practices. Finance will schedule regular grant reviews, inclusive of program expenditures. Contact Person: Richonda Pelzer, Chief Financial Officer Anticipated Completion Date: March 31, 2026

To whom it may concern: The Carmelite System, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING – FEDERAL AWARD PROGRAM AUDITS 2024-001 Federal Agency: U.S. Department of Homeland Security Federal Program Title: Federal Emergency Management Agency Disaster Grants Assistance Listing Number: 97.036 Federal Award Number and Year: 4496DR 2024 Pass-Through Agency: State of Massachusetts Pass-Through Number: CTFEMA4496STPAT00971 Criteria or Specific Requirement: In accordance with 2 CFR §200.403(g), to be allowable under federal awards, costs must be adequately documented. Additionally, 2 CFR §200.303 requires non-federal entities to establish and maintain effective internal control over the federal award that provides reasonable assurance that the entity is managing the award in compliance with federal statutes, regulations, and the terms and conditions of the award. Condition: During testing of expenditures under the FEMA grant, the System was unable to provide documentation showing approval of an invoice dated May 2020. This invoice was selected as part of the single audit sample. The lack of approval documentation represents a deficiency in internal controls over compliance with federal requirements. Questioned Costs: None. Context: The invoice in question was incurred in May 2020, prior to the implementation of the Acumatica AP approval workflow. In June 2020, the facility transitioned to Acumatica, which provides electronic tracking of invoice approvals. Cause: At the time of the expenditure, the facility did not have a centralized or electronic approval process in place. Approval documentation was maintained manually and was not retained or accessible during the audit. Effect: The absence of approval documentation for the invoice creates a risk that expenditures may not be properly reviewed or authorized, potentially leading to noncompliance with federal requirements. Although the cost was ultimately deemed allowable, the control deficiency could impact future compliance if not addressed. Recommendation: We recommend that the System ensure all expenditures under federal awards are supported by documented approvals. For legacy transactions, efforts should be made to retain or reconstruct approval documentation where feasible. Continued use and monitoring of the Acumatica system should be maintained to ensure compliance going forward. Planned Corrective Actions: Management agrees with the finding. The invoice in question was incurred during an emergency response period prior to the implementation of the Acumatica system. While approval was likely obtained at the time, documentation was not retained. With the implementation of the Acumatica AP approval process in June 2020, the System has taken appropriate steps to address the finding and enhance internal controls over invoice approvals. Name of contact person responsible for corrective action: Corrinne Schindler

All five (5) properties were SOLD

Management has reinforced the effective execution of existing controls around proper documentation of all expenditures and record retention for these expenditures. Monthly and year-end procedures have been updated to ensure compliance with these procedures. Anticipated completion date: June 30, 2025.

Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies. Senior staff will review payroll data to ensure calculations are being made and reported. Expected Completion Date: The Organization expects all findings to be resolved by December 31, 2025

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services (DHSS) Audit Finding Number: 2024-008 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: Corrective action planned is as follows: The agency does not agree with the audit findings and therefore no corrective action is required. Explanation and specific reasons are as follows: Department of Health and Senior Services (DHSS) disagrees with this finding because the previous audit finding in the FY2023 SWSA was not sustained by the federal funding agency, therefore no finding or corrective action is required.

The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior to supervisor's approval of the cost.

Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inadvertently recorded twice for the fiscal year, resulting in an overstatement of personnel costs charged to the federal award. Further, indirect costs were charged in excess of the budgeted and approved amount under the grant agreement. Corrective Action Plan – Henry Ford Health agrees with this finding. The payroll expense was corrected in the Schedule of Expenditures of Federal Awards and will be corrected in September 30, 2025, Federal Financial Report. Prospectively the payroll for the employee in question will be processed through our automated payroll time and effort process, rather than through manual journal entries, thus reducing the risk of error. Additionally, set up and review procedures have been enhanced to improve the controls related to recovery of indirect costs. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.

AACF concurs with this finding. AACF submitted a corrective action plan to AmeriCorps and on January 31, 2025 AmeriCorps accepted their corrective action plan and closed the finding. AACF will ensure all requirements under 2 CFR 200.403 and 45 CFR 2540.200-207 are met moving forward.

Finding 2024-004: Cutoff Procedures Issue: Previously, there were no formal cutoff procedures to ensure expenses were recorded in the correct period, which caused inconsistencies and required post-year-end journal entries to correct expense timing. • What's been done: Contracts are now recorded as prepaid or accrued expenses and are being expensed monthly. • Next steps: Salaries and benefits incurred before month-end will be accrued to grants at grant cutoff dates (e.g., September 30) and at year-end. Estimated monthly accruals for salaries will be implemented. • Timeline: Full implementation by the end of September 2025. • Responsible party: Finance manager with oversight by President

The Foundation must submit all expense documentation to New York State for reimbursement approval. Effective immediately, the Foundation will retain at least two copies of such documentation for support of expenses.

All grant expenditures are reviewed by the Director of Grants and Compliance so that no grant expenditures are paid prior to services being received. The current Director of Grants and Compliance took over this position and procedure in November 2024. The material weakness occurred during a time of significant turnover among leadership staff at First Step, prior to the new DIrector of Grants and Compliance taking over this position and procedure. The Director of Grants and Compliance will have the responsibility to ensure the corrective action plan is in place.

2024-005 Reporting Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that the Couty implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2025.

2024-004 Review of Casefiles Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2025

FINDING 2024-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed or Unallowed and Allowable Costs/Cost Principles. Audit Findings: Material Weakness, modified opinion. Contact Person Responsible for Corrective Action: Amy Scarbrough, Sullivan County Auditor Contact Phone Number: (812) 268-4491 Email: ascarbrough@sullivancounty.in.gov Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We understand no allowable cost policy was ever implemented by the County Commissioners and County Council. County officials will work together to make such policy based on Federal Guidelines, which include guidelines that donations not allowable. Expenditures and documentation will be reviewed to verify that future federal funds are not used for donations. Completion Date: March 1, 2026