Corrective Action Plans

Finding 2023-006: Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. The secondary review of match claim workbook did not identify the clerical errors. During testing of expenditures, the following items were identified: a) The number of hours an employee worked per the approved timesheet vs. the hours claimed in the match claim workbook resulted in a clerical error. (1 instance) b) Per review of the supporting timesheet and paystub, an employee had mobile crisis pay which was not accurately reduced in the calculation for match in the match claim workbook (2 instances). Responsible Individuals: Staff Supervisors (Michelle Theesfeld, Kari Van Dam) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. CEO will review all grant staff that also provide mobile crisis to ensure that mobile crisis pay is removed before allocating salary and fringe benefits to grant programs. Anticipated Completion Date: Beginning in January 2023, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

ALN No. 93.498, Provider Relief Fund; Award Year: Period 5: January 1, 2022 to June 30, 2022 Finding: Activities Allowed or Unallowed – The controls were not sufficient to ensure that depreciation expense for capital purchases were excluded when the capital expense was also submitted for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that ledger details are appropriately filtered to exclude depreciation expense for costs already considered during the review of capital expenditures. The Director of Finance will review ledger details prior to submission to ensure only appropriate ledger accounts are included in requests for reimbursement. Person(s) Responsible for Implementing: Jia Paulucci, Director of Finance and Lindsey Soboloski, Controller Implementation Date: February 12, 2024

The Payroll Department has taken immediate action to develop additional safeguards to ensure changes in pay records are accurately reflected on pay lines. We developed monitoring reports to review data extracted from Kronos to data loaded to pay lines. The central Payroll team will use these reports to identify potential discrepancies and correct pay lines prior to giving department liaisons access to the system to review payroll data. Additionally, Payroll will conduct its routine Kronos Security Audit with Business Officers in October. Once complete, Payroll will communicate with designated HR/Payroll Liaisons and Kronos timekeepers to remind them of their roles and responsibilities as it pertains to monitoring and reviewing payroll data during payroll processing. Lastly, Payroll has worked with Human Resources IT to develop a query that will mimic the paysheets and provide an additional review tool at the department and budget center level. Once fully tested it will be rolled out to the Business Officers to assist in the payroll review process. Anticipated Completion Date: December 31, 2023 Person Responsible for Corrective action: Amelia Hood, Director of Payroll Contact/Responsible Party: Sherri Rowland, AVP and Controller Contact Information: sherrir@clemson.edu

The Home contacted the Office of Refugee Resettlement (ORR) and was instructed to keep the funds and submit a carry-over request for these funds.

Finding 2023-004 – Special Education Cluster – Earmarking Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-508-0504 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Business Affairs & HR will work with the Special Education Coop to ensure compliance with the Earmarking requirement. Anticipated Completion Date: February 2024

Pacific University acknowledges the importance of an effective control environment. University policies do require approval of all timesheets. Management will re-emphasize the importance of this key approval control and periodically review supervisor compliance (with follow-up on exceptions). The approval requirement will also be added to Pacific’s mandatory annual compliance training for supervisors.

Finding Number: 2023‐010 Federal Program, Assistance Listing Number and Name: 14.218, Department of Housing and Urban Development, Community Development Block Grant/Entitlement Grants Cluster, Community Development Block Grant/Entitlement Grants (CDBG) 14.241, Department of Housing and Urban Development, Housing Opportunities for Persons With Aids (HOPWA) 14.905, Department of Housing and Urban Development, Lead Hazard Reduction Demonstration Grant Program (Lead) Condition: Original Finding Description: The City duplicated costs charged to certain grants. Contact Person Responsible for Corrective Action: Regina Greear (ODFS) and Cynthia Saxton (OGA) Anticipated Completion Date: June 2023 Planned Corrective Action: The City will review during the AFCAP process and implement additional training that includes a review of its journal entry controls and approval processes to ensure journal entries are posted accurately and no duplicates costs.

Identifying Number: 2023-001 Finding: For 3 out of the 26 transactions selected for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program, the expenditures were recorded for an inaccurate amount. For 1 out of 25 transactions selected for the Transitional Living for Homeless Youth program, the expenditure was not accrued in the appropriate fiscal year in accordance with U.S. GAAP. Corrective Action Plan for Audit Finding 2023-001: The first item above related to rental payment. Incorrect payment made due to incorrect information/approval from the program. An additional level of lease review by Director of Finance and Business added to confirm payment matches lease upon initiation of new leases and lease renewals. The second item above related to a gas card account. The Director of Finance & Business and Director of Accounting have discussed this. An item added to year-end/audit check list to review October statement and identify/accrue any expenses incurred on or prior to September 30. Responsible for Corrective Action Plan: Julie Pool, Director of Finance & Business

Finding Number 2023-002 • Significant deficiency in internal controls over compliance related to allowable costs and period of performance. Criteria • 2 U.S. CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards require that costs must be necessary and reasonable for the performance of the Federal Award, that costs be determined in accordance with GAAP, and that costs be adequately documented including the allocation of those costs. Condition/Context for Evaluation • IPHC’s internal controls over non-payroll charges to the Federal Award did not include review for allowability, accrual in the proper period, or that adequate documentation existed to support the amounts charged or allocated. Three out of 25 nonpayroll disbursements tested did not include evidence supporting one or more of these controls. Questioned Costs • $2,674 Cause • IPHC’s operation of internal controls were not sufficient to ensure allowable costs were charged in accordance with 2 U.S. CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Effect or Potential Effect • As a result, charges were made to Federal awards that were not allowable. Repeat Finding • Not applicable. Recommendation • We recommend that IPHC ensure internal controls include reviewing costs charged to the Federal Award for conformity with 2 U.S. CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards for allowability, allocability, and reasonableness. o Allowability 200.403, 200.404, 200.405 o Allowable budget period – 200.403 (h) Contact Person(s): • Executive Director: David Wilson (david.wilson@iphc.int); • Assistant Director: Andrea Keikkala (andrea.keikkala@iphc.int) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: We acknowledge that the deficiencies identified, while minor in dollar value to the grant, represent areas for improvement. The specific issues identified were: 1. Field office rental: A field office rental statement was partially charged to the incorrect fiscal year. Reason: The landlord submitted the invoice for payment after the year-end close (FY2022) and was subsequently fully charged to FY2023, instead of being split across fiscal years. 2. Postage (2 elements): The IPHC loads postage stamps on a stamps.com account to process missing logbook notices to vessel owners, a function that pertains to a grant. Clear delineation of the cost of the stamps allocated to the grant and the stamps allocated to activities that do not qualify under the grant were not enumerated. The employee that requested the stamps in the procurement software did so because the lead team member was not available. When procuring the stamps the face-value of a stamp was used at $0.60 instead of $0.57, a discount the organization receives due to bulk purchase and stamp.com membership. The cost of this error was $9.96. At the start of FY2023, we used a single operating Fund (Fund 30 – Statistics) to record income and expenses for data related activities that included some grant funds. During the course of the year, we commenced the development of the new 5-year grant application with NOAA Fisheries to cover IPHC’s Directed Commercial Catch Sampling of Pacific halibut in Alaska (IPHC Grant 802) (Grant Number: NOAA-NMFS-AK-2023-2007663) from FY2022-FY2026. During this grant renewal/development process, a decision was taken to split Fund 30 – Statistics into two, with Fund 35 AK Cost-Recovery being created. This new Fund 35 was developed to contain only those expenses and income that were deemed as eligible under the grant rules. Over the course of the year, the Secretariat categorized income and expenses between the two Funds, which involved recoding some transactions coded to Fund 30 at the start of the fiscal year, to Fund 35 later in the year. For FY2024, we will continue to undertake monthly reconciliation and month-end close processes to ensure charges are appropriately coded and attributed. In addition, the year-end reconciliation and close processes will support the attestation of funds spent under the grant within one month of the fiscal year ending. This proactive approach aims to ensure timely completion for the single audit, allowing for comprehensive scrutiny of costs assigned to the grant before incorporating financial statements for review during the single audit process. Further, we will ensure preliminary scrutiny and month-end close of financial reports pertaining to grant funds before loading them to the auditors for review. Finally, our procedures have already been improved to ensure that costs charged to the federal awards are charged to the appropriate activity code and are allowable under federal cost principles. Anticipated completion date: Completed - 1 December 2023, and annually by year-end closeout.

Finding Number: FS-2023-003 Contact Person: Richard Edwards, Director and Veryl Begay, Business Manager Anticipated Completion Date: March 31, 2024 Planned Corrective Action: When the Business manager left without turning over access or authority, KRCI struggled to perform even the smallest of tasks. In Addition to the obstruction and difficulty finding records, the former Business Manager with the approval of a Board Member, removed numerous records from the campus when clearing their office. A police report was made regarding the potential theft and a folder containing credit card information was returned by the former employee, but KRCI is not confident that all records belonging to the Campus were returned. No central system was established for archiving and security of procurement records. There were no backup systems or redundancy, and separation of duties did not exist due to the extremely limited staff.

Management will ensure an effective review of reimbursement requests prior to submission to ensure all costs requested are legitimate and allowable. Contact Person: Mayor Leroy Sullivan and Sandra Williams. Anticipated Completion Date: Annual basis/as needed

The finding is correct in the fact that money was charged to the wrong grant award. However, as a whole with the grant awards from all of the American Rescue Plan Act, Vantage Career Center gave more money to students then the grants required. Moving forward the Treasurer will be more involved with the requirements of administering the grants from the beginning.

Management agrees with this finding and will implement a more detailed review process of FEMA grant reimbursement requests for future disasters to ensure equipment hour costs reported are accurate. Anticipated Completion Date: June 30, 2024. Responsible Contact Person: David Yellott.

Finding: 2023-002: Questioned Cost – Material Weakness Costs for US Department of Transportation, Mobility Management Grant 20.507 Section 5307 included a $30,000 charge for use of the Data Management System (DMS). The charge is based on a contract rate charged to outside entities that varies depending on the number of users. Management stated the charge was to recoup costs for use of the DMS. Costs for the DMS consist of historical costs to get the system functioning, along with current personnel costs to operate the system and provide the contracted training. The historical costs occurred outside the period of performance and are thus unallowable. Personnel costs are already being charged to the grant through the allocated payroll and benefits of trainers and other personnel, and thus should not also be charged through the contract rate. In addition, if the contract rate includes a profit component this would also be unallowable to charge to the grant. Auditor Recommendation: We recommend that costs charged to federal grants be reviewed by an individual familiar with the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 as part of the SEFA review process. Contact Person Responsible for the Corrective Action: Lisa Cappellari, Chief Financial Officer, LisaC@paratransit.org Management Response and Corrective Action Plan: After the end of Fiscal Year 23-24 on 6/30/2024, Jody Wadley, Finance and Grants Manager, and Lisa Cappellari, Chief Financial Officer, will compile all expense to be charged to any federal grants. Tiffani Scott, Chief Executive Officer, will review the expense against the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 to make sure all expense is eligible.

Condition: A sample of 118 payroll-related expenditures were randomly selected for testing using a random sampling approach, of which included a total of 37 district employees paid & claimed under this grant. These payroll-related expenditures were reviewed to determine if appropriate internal controls were implemented and applicable compliance requirements were met. Upon completing this testing, we noted the following discrepancies: -There were 4 employee salary & benefits claimed that were not included in the 22-4998-E3 grant budget detail. The budget specified teachers & paraprofessionals, and support staff were not included, resulting in known questioned costs of $4,857.50. -There were 11 employees where a portion of the claimed payroll & benefits were deemed allowable per the budget but $8,947.88 was deemed not allowable, resulting in known questioned costs of $8,947.88. -Additionally, there were $6,686.25 of the employee salary & benefits that was not deemed allowable per the budget as the pay period dates did not align with “loss of learning” related pay dates or other approved activities. Plan: The District will review its policies and procedures to ensure that potential expenditures are approved are deemed to be allowable before spending federal funds. In addition, the District will consider implementing a monitoring process to ensure that control procedures are being followed. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made. On occasion, payment requests do not have an invoice number. To prevent duplicate payments, the Accounts Payable staff require original invoices and uses a system generated invoice number, or a will use a manual entry numbering convention to prevent duplicate invoice numbers. The invoice data is entered by an Accounts Payable specialist and reviewed by the Accounts Payable Manager. On occasion, A/P must request corrected invoices from vendors who try and reuse invoice numbers. The A/P Manager reviews invoice numbers during the check run for accuracy. Purchasing and A/P will also periodically review the vendor database for duplicate vendors. For construction projects that list a pay application number instead of an invoice number, A/P will implement a consistent invoice numbering convention to avoid duplicate payments. The A/P specialists will also review the PO payment history prior to processing. Responsible party(ies) for corrective action(s): Accounts Payable Manager Corrective action(s) timeline: December 1, 2023

The District acknowledges the finding regarding the unallowed costs associated with the 21st CCLC Grant. During the audit process, we found that salary costs within this grant were included in error and should not have been. We have contacted both the fiscal department for 21st CCLC and NYSED Grants Finance, in hopes to correct this issue. We adjusted the FS10F report for final expenses and copies are being sent out to the appropriate departments for correction. This issue should be resolved by January 2024 and will be implemented by the Business Manager, Christopher Karwiel.

In order to ensure proper compliance with federal award distribution, the CFO or Controller will review for proper support and documentation before any federal funds are released. Furthermore, the CFO and Controller will review the sample of 60 expenditures the auditors reviewed for the fiscal year 2023 audit, and immediately develop procedures to strengthen internal controls surrounding the disbursement of federal funds.

The School District of the City of Harper Woods submits the following corrective action plans concerning findings on the schedule of findings and questioned costs: 2023-001-Audit Adjustments-Material Weakness Corrective Action The District's Chief Financial Team in coordination with the financial consultants will ensure that accounting records are completed timely and review and correct the 147c payment accruals for proper reporting in the following fiscal years. This correction will be completed by 6/30/24. 2023-002 -Material Weakness & Material Noncompliance-Allowable Costs/Cost Principles related to Title 1, Part A -Grants to Local Education Agencies, Assistance Listing Number 84-010A, Award Number 231530 and the Education Stabilization Fund, Assistance Listing Number 84.426D, Award Number 213712 Corrective Action The District's Chief Financial Team in coordination with the financial consultants and grant consultants to simplify the grant budgets so that it is easier to stay within each grant function. Also, a review will be made to ensure that the district is within budget in each grant function. This correction will be completed by 6/30/24.

Recommendations: Management should enhance its internal control procedures to ensure all disbursements and payroll transactions charged to the federal program are supported by complete and properly approved documentation consistent with 2 CFR Part 200 and the operating contract. This includes retaining invoices, approvals, check copies, personnel files, and pay-rate authorizations. Management should assign clear responsibility for recordkeeping, implement periodic reviews for completeness, and provide staff training on documentation and retention expectations. Views of responsible officials and planned corrective actions: Management agrees with the findings and will ensure that all original supporting documents are maintained at the organization’s office in a secure location for a minimum of three years after an independent audit, and that every transaction is properly authorized and documented before expending monetary resources. Anticipated Completion Date: May 1, 2024

Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation methodologies ▪ Require approval and documentation of all journal entries affecting federal programs ▪ Provide training to staff on Uniform Guidance cost principles (2 CFR 200 Subpart E) ▪ Conduct periodic internal reviews to ensure compliance

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025

Chairman of the Board of County Commissioners: These disbursement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure compliance with grant requirements, • establishing written standards of conduct to address and set clear guidelines over grant requirements, • and enhancing oversight and review to ensure all processes are fully compliant with federal regulations. Our goal is to build a consistent, transparent procurement framework that safeguards both compliance and public trust. County Clerk: I was not the County Clerk in office at this time. To correct this issue. the County plans to develop a SOP to timely and accurately track and report on federal funds. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.