Corrective Action Plans

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

Corrective Action Taken Management concurs with the finding. The Organization transferred $151,099.42 from its operating funds back into the SFSP program account prior to the financial statements being available to be issued, thereby restoring the unallowable charge. Additionally, to prevent recurrence, the Organization obtained competitive bids and received approval for a written payroll services contract before June 2025, in advance of the start of the camp season (i.e. the Organization’s operating period). This process was conducted in accordance with federal procurement requirements. Planned Ongoing Corrective Action: The Organization has strengthened its procurement and contract approval procedures to ensure all future contracts funded by the SFSP are subject to competitive bidding, documented in writing, and approved by the State agency prior to charging costs to the program. Responsible Official: Chaim Mendel Friedman, Camp Program Administrator, is responsible for overseeing corrective actions and ensuring compliance with procurement standards and cost allowability requirements. Completion Date of Corrective Actions: Corrective actions were completed prior to the date the financial statements were available to be issued, with continuing oversight in subsequent program years.

FINDING 2024-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Clerks office will identify non- compliant activities to ensure that funds are being used appropriately and according to federal guidelines and principals. We will consult with the relevant personnel to ensure understanding of allowable and unallowable activities and identify areas that may need additional training. We will enhance our review and approval process and provide clear documentation requirements to our departments. Anticipated Completion Date: This corrective action plan will go into effect immediately.

Finding Number 2024-005: Activities Allowed or Unallowed, Allowable Costs/Cost Principles – Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action: To ensure compliance with GAAP and accurate reporting on the SEFA, Management will implement formal policies and procedures to accrue federal expenditures in the period in which costs are incurred. Grants Accounting will review payroll transactions and related fringe benefits at period-end to confirm proper accrual and recording. Management will also collaborate with the Payroll Service Provider to enhance accuracy and reduce errors in payroll allocations. These actions are intended to ensure federal expenditures are recorded in the correct fiscal year and prevent recurrence of prior year findings. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, and Luz Gonzales-Toscano Anticipated Completion Date: January 2025 – immediate term and December 2026 software implementation.

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFleur, Executive Director Anticipated Date of Completion: December 31, 2025