Corrective Action Plans

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

An error was identified in the Excel spreadsheet (Model) used to allocate technology costs to projects where Coleridge is obligated to provide Administrative Data Research Facility (ADRF) services. The effect of this error was costs were under-allocated to projects. Corrective Action Plan: 1. The error in the Model has been corrected. 2. Control checks will be built into the Model to highlight when calculations are not working, or outputs fall outside expected ranges. 3. On a monthly basis, the Controller will review the Model and sign off in writing that the allocations are correct. No invoices will be released until the review and sign-off has been completed. 4. On an annual basis, an internal audit will be performed on the Model to validate that calculations are working as intended. The audit will be conducted by a member of the Finance department who is not a user of the Model. Any issues identified during the audit will be documented. The Controller will take action to remediate all issues and certify in writing when this work has been completed. No invoices will be released until the certification has been completed.

Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interpretation. As a result of this finding, BCDJFS will reassign the FCFC Coordinator to the shared cost pool and reimburse the shared cost pool from the applicable FCFC allocations through a MOU signed between the council and BCDJFS

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.

Generally, 4th Quarter cross charges are processed in January. ACED will process cross-charges monthly and accrue any remaining costs incurred (payroll and non-payroll), should there be any, at the end of the 4th Quarter. This procedure is written in our policies and procedures manual. (p. 38) D. Timetable of dates for performance of planned corrective action steps, including completion date: This process was written into our policy and procedures manual (attached) which was awaiting HUD’s review and will be implemented in the 3rd quarter of 2025 to align with the CDBG 2025 program year. Accruals for the end of 2025 will be submitted before January 2026.

ACED has developed a procedure to ensure that cross charges are done timely. The process is outlined in the attached policy and procedure manual. (p. 38). Since the error occurred due to staff turnover, current ACED staff have been trained and others cross-trained to process cross charges and properly record them in JDE. ACED will re-examine all cross-charges to identify charges that were not properly recorded in JDE.

We agree with the findings and recommendations. This was an isolated incident whereas the payment amount was mistakenly pulled from the wrong line on a contractor’s pay application. This overpayment was missed in the subject fiscal year as the program was still active. Once the overpayment was identified, the county sought reimbursement from the vendor for the overpayment and has since received the funds. The reimbursement will be included as program revenues in the next audit report. The County will reconcile contract values as each pay application is processed in lieu of awaiting program/project closeout in the future.

FINDING 2024-003 Finding Subject: COVID 19 Coronavirus State and Local Fiscal Recovery - Subrecipient Monitoring Contact Person Responsible for Corrective Action: Gretchen Parker Contact Phone Number and Email Address: 765-648-6113 gparker@cityofanderson.com Views of Responsible Officials: "We concur with the finding." Description of Corrective Action Plan: The city has several individuals involved in the monitoring of activities related to the COVID 19 Coronavirus State and Local Fiscal Recovery federal award. The city has implemented procedures to ensure oversight and review of subrecipient reports is properly documented. Anticipated Completion Date: September 1, 2025

We have adjusted our policies and procedures to assure that every claim submission is reviewed by both the Controller and CFO prior to submission. Claim forms and appropriate documentation will be submitted to the Controller who will give initial review. Review will consider timeliness of items claimed as well as appropriateness for the particular federal grant. CFO will then provide final authorization in writing to both grant accountant and controller at which time claim for reimbursement can be submitted by grant accountant.

Significant improvements were made in 2024, and again this year’s findings highlight the need for stronger documentation of signed contracts, approved rate changes, and allocation support. To address this, we are further expanding use of the HR Solution’s (Rippling) workflow and document management tools to automate approvals and ensure a complete audit trail. In addition, our new global hub structure, with dedicated HR support functions, will provide greater oversight and consistency across entities. These measures will enhance compliance and reduce the risk of recurrence going forward.

U.S. Department of Housing and Urban Development – CFDA 14.228 Condition: The County charged payroll costs using an internal allocation method that included salaries, benefits, and supplies, rather than actual expenditures. This method was not supported by an approved cost allocation plan. Additionally, the hours charged were based on total grant administration time, not specific to the CDBG program. Recommendation: The County should ensure that all costs charged to federal programs are based on actual expenditures or an approved cost allocation plan. Documentation should be maintained to support all reported costs, and internal controls should be strengthened to prevent reliance on unsupported methodologies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will not be applying for any CDBG grants in the future unless there is adequate administrative cost allocation in the grant. The County will continue to make every effort to adequately close out CDBG grants and provide reports to the granting organization as staff and priorities allow. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for corrective action plan: Completed and on-going

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.

2024-005 Lack of Written Allocation Plan for Shared Costs Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A plan has been written for FY25.

Item: 2024-002 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

Correction action • Finance will work HR and Program staff to document written procedures for staffing allocations. • Finance will strengthen monthly project monitoring of project activity and also ensure that budget changes, if necessary, are approved by the Grants Manager. • Drawdown process is being revised to ensure that the general ledger activity, pending draw request, and vendor payables are all in sync. • Finance will contact Grant Manager responsible for each grant to develop plan of action for returning any overdrawn funds. Responsible Person • Associate Director - Finance Anticipated completion date • September 30, 2025

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Uniform Guidance.

Finding 2024-003: Unsubstantiated Expense The single audit report included the following recommendation: We recommend that management strengthen the process to identify and review funding sources of underlying expenditures, that support the amounts of the reclassification journal entries. This could include reviewing approved budgets for the federal award in scope at a necessary level of detail to determine appropriateness of allocations in a timely manner. Management Response/Status of Action Plans: Amtrak believes education and reinforcing the existing upfront controls to ensure the correct initial coding of the expenditures is correct is the best way to address this issue. When this issue was identified during the audit, the company coordinated a meeting with the department where these costs originated to reinforce the need to properly code the expenditures in the purchase order process. Leadership in that department acknowledged the miscoding and committed to proper coding going forward. The company understands that the issue of training on this control to properly code purchase orders may exist in other departments and will develop communication to reinforce education in the proper processes and controls in this area. The contact for this item is Carol Hanna, VP Controller. Amtrak anticipates that changes described above will remediate this finding in the fiscal year ending September 30, 2025

During the fiscal year under audit, NASF hosted two events at the same hotel – one charged to a nonfederal program and the other related to a federal program. Initially, all event-related cost were charged to the nonfederal program. Subsequently, $28,500 was reclassified to the Federal program. As a result, $18,387 was incorrectly charged to the Federal award. The Executive Director and Chief Financial Officer have established the following corrective action plan to be completed in May, 2025 and going forward: 1. Include individual grant Profit & Loss statements to the monthly close review process to help strengthen internal controls over expenditures and make sure all cost charged to the programs are allowable under 2 CFR 200.403. 2. Provide training to NASF staff and contractors on the requirements for allowable cost. 3. NASF has informed the funder (U.S. Forest Service) - Lynne Sholty (Supervisory Grants and Agreements Specialist) about the unallowable cost of $18,387. At time of this response, we are awaiting invoice so NASF can repay the balance in full. This corrected action has an anticipated completion day of 60 days (June 30th, 2025) by the Chief Financial Officer (Rafael Chapman) in conjunction with Executive Director (James Farrell).

This finding is related to activities on our VOCA grants. This exception was related to a process in place prior to May 2023 for allocating our outside contracted IT services Again, in May 2023 FRLS added an electronic transaction approval process via Teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. FRLS failed to update its allocation for this prior allocation method for this legacy vendor. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This change will be made within the next 60 days.

Georgia Tech management agrees that internal audit reports demonstrated departmental deficiencies in knowledge of policies and procedures that needed to be addressed. Upon disclosure of Internal Audit’s recommendations, the departments and central offices immediately responded with additional training, proactive compliance reviews, and re-enforcement of existing policies and procedures via Institute wide communications and enhanced reviews of support. New system controls regarding spend authorizations were put in place, with Georgia Tech’s Internal Audit department continuing to test these controls through the month of February. Central and departmental units within Georgia Tech will continue to work together to further enhance guidance and training to faculty and staff and to identify and test controls in our systems that will mitigate these issues.

Percentages used for allocations will be reviewed annually across all grants/programs and updated during the budget process. These allocations will be reviewed by the CFO.

a. Name of Contact Person Responsible for Corrective Action: Candy Norvell b.Corrective Action Planned: North Tippah is transitioning to a digital time clock system. All employees will log their time through the Time Trust system. The Food Service Director ,business manager and the superintendent will review and make adjustments to the part time accounts payable employee’s salary. c.Anticipated Completion Date: 7/1/25

Finding Number: 2024-001 Planned Corrective Action: Meals on Wheels of the Monterey Peninsula (MOWMP) will address the finding by taking the steps outlined below: 1. Expenditure Allocation: Controller and/or bookkeeper will allocate expenditures based on the number of meals prepared each month and the percentage of meals prepared for each program and funding. Yearly reviews of the allocation process will be conducted to ensure accuracy and relevance. Adjustments may be made based on changes in meal demand, program requirements, funding sources, or other factors affecting meal preparation costs. 2. Payroll Reporting: On a yearly basis, Managers and/or Directors will allocate the amount of time each employe works based on tasks performed and the amount of time worked on federal award activities. This allocation will be expressed as a percentage of total work hours performed. Periodic adjustments to time allocations may be necessary to reflect changes in project priorities, staffing levels, or other factors affecting workload distribution. Person Responsible for Corrective Action Plan: Leadership Oversight – Christine Winge, Executive Director Operational Oversight – Kay Smith, Controller Anticipated Date of Completion: MOWMP will complete the Corrective Action Plan by June 1, 2024 and these new policies and procedures will be in full effect throughout fiscal year 2025 and beyond. We will continue to review effectiveness and make changes as necessary.

2024-002 Allowable Costs & Principles a. Corrective Action-PHA will work with its Fee Accountant to create a detailed, comprehensive expense allocation plan. The current allocation plan listed as an activity level control has been in place for many years.