Corrective Action Plans

Status: In progress. Planned Corrective Action: This instance has been corrected as the employee's salary has been removed from the ESSER program and replaced with another eligible employee for FY23. Moving forward, employees charged to the High Cost Services program will be included in the overall grant tracker to ensure no more than 100% of their salary has been allocated across all grants. An additional quality review will be conducted prior to the final draw-down of federal grants (by July 15th, annually) to ensure that no employee has had more than 100% of their salary allocated to federal programs. Person(s) Responsible: Justin Pickel, Chief Operating Officer Estimated Completion Date: July 15, 2024

Name of Contact Person: Michael Gaddy Executive Director Corrective Action: Management has already developed and adopted a Cost Allocation Plan. Management will ensure that the Cost Allocation Plan is followed to allocate shared costs properly. Proposed Completion Date: Immediately

Audit Finding Reference: 2023-002 – COVID-19 Education Stabilization Fund - Elementary and Secondary School Emergency Relief Fund – Assistance Listing Number #84.425D Planned Corrective Action: We will add a field to our payroll reports to identify within the system ESSER related salaries and wages so we can compare those reports to our final payroll numbers. Name of Contact Person: Jennifer Rhoads Sr. Director of Accounting Jenniferrhoads@achievementfirst.org Anticipated completion date: November 16, 2023

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER (INCLUDING COVID-19 FUNDING) – FEDERAL ALN 84.027 AND 84.173 2023-002 Internal Control Over Compliance and Material Noncompliance With Federal Allowable Costs Requirements Finding Summary 2 CFR § 200.405 specifies a cost is allocable to a particular federal award if the goods or services involved are chargeable or assignable to that federal award in accordance with relative benefits received. This standard is met if: the cost is incurred specifically for the award, the cost can be distributed in proportions that may be approximated using reasonable methods, and if the cost is necessary to the overall operation of the District and is assignable in part to the federal award in accordance with the principles in 2 CFR 200 Subpart E – Cost Principles. During our audit, we noted that the District did not have adequate internal controls in place to ensure all salary costs charged to the federal special education cluster program met the standard for an allowable or allocable cost as defined by the U.S. Office of Management and Budget’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) allowable costs standards, which resulted in a reportable instance of noncompliance. Corrective Action Plan Actions Planned – The District’s Finance Director, along with special education staff, will review all salaries and benefits being charged to the special education cluster in fiscal 2024 to ensure that adequate time and effort documentation will be maintained for all salaries charged to the program so only allowable costs are being claimed for federal reimbursement. The District will also review its policies and procedures relating to allowable costs for its federal programs to ensure compliance with the Uniform Guidance in the future. Official Responsible – Brady Hoffman, Finance Director. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – Brady Hoffman, Finance Director, will monitor implementation of the corrective action plan to ensure compliance with the Uniform Guidance in the future.

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. Unallowable costs will be identified and documented in the Accounting Policies and Procedures Manual and communicated to the Finance Department and the Organization’s employees. The CFO will regularly communicate these requirements to directors and staff through weekly and monthly meetings to ensure a clear understanding of allowable versus unallowable costs. In addition, quarterly budget-to-actual analyses will be prepared and reviewed to monitor expenditure and ensure costs remain within approved budget limitations.

Management’s Planned Corrective Action: Disagree; There was an error in staff name and not billed to SAPC Substance Abuse Prevention and Control-CPS. Responsible Party: Beaulieu Accountancy Corporation, Accountant Completion Date: 9/25/2024

The HS program has established an internal process of requester/approver in place to review the transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

Contact person(s) responsible: Accounting Manager, Nancy Wilson Recommendation: We recommend that Coalition develop controls and procedures to correctly allocate cost to all activities and funding sources that benefited from the costs. Management’s Response: Corrective action plan: OCADSV added an Administrative Cost Center to its General Ledger effective 10/01/22, the beginning of FY23 and began costing administrative payroll cost to that cost center. Additionally, the organization retrained administrative staff on direct cost allowable activities vs. administrative activities relative to timekeeping and timesheet preparation and the necessity of daily work descriptions supporting the hourly allocation. The Payroll policy that requires supervisors to review and sign off on timesheets and hourly allocations to cost centers was also reviewed. Audit costs for FY22 will be allocated in accordance with 2 CFR 200.405 requirements. Beginning with FY23 all accounting and other admin payroll related cost will be allocated to the administration cost center with the exception of time related to specific grant or other cost center. FY22 grant expenditures were reviewed post year-end and a line-by-line review was conducted to bring the direct and indirect expense cumulative total into compliance with audit findings. Any outstanding reports were adjusted to reflect the adjusted Life of grant to current date reporting. Executive, Financial and Grant Management staff will, during FY24, complete the Online Grants Financial management Training available at onlinefmt.training.ojp.gov to improve knowledge and compliance with 2 CFR 200 guidance and requirements. The said training will be incorporated into onboarding processes for any newly hired employee who have direct responsibilities related to grant management and/or reporting. Effective 6/21/23 and ongoing UPDATED Management’s Response: OCADSV is continuing its’ efforts to implement controls and procedures for directly or indirectly allocating costs to Programs based on the benefit of the cost. The updated policies and procedures manual was approved December 2024 by the board. Direct allocation is continued to be used when a specific budget program line for funding exists, or where Program(s) can be identified. For indirect cost allocation different allocation methods are used, depending on the cost type and only after the Program(s) where the costs benefited are identified. Processes implemented in FY24 and FY 25. Financial staff review grant expenditures line by line, using program budgets to actual provided by the accounting software as additional support, in preparing quarterly funding reimbursements for FY25. Anticipated completion date: 09/30/24

Panthera implemented Chrome River which is a platform that enables electronic review and approval of invoices as part of Panthera’s expense management process. As Panthera expands its operations internationally we plan to implement more controls and procedures to ensure foreign affiliates are properly maintaining all required expenditures documentation and approvals on spending.

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update subrecipient award agreements to ensure the final approved scope of work or project description is specified. Completion Date: March 29, 2023 Explanation: Policies and procedures were updated in 2023 in response to an OJJDP/OCFO recommendation to ensure subaward files contain the requisite components for the award agreement. In addition to these updates, which include a master file checklist, National CASA/GAL has updated the subrecipient Terms & Conditions agreement to include CFR requirements as recommended.

Finding 2022-003Material weakness in internal controls over compliance for allowable activities and costs and material non-compliance inthe Coronavirus State and Local Fiscal Recovery Fund program.Contact Person(s):Nicholas Lee, Chief Financial OfficerCorrective action planned:The Organization will provide additional training to employees responsible for incurring costs in accordance with 2 CFR200.403. Additional resources have been assigned to review and ensure documentation and policies are retained to supportthe distribution of charges between projects. Anticipated completion date:June 30, 2023

CORRECTIVE ACTION PLAN 2021‐2022‐ Finding 1: Significant Deficiency – Allowable Costs/Cost Principles Management’s Response: Delaware County Literacy Council has implemented and followed a cost allocation plan to share costs among different grants consistently. DCLC has instituted a timekeeping and reporting system that properly allocates the cost of salaries and benefits to programs and grants. Data gathered from this system includes the ratio of hours worked in each program to hours worked overall which is used to allocate other expenditures that are attributable to more than one program or grant. DCLC will be within compliance of U.S. Code of Federal Regulations (CFR), Title 2: Grants and Agreements, Part 200 – Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, Subpart E – Cost Principles Sec. 200.405 Allocable Costs Completion Date: April 8, 2024 Name(s) of Person(s) Responsible: Colleen Duran, Executive Director

March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) are managed through a labor allocation whereby amounts of non-direct charged wage time are charged to various programs incorrectly. Corrective Action: We agree with the finding. We have addressed this issue with management within the consortium to properly allocate non-direct wage time. This includes the current (March of 2024) procurement of a sufficient payroll and time keeping software to assist in the remediation of this finding. Contact Person: Shamar Herron: Sherron@mwse.org Completion Date: August 2025, procurement will be completed and system implemented. Respectfully, Shamar Herron

Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to recommend to management the establishment of procedures and controls allocate costs between grants based on actual costs attributed to grant and the particular expenditure allowed by the grant. All such allocations will be supported by activity-level substantiation and be reviewed. Documentation of the allocation methodology, review and approval will be maintained in writing

COSA has already strengthened its procedures and documentation policies to ensure staff documentation are correct. Timesheets are being reviewed by management in the program and finance departments on a monthly basis.

Program: AL 20.509 ? Formula Grants for Rural Areas ? Allowability & Subrecipient Monitoring Corrective Action Plan: The Controller Division, Audit Section, will provide support through continued engagement and work collaboratively as an additional resource to the NDOT Transit staff and transit recipients. NDOT Transit staff in collaboration with the Controller Division will be improving the standard operating Procedures which will be utilized for the in-depth review of monthly invoices moving forward. Contact: Khalil Jaber Anticipated Completion Date: Ongoing

Program: Various, including AL 93.778 ? Medical Assistance Program ? Allowable Costs/Cost Principles Corrective Action Plan: The Print Shop will complete a detailed analysis on the analyzed data, and update rates. State Accounting will offset rates to spend down its fund balance to a 60-day operating level. Contact: Philip Olsen / Ann Martinez Anticipated Completion Date: June 30, 2025

Program: AL 93.558 ? Temporary Assistance to Needy Families; AL 10.561 ? State Administrative Matching Grants for the Supplemental Nutrition Assistance Program; AL 93.658 ? Foster Care Title IV-E ? Allowable Cost/Cost Principles Corrective Action Plan: DHHS will continue to train staff on the proper RMTS procedures, which includes correct method of validation. Contact: Patrick Werner Anticipated Completion Date: 06/30/2023

Program: Various, including AL 10.561 ? State Administrative Matching Grants for the Supplemental Nutrition Assistance Program; AL 93.558 ? Temporary Assistance for Needy Families; AL 93.566 ? Refugee and Entrant Assistance State/Replacement Designee Administered Programs; AL 93.575 ? Child Care and Development Block Grant ? Allowable Costs/Cost Principles Corrective Action Plan: Several areas within DHHS are currently working to improve upon the process of determining how staff are paid during the hiring process and when turnover occurs. Contact: Patrick Werner Anticipated Completion Date: 02/01/2024

CAP for Finding: 2022-704 Finding 2022-704: Research and Development Cluster?Unallowable Costs Planned Corrective Action: We agree with the condition that expenditures noted by the auditors were posted to federal awards in error. Our institution has robust policies and procedures in place along with multiple levels of review for transactions that post to awards. However, there may be rare instances where a transaction posts to an award for which it is not allowable or allocable. As noted by the auditors, they sampled from a population of $86.9 million from certain expenditure codes and only questioned $650 in costs. These expenditures have now been transferred off the awards to non-sponsored funding. To help Research Administrators manage Research and Development Awards, RSP (Research and Sponsored Programs) offers a variety of tools. RSP maintains a website that houses policies and procedures related to all relevant Research Administration topics. In addition to this, the RSP website has FAQ (Frequently Asked Questions) pages on a variety of Research Administration topics. RSP also offers a comprehensive training program called RED (Research Education Development). We offer courses that include topics such as a basic introduction to research administration, closeout of awards, cost-share, cost-transfers, and many others. We will remind administrators and their staff of all the relevant information our website houses and that they should take any pertinent RED. Lastly, we will remind staff that they can retake courses if they haven?t taken them recently and want to refresh their knowledge. Anticipated Completion Date: 5/31/23 Person responsible for corrective action: Kyle Everard, Manager of NSF-DOE Team Research and Sponsored Programs Kyle.Everard@rsp.wisc.edu

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Jamie Arce, Controller Contact Phone Number: 574-322-4863 Views of Responsible Official: Management agrees with the finding. Description of Corrective Action Plan: The City will review its existing policies and procedures surrounding adequate supporting documentation and will update policy as required. Training on this requirement will be provided to all City Staff involved in procurement. Anticipated Completion Date: October 31, 2023

Finding # 2022-007 Title of Finding Subrecipient Monitoring Contact Person Brook Hinzman Anticipated Completion Date June 2023 Corrective Action planned to be taken: Will comply and monitor subrecipient spending going forward.

Item: 2022-003 Assistance Listing Number: 14.241 Programs: Housing Opportunities for Persons with Aids Federal Agency: U.S. Department of Housing and Urban Development Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 144347 Award Year: July 1, 2021 ? June 30, 2022 and July 1, 2022 ? June 30, 2023 Compliance Requirement: Allowable Activities and Costs Criteria: In accordance with 2 CFR ? 200.405 - Allocable costs ? a cost is allocable to a particular Federal award or other cost objective if the goods or services involved are chargeable or assignable to that Federal award or cost objective in accordance with relative benefits received. This standard is met if the cost is incurred specifically for the Federal award, benefits both the Federal award and other work of the non-Federal entity and can be distributed in proportions that may be approximated using reasonable methods and is necessary to the overall operation of the non-Federal entity and is assignable in part to the Federal award in accordance with the principles in subpart E. Condition: In fiscal year 2022, the Organization did not have an adequate process to review and approve employee cell phone costs charged to the program resulting in non-program costs being charged to the program. Name of Contact Person: Mike Fett, CFO Phone Number: (602) 265-8338 Anticipated Completion Date: September 30, 2023 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish additional policies and procedures to ensure adequate review of cell phone bills occurs and terminated and transferred employees are removed immediately. Additionally, we will implement proper review controls over the cost reimbursement reports to identify issues like these timely.

Item: 2022-002 Assistance Listing Number: 14.231 Programs: COVID-19 Emergency Solutions Grant ? Homeless Street Outreach Federal Agency: U.S. Department of Housing and Urban Development Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 154962-0 Award Year: July 1, 2021 ? June 30, 2022 and July 1, 2022 ? September 30, 2022 Criteria: In accordance with 2 CFR ? 200.405 - Allocable costs ? a cost is allocable to a particular Federal award or other cost objective if the goods or services involved are chargeable or assignable to that Federal award or cost objective in accordance with relative benefits received. This standard is met if the cost is incurred specifically for the Federal award, benefits both the Federal award and other work of the non-Federal entity and can be distributed in proportions that may be approximated using reasonable methods and is necessary to the overall operation of the non-Federal entity and is assignable in part to the Federal award in accordance with the principles in subpart E. Condition: In fiscal year 2022, the Organization did not have an adequate process to review and approve employee cell phone costs charged to the program resulting in non-program costs being charged to the program. One employee's phone bill continued to be charged to the grant after they stopped working on the program. Name of Contact Person: Mike Fett, CFO Phone Number: (602) 265-8338 Anticipated Completion Date: September 30, 2023 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish additional policies and procedures to ensure adequate review of cell phone bills occurs and terminated and transferred employees are removed immediately. Additionally, we will implement proper review controls over the cost reimbursement reports to identify issues like these timely.

The allocation of costs between our two federal programs and other programs are made by the Program Director or after discussion between the Program Director and the Federal Grant Manager; then communicated to the accountant. In addition, our accountant has the program knowledge and ability to question cost allocations. Beginning mid-September, 2023, the basis for allocations will be documented on an invoice or other supporting documents. Effective June 2023, weekly payroll time records allocating hours to projects and programs are prepared by each employee. Those time records are approved by the Program Director or the Treasurer, as appropriate. The allocations are then reviewed by the Federal Grant Manager and entered bi-weekly into the accounting records.