Corrective Action Plans

Corrective Action Plan Finding 2024-001 Finding Summary: The Center did not exclude charges for patient care when calculating modified total direct costs (MTDC) in accordance with Uniform Guidance and TxGMS and thus the indirect rate used in calculating the indirect amount charged to the grant was not consistently accurate. Corrective Action Plan: The Center has historically calculated the indirect amount using the same methodology over time. Given the small volume of patient receipts, the impact on the total indirect amount is minor. We believe that had we modified our calculations, we would have had enough modified total direct costs to cover the change in the calculation. The Center will modify all future calculations to ensure alignment. We will also review the fiscal year covered under this audit to understand what the impact of the change would have been on the split between cost types. Note that since we are midway through our next fiscal year, and we consider the differences minor, we have determined that we will correct for any future reimbursement requests, but will not modify prior reimbursement requests. Similarly, we will conduct a review of that fiscal year to determine the impact of the change and verify it is not significant. Responsible Individuals: Rusty Taylor, CFO Joe Carrington, Director of Financial Planning and Analysis Anticipated Completion Date: August 2025

Views of Responsible Officials and Planned Corrective Action: The Department will execute an amendment to the grant agreements for all ARPA funding not disbursed as of 7/1/2024 to include the missing data as detailed in the finding. Staff will be trained on Uniform Guidance requirements. Anticipated Completion Date: June 30, 2025 Contact Person: Debby Dickson Water Development Division Manager Arkansas Department of Agriculture-Natural Resources Division 1 Natural Resources Drive Little Rock, AR 72205 (501) 225-1598 Debra.Dickson@agriculture.arkansas.gov

Views of Responsible Officials and Planned Corrective Action: In 2023, ASBO sent out Amendment #1 for all SLFRF subgrants. This amendment was a one-page sheet providing information for all the requirements listed in 2 CFR § 200.332(a)(1). The subrecipient listed in this finding, Extreme Broadband, did not acknowledge or return their amendment. We will begin to request acknowledgement from this provider on a continuous quarterly basis. Anticipated Completion Date: March 4, 2025 Contact Person: Glen Howie, Jr. Director, Ark State Broadband Office Department of Commerce 1 Commerce Way Little Rock, AR 72202 (501) 682-1123 Glen.Howie@Arkansas.gov

Corrective Action: The Business Manager will calculate the indirect \ cost rate using the rate provided by MDE for the expenditures occurred. The calculation will be reviewed and signed off on by the Federal Programs Director and Child Nutrition Director. This calculation will take place at year end once expenditures are booked. Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: February 18, 2025

Food Distribution Cluster US Department of Agriculture / Oregon Department of Human Services / Farmers Market Fund Federal Assistance Listing Number: 10.565, 10.568, 10.569, 10.182, 10.331 Federal Program Name: Food Distribution Cluster, Local Food Purchase Assistance Cooperative, Gus Schumacher Nutrition Incentive Program OFB’s View on Finding: OFB acknowledges the finding and agrees with the auditors' assessment Responsible Party: Katie Kenton, Interim Co-Director of Finance (Strategic Finance); Nan Wang, Interim Co-Director of Finance (Operational Finance); Starr Yurkewycz, Director of Partnerships and Programs; Nathan Harris, Director of Community Philanthropy; Shannon Oliver, Interim Director of Operations Corrective Action Plan: Finance will assess requirements and establish procedures and internal controls to ensure the consistent application, billing, and reporting of indirect cost rates across all federal awards. This will include collaborating with grant writing staff during the pre-application and pre-award phases to centralize grant preparation and ensure indirect rates are accurately applied in grant proposals and budgets. Multiple dedicated review steps in the grant lifecycle will be developed to both ensure accuracy of the rates charged and address any changes from the Federal Government. Existing strengths, tools, and capacity will be reviewed to support this process, including alignment with subrecipient indirect cost practices. Training will be provided to individuals responsible for these controls to ensure accurate implementation and ongoing compliance. These actions will improve our ability to manage indirect costs effectively and ensure compliance with federal requirements. The anticipated completion date is June 30, 2026.

State Treasurer’s Office Response/Corrective Action Plan: The Office of State Treasurer does agree with finding that our grant award template did not make subrecipients aware of all required grant award information for the Mineral Leasing Act as required. The Office of State Treasurer will review and update its grant award templates to ensure that subrecipients are made aware of all required grant award information. Contact Person: Nicole Krivoruchka, Director of Finance Anticipated Completion Date: December 31, 2025

Finding Number 2023-006 Subject Heading (Financial) or AL no. and program name (Federal) 93.658 – Foster Care Planned Corrective Action The risk assessment cannot be completed until we have actual data and performance needed to make that assessment. Subrecipient risk assessments are completed at the beginning of the fiscal year based on prior year data and performance. The changes to all of the subrecipient agreements identified have been in process and were completed during State fiscal years 2024 and 2025. Additional findings are expected for the 2024 audit since the audit timing is currently almost two years in arrears. Anticipated Completion Date February 2025 Responsible Contact Person Kevin Haddock

Finding Number 2023-096 Subject Heading (Financial) or AL no. and program name (Federal) ALN: 21.019 Federal Program name: Coronavirus Relief Fund (CRF) Planned Corrective Action The State agrees with this finding. Within OMES, oversight and management of Federal grants has been transferred to the OMES Grant Management Office (OMES-GMO) which is staffed with individuals with several years of grant experience. OMES-GMO has a multi-level system of internal controls for grant management and oversight that includes routine monitoring, desk review, and site visits for all projects and associated project/administrative expenditures to ensure allowability, accuracy, and assist in the detection of fraud. Finally, OMES Finance has developed processes which provide for a more thorough coding of expenditures and proper review of expenditures when reporting on their GAAP Z. The State disagrees with the finding. The State had two Grant Award Notifications in place with the Boys and Girls Club which reflects the monies awarded to be used on the capital improvements and Club on the Go Mobile Clubhouses. This indicates the funds were obligated during the covered period. Per the email from the Keri for Jill Geiger Consulting, no signatures on the GANs were required and the Uniform Guidance does not require the GAN to be signed. Anticipated Completion Date September 2022 Responsible Contact Person Brandy Manek

The City will review the process for identifying federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards. This will include inquiries of the Engineer’s Office.

The School District will review the Uniform Guidance requirements and ensure all expenditures are accurately reported on the School District’s Schedule of Expenditures of Federal Awards.

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of subrecipient activities Prevention Activities/TANF. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

2023-006 Management Response: Management respectfully disagrees with this Finding. • Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). • Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. • Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. • Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. • Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. • Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.

Plan: BCPN confirms that indirect costs are calculated in accordance with government guidelines outlined in 2 CFR Part 200. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: Due to adopting to use a calendar year instead of a fiscal year, BCPN's indirect costs for FY24 will be reflected in the financial statements for the period ending June 30, 2024, rather than December 31, 2023. We confirm that the indirect costs are being billed and spent in compliance with the guidelines outlined in the government contract and there is no need for funds to be returned.

Public Health agrees with the recommendation. Public Health will develop a process for conducting risk assessments of subrecipient funding, develop and implement procedures for obtaining single audit reports from subrecipients, as well as a system to monitor and track compliance with the single audit mandate among subrecipients. Public Health will ensure each subaward includes all requirements imposed on the subrecipient so that the federal award is used in accordance with Federal Statutes, regulations, and terms of conditions of the federal award. Estimated Implementation Date: May 2025 Contact: Melissa Relles, Assistant Deputy Director Division of Operations, Center for Preparedness and Response California Department of Public Health

California Department of Transportation (Caltrans) has determined that federal award information is not always disseminated to the project managers. Caltrans will review current policies and procedures of each division and revise, if necessary, so that best practices are followed. Caltrans Internal Audits Office will be working with Local Assistance’s single audit report monitoring process and take on the responsibility to monitor for all Caltrans divisions. Estimated Implementation Date: June 2025 Contact: Ben Shelton, Chief – Caltrans Internal Audits Office Division of Risk and Strategic Management

Consortium’s Fiscal Agent will ensure that supporting documentation will be maintained for all expenditures to ensure that each expenditure charged to the program is for an allowable activity/cost.

The Village Treasurer will start preparing the Schedule of Expenditures of Federal Awards each year or contract with a CPA firm for assistance in preparing the Schedule of Expenditures of Federal Awards each year.

Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis including computing actual indirect cost rates at the conclusion of each audit. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller

All future federal expenditures will be reconciled to the disbursement ledger.

Action taken in response to finding: Trilogy submitted an application to apply for a new indirect cost rate in January 2024, we also received provisional approval from the federal agency to continue use of our prior approved indirect cost rate. Since then, Trilogy has clearly defined compliance requirements for maintaining an up-to-date indirect cost rate. This includes developing a timeline of responsibilities, documents and steps needed for approval. This also includes the development of an annual calendar for Finance to be proactive about expiring NICRA agreements. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes Planned completion date for corrective action plan: August 2023 and January 2024.

Views of Responsible Officials: Prior to receiving this finding, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. Incorrect application of the de minimis rate was due to an error in the funder-provided spreadsheet. HIPS Finance Manager has been tasked with checking all spreadsheet calculations prior to submissions of financial reporting.

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

Material Weakness over Schedule of Expenditures of Federal Awards (SEFA) Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is “live” as of August 2022, the City is currently working to refine the software and fully utilize functionality. The Workday grants modules requires the grant funding source be defined prior to grant approval and fields are available for the AL titles and numbers and sub-recipients’ information. The implementation of the Workday grants modules centralizes much of the grant management function by requiring the agencies to upload the grant documents into Workday. The City has: • Held weekly meetings for two years with agency grant representatives to design and configure the Workday grant module. • Uploaded the grant award, sponsor information and grant budget data into a Workday. • Implemented a “new grant” request which uses a Workday business process. • In the process of reviewing and correcting recoverable costs per grant award so it is properly recorded. • Within Workday we are able to track grant performance period, CFDA, manage and capture grant related expenditures and calculate automated billing to sponsors on recoverable costs Business processes have been developed and implemented in Workday’s grant management module to include: Definition of the grant funding source by creating a system-generated grant work tag (identifier) upon receipt of the Sponsor’s Notice of Award; populated fields in Workday with passthrough award data with Prime Sponsor and Bill to sponsor Billing data, and modification of the create award process to add the Grants Management Office to final approval. In FY 24 the City implemented a citywide Grants Management Committee coordinated by the Mayor's Office of Performance and Innovation. Through feedback from this workgroup we identified an expanded scope of responsibility for the Grants Management Office; including oversight and compliance, technology, training and budget monitoring. In the short term a new Grants Director position was created and onboarding is to occur in the first quarter of FY25. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City. Completion Date: June 2024