Corrective Action Plans

Auditor's Recommendation: The Auditor recommends the Organization implement controls for documenting and retaining information to indicate the Organization follows the requirements over 2 CFR section 200.430(i), and that all time charged to the grant are reviewed for approval. Management’s Response: In fiscal year 2024, LIFE Inc. implemented the following: • Reviewed, updated and established policies/procedures that aligned with the compliance of 2 CFR, 200.430(i). • Implemented a newly customized timekeeping system that enabled accurate recording of time spent on grant-related activities and that ensured capabilities for supervisory review and approval. • Conducted training sessions for all staff on updated policies regarding timekeeping procedures, the new online timekeeping portal and adherence to federal regulations. • Scheduled internal audits and reviews at least once a fiscal quarter to ensure that the new timekeeping system was being used correctly and that all time charged to grants was appropriate and compliant with LIFE Inc.’s policies/procedures and federal regulations. Due date of completion: August 31, 2024 Responsible Officer: Executive Director, Michelle Crain

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month period of transition at the Fund, while maintaining that proper allocation process was followed up to the point of record keeping. The Fund understands the reasons for the missing timesheets and that these cases were unique and not indicative of the normal and prevalent internal control over the completion and approval of timesheets. The allocation of payroll for the months tested were based on the consistent and correct application of the payroll costs allocation methodology however in a limited number of cases the allocation spreadsheets weren’t properly saved. After announcement of dissolution, there was considerable staff turnover and rapid transition which created challenges and delays. We did maintain an effective control environment. This has been resolved. Management is saving allocation spreadsheets, and other required documentation as per policy on an ongoing basis.

Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, another instance was identified in which a timesheet was not complete and was missing hours worked. Corrective Action Taken or Planned: Management plans to reiterate the applicable policy and ensure timesheets are prepared, reviewed and contain the appropriate approvals. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Karen Reitan, President and Chief Executive Officer Management Response: Management concurs with the finding.

FINDING 2023-010 Finding Subject: Education Stabilization Fund – Allowable Cost/Cost Principles Summary of Finding: To receive reimbursement for ESSER expenses paid, the School Corporation’s Treasurer completed a reimbursement request, and the Director of Curriculum reviewed it. The documentation attached to the reimbursement request; however, did not include the following items: 􀁸 For one teacher, the School Corporation did not provide a Board approved contract or Salary Ordinance showing the approval of this teacher's position as a part-time tutor at $50 per hour. There was only an offer letter to the teacher from the Director of Curriculum. 􀁸 For the purchase of equipment in the amount of $318,922, the School Corporation did not provide a contract instead only a PO with a quote and a letter with the School Board’s approval to purchase. Additionally, there was no indication in the board minutes that this purchase had been put out to bid to the suppliers. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When the Business Manager and Director of Curriculum review the reimbursement form each month, an additional check for contracts of all employees paid will be added. All procurement documentation, including contracts, will be added to the archived documentation for purchase orders. Anticipated Completion Date: March 31, 2024

FINDING 2023-004 Finding Subject: Child Nutrition Cluster – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. The School Corporation paid $23,682 of administrative salaries that were allocated to the School Lunch fund based on fixed percentages. There was no supporting documentation to indicate how the percentages were determined or time records indicating time spent on the program by the applicable administrators. INDIANA STATE BOARD OF ACCOUNTS 40 􀀃 “Meeting􀀃students􀀃where􀀃they􀀃are􀀃and􀀃leading􀀃them􀀃forward…every􀀃student,􀀃every􀀃day”􀀃 Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently 50% of Pam Frost’s salary is paid from the Lunch Fund. A new internal control will be created to document that 50% of her time is spent on food service work and 50% of her time is spent as the ECA treasurer for the elementary school. Anticipated Completion Date: August 31, 2024

The University will review and enhance its procedures and internal controls to monitor or ensure the completeness and accuracy of all federal grants, to ensure they are separately recorded within the general ledger and all expenditures and activities are processed in accordance with applicable federal guidelines. The campus will implement effort reporting procedures for the SNAP Cluster program that include accounting for all employee activities for the program and the University implement appropriate controls to ensure costs charges to the SNAP program are based on actual costs incurred and are properly determined and calculated based upon the Uniform Guidance allowable cost criteria.

For employees who are paid in full or in part with federal and other funds, management will increase the frequency of the time and effort reporting to quarterly intervals. Specifically, employees will document their time and effort based on funding sources for each payroll period; and at the end each quarter, management will review and compare the actual time and effort percentages with the current ADP Labor Distribution Report for reasonableness. The Management review report will be used as a basis to effect changes to the labor distribution report using the employee status change forms. The time and effort documentation will be available for audit. The implementation of the Corrective Action Plan did not commence until fiscal year 2025 given the timing of the fiscal year 2021 and 2022 audits and receipt of this finding.

Since March 2024, PLC has been charging personnel costs to the program based on actual time recorded in the organization’s case management software, with quarterly audits of time to ensure accuracy. PLC also began charging non-personnel costs based on ratio tied to actual time recorded. For program costs prior to March of 2024, PLC completed a regressive analysis to determine the amount of actual time worked on the program. This process included review of time recorded in our case management software to determine which portions should have been allocated to this program and, for those staff who do not record time in the case management software, forensics analysis of their grant activities during the period to determine the actual time worked. Personnel and non-personnel costs charged to the program prior to March 2024 were recalculated based on these calculations of actual time worked on the program

Contact Person Evan Peltier Planned Corrective Action Dunseith Public School Dist. #1 will implement the recommendation from Brady Martz. Planned Completion Date The planned completion date is June 30, 2025.

Finding: 2023-005 • Condition: There are no written policies and procedures for allowable costs/cost principles, cash management, procurement and suspension and debarment requirements. • Planned Corrective Action: Financial policies and procedures will be created and implemented. Contact Person: Katherine Jaeger Anticipated Date of Completion: 6/30/2025

Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization conducted a review after the completion of the year end to ensure reconcile the total amounts charged to the grant back to accounting records to ensure compliance, however, this was not done in a timely enough manner to correct for misstatements. In the future the Organization will review support and reconcile on a more frequent basis.

Management accepts this finding and notes that payrolls effected were at the very end of the current audit period and that the error was identified and corrected independently in the subsequent fiscal year. To further address this repeat issue, payroll will run monthly payroll queries and conduct an internal audit of payroll. Additionally, the Sponsored Research Office will work with PI’s to encourage them to plan their summer research efforts such that a research project is not included on more than one summer salary request forms. Although management feels this was an isolated incidence, the University will implement a set of controls that require a secondary review of all manuals calculation for payroll authorizations.

2023-012– Support for Payroll Allocations Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control Over Compliance (Allowable Costs/Cost Principles). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All awards. Auditor Description of Condition and Effect: During testing it was noted that the actual amounts charged to the grant were initially charged using the allocation rates from the previous pay period, and subsequently adjusted to the proper amount through a manual journal entry. When factoring in the amounts of the journal entries, the amount charged to the grant still differed from the support provided for 3 items of the 29 tested. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all allocations of personnel cost are allocated according to the support retained. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Phillip Moore, Chief Financial Anticipated Completion Date: January 22, 2025

In 2025, the Chief Financial Officer in conjunction with the entire fiscal team is implementing a time and effort process using the Salesforce platform. The staff will indicate the hours worked in each project/grant daily. Laura Perozo, Chief Financial Officer, is monitoring this process and will make this correction by June 30, 2025.

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend the Organization utilize one spreadsheet for allocating payroll costs and implement additional controls to ensure the allocations to Federal grants accurately reflect the actual hours worked. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ventures has stopped utilizing multiple allocation spreadsheets and will only use one spreadsheet. This single spreadsheet will be utilized for all payroll cost allocations and will be housed within the finance department under restricted access. The allocation of expenses to grants will be based on the FTE count per the payroll allocation spreadsheet. Changes to the allocations will be documented and shared with the Executive Director. Name(s) of the contact person(s) responsible for corrective action: Theo Everheart and Monique Valenzuela Planned completion date for corrective action plan: 07/31/2024

FA 2023-002 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021) S425U210012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: $98,807 Repeat of Prior Year Finding: FA 2022-002 Description: A review of expenditures charged to the Elementary and Secondary Emergency Relief Fund program revealed that the School District's internal control procedures were not operating to ensure that expenditures were appropriately documented to support allowability. Corrective Action Plans: District office will review payroll process and develop a procedure to ensure proper documentation is kept in an orderly manner. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2023-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010-21A (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: $6,942 Repeat of Prior Year Finding: FA 2022-001 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawbacks are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will included detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

Unique – AIDS has read the proposed recommendations and has agreed to comply although our funding sources has never had any issues with the allocation methods being used since inception. Unfortunately, we are not able to modify the budget estimates for the past fiscal year. Rest assured that going forward, Unique People Services will strive to maintain its books as recommended with the time study for the very few employees that have been allocated to the two programs being impacted by the audit field work. Please note that it has never been our intentions not to comply with the regulations, but since the issues were never raised or brought to light in prior years, we felt that it was not necessary to alter the process. However, going forward, we are committed to fully comply with 2 CFR 200.430 charges to Federal awards for salaries and wages in order to accurately reflect the work performed by our employees and anticipate to have this completed by February 28, 2025. The Chief Financial Officer, Ive Pierre, is monitoring this process

Views of responsible officials and planned corrective actions: Management agrees with this finding and will ensure copies of all employee contracts are maintained. See 2023-004 for management’s detailed action plan, timeline, and the responsible parties for all Education Stabilization Fund findings.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will ensure all time certifications are signed by employees and reviewed and approved by the appropriate School personnel. See 2023-004 for management’s detailed action plan, timeline, and the responsible parties for all Education Stabilization Fund findings.

Views of responsible officials and planned corrective actions: Management agrees with this find and will review time certifications in comparison to salaries and wages recorded to the program. See 2023-004 for management’s detailed action plan, timeline, and the responsible parties for all Education Stabilization Fund findings.

Audit Finding Reference: 2023-007 Management’s Response and Planned Corrective Action: Implement a record keeping process for all rates and weighted rates for payroll. Name of Contact Person and Completion Date: Name: William Manzi

Item: 2023-004 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 § 200.430 – Compensation – charges to federal programs for salaries and wages should be supported by a system of internal controls which provides reasonable assurance the amounts charged are accurate, allowable and properly allocated. Condition: Incorrect allocation of employee hours were charged to the federal program. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2024 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. Billings are reviewed by supervisors, including a review of the underlying supporting documentation, prior to submission of the billing. Additional training and record retention practices will be added and/or enhanced to ensure there is evidence of supervisory review of the underlying supporting documentation. Such review and record retention processes will include documentation of noted discrepancies and rationale for such discrepancies if not corrected.

Finding 2022-06 Unallowable and Improperly Documented Payroll Expenditures Condition: The Organization failed to establish critical processes and internal controls over payroll expenditures to ensure compliance with Uniform Guidance requirements and several compliance issues were identified. As part of audit procedures, 44 transactions were selected in a testing sample from a population of 243 direct payroll transactions. Of the transactions tested, the auditors noted 8 instances of payroll costs overclaimed by way of claiming the same work effort for the same period on multiple grants. The auditors noted 18 instances of failure to properly calculate and allocate the work effort completed by employees that worked on multiple grants and programs. The auditors noted 9 instances of the Organization failing to have approved pay rates on file that matched the amounts paid to the employees. The auditors also noted a significant lack of supervisory approval on timesheets or other time allocation support. Corrective Actions Taken or Planned: - Conduct mandatory training for all supervisors to reinforce the importance of: + Accurate timesheet approval processes. + Proper time allocation for employees working on multiple grants or programs. + Ensuring timely and consistent documentation of payroll expenditures. - Engage Christy Paddock Advisors LLC (CPA firm) to: + Oversee payroll allocation processes to ensure employee time is properly distributed across grants and programs based on actual work effort. + Implement controls to flag and prevent duplicate payroll charges to multiple grants. + Payroll expense reports will be systematically reviewed and approved by the CPA firm and VOICES’ executive team prior to filing federal claims. - Ensure all approved pay rates are documented, signed, and filed for each employee. - Configure QuickBooks to ensure payroll costs and grant allocations are: + Clearly identifiable and traceable. + Linked to corresponding grants and federal claims. - Revise the PTO policy to address liability and improve tracking by: + Implementing a "use-it-or-lose-it" policy with a defined carryover limit. + Removing PTO payout upon termination to reduce financial exposure. + Communicate the updated policy clearly to staff and implement tracking in payroll systems.

U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.045 – Special Programs for the Aging_Title III, Part C_Nutrition Services – 2301KSOAHD Management’s Response: The department had been using set percentage allocations for grants in the payroll system. They are working with payroll and IT to be able to do real time reporting on personnel, number of daily hours per grant. This should be implemented in 2025. Views of Responsible Officials and Corrective Action: The reason for recurrence is the finding was communicated late in the prior year and due to transition and turnover within the department's staff. Management agrees with the stated finding and has implemented a corrective action plan. Management will ensure this is addressed by December 31, 2025. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS