Corrective Action Plans

In response to the noted deficiencies in salary rates and allocated costs, Management introduced Personnel Action Forms (PAFs) to document any changes in an employee’s salary or supervisory status. These forms ensure that salary adjustments are properly recorded and authorized in alignment with standard operating procecures and with the necessary supervisory approval. If a salary or supervisory status changes is due to a promotion or interim role, a formal letter accompanies the PAF, clearly outlining the terms of the change. These letters require signatures from the employee, their supervisor, and the CEO and are securely stored in the employee’s e-file with Human Resources. To further improve the documentation process, Management is transitioning to a new Applicant Tracking System (ATS) that integrates with Management’s PEO system, Paychex. This system allows for electronic distribution and automatic storage of offer letters, ensuring they are consistently filed and easily retrievable. These procedures reinforce the existing Payroll policy, ensures staff receive targeted training on relevant requirements such as timesheet approvals, and incorporates additional review measures into the payroll process. Furthermore, the Grants Director must review timesheets and payroll rates for allocations before payroll costs are requested for reimbursement. The payroll platform has been upgraded to manage employee pay rate changes, and the Human Resources manager is required to maintain approved documentation of pay rate changes in a centralized location, thereby ensuring full compliance with federal requirements relating to allowable salary costs and time and effort documentation. In addition, employees whose compensation is charged to federal awards complete biweekly time and effort certifications identifying the program or cost objective worked. Certifications are approved by the employee’s supervisor and retained in payroll records. Payroll charges to federal awards are based solely on certified time.

The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.

Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – Training will be provided for all employees involved with the grant if the Cooperative receives a similar grant in the future. Completion Date – As needed

Audit Finding: 2023-002 – Lack of Documentation of Review and Approval Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts reconcile payroll, and a workflow ensures accurate NOPA listings for payroll purposes. Additionally, in order to ensure that Notice’s of Personnel Actions are updated on a timely basis, ensuring that salaries are charged to the respective account, DHS has implemented the following process: (1) Provisional Payroll Codes are requested prior to the close of the Fiscal Year by the Department of Finance through the Office of Management and Budget through the established process. (2) Once the codes are received, the Division of Human Resources will update the most current Personnel Distribution Sheets to reflect active employees. (3) The sheets will be submitted to Fiscal certification by the CFO, (4) NOPAS are updated with the provisional codes.

Once payroll is processed by the Department of Finance, on the payday, a Flex Earnings Report is generated by the staff. A reconciliation is performed to ensure that all employees and their respective fringe benefits are captured and drawn. The Department of Finance posts said payroll. Staffing continues to identify deficiencies in the posting which occur in varying periods after the actual pay day. DHS has incorporated into its internal controls a step to ensure that the accounts, in retrospect, are reconciled to the actual Flex earning report. DHS intends on meeting with the Department of Finance to identify the nuances that create postings to occur contrary to the Flex Earning Report account coding.

The Government concurs with the auditor’s findings and recommendations. VIDE is addressing audit findings related to payroll activities by enhancing internal controls to ensure compliance with federal regulations. Key measures include improving timesheet management through electronic submission, mandatory supervisor review, and secure storage. Additionally, VIDE will strengthen rate verification processes with a standardized checklist for comparing NOPA rates with payroll system rates, requiring payroll staff to complete it at each pay cycle and maintain a discrepancy tracker. Mandatory training sessions will be conducted for employees and supervisors to ensure understanding of the new policies, covering timesheet completion, rate verification, and adherence to guidelines.

VIDE acknowledges the audit findings regarding the Special Education Cluster payroll discrepancies and concurs with the recommendation. VIDE is taking immediate action to align payroll controls with established fiscal improvement plan. To address the pay rate discrepancies between NOPAs and the payroll register, the Budget Team and the Deputy Commissioner of Fiscal and Administrative Services will review and approve every personnel action in the ERP prior to the NOPA being executed. This review matches the action against the approved grant application or staffing list to ensure the pay rate is accurate before the payroll cycle begins.

VIDE acknowledges the audit findings regarding the Special Education Cluster payroll discrepancies and the unreported fraud incident and concurs with the recommendation. VIDE is taking immediate action to align payroll controls with the established fiscal improvement plan and to institutionalize a mandatory federal reporting protocol for fraud. To address the pay rate discrepancies between NOPAs and the payroll register, the Budget Team and the Deputy Commissioner of Fiscal and Administrative Services will review and approve every personnel action in the ERP prior to the NOPA being executed. This review matches the action against the approved grant application or staffing list to ensure the pay rate is accurate before the payroll cycle begins. To address fraud reporting, VIDE will implement a Federal Mandatory Disclosure Policy in strict accordance with 2 CFR §200.113 that designates the Office of the Commissioner and the Internal Audit Division as the responsible parties for reporting any credible evidence of fraud, bribery, or gratuity violations to the Federal awarding agency and the OIG. Accordingly, the specific incident cited in the finding regarding the $5,221 theft related to bus driver timesheets will be immediately reported to the U.S. Department of Education’s Office of Inspector General via the online hotline and formal written correspondence to cure the non-compliance. Furthermore, to prevent recurrence of the specific falsified timesheet scheme, VIDE will implement a Service Verification Log for bus drivers and similar service staff wherein supervisors will be required to cross-reference timesheets against daily trip logs or service logs before approving time in the payroll system. Finally, to ensure ongoing compliance, the Office of Fiscal and Administrative Services will conduct monthly spot checks of ERP logs to ensure pre-execution reviews are occurring, and the Internal Audit Division will maintain a log of all investigations to verify that a Notification of Federal Disclosure is attached to any file involving federal funds.

We acknowledge that some timesheets were currently unavailable because the employees in question are no longer employed at DPNR, and as a result, their user profile is no longer active within the system. We have requested assistance from the Department of Finance in retrieving the necessary timesheets unfortunately, the required information has not yet been provided. DPNR will continue to collaborate with the Department of Finance to ensure the retrieval of any relevant files or reports, and we remain committed to resolving all the findings. We recognize that these findings highlight areas where improvements are necessary to ensure better compliance with applicable policies and regulations governing payroll and grant management. We are committed to implementing corrective actions and enhancing internal controls to prevent recurrence.

The Government concurs with the finding. OTAG implemented enhanced payroll controls including a dual manual and electronic timesheet system, verification of pay rates against NOPA forms, and separation controls to discontinue benefit charges upon employee separation or retirement.

VIDE acknowledges the audit finding regarding the Child Nutrition Cluster payroll and concurs with the recommendation. Because this is a recurring finding from prior year 2022-023, VIDE will develop and institute stricter fiscal controls to address the root causes of documentation and allocation discrepancies for this program. To prevent discrepancies including unapproved project codes and pay rate mismatches between NOPAs and payroll registers, the Fiscal Team will take the lead in preparing and maintaining the official staffing list for federally funded personnel within this program, an effort that involves reviewing the grant application for all positions and informing HR of required action entries. Furthermore, VIDE will implement a control where the Budget Team and the Deputy Commissioner of Fiscal and Administrative Services will review and approve every personnel action in the ERP prior to the NOPA being executed to match the action against the approved grant application or staffing list and ensure the project code and pay rate are accurate before the payroll cycle begins. To address the unavailability of timesheets, the program will implement a strict reconciliation protocol wherein the Program Director or designee will verify that the payroll register aligns with approved timesheets prior to performing the drawdown and posting. These timesheets will then be digitally archived in a centralized SharePoint repository organized by pay period to ensure that time and effort documentation is securely retained and immediately available for audit review. To support these new protocols, mandatory training will be conducted for relevant staff and supervisors on these new timesheet procedures, federal time and effort requirements, and the new NOPA reconciliation workflow. Finally, the Office of Fiscal and Administrative Services will conduct monthly spot checks of the SharePoint repository and ERP logs to measure the effectiveness of these controls.

The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts reconcile payroll, and a workflow ensures accurate NOPA listings for payroll purposes. Additionally, in order to ensure that Notices of Personnel Actions are updated on a timely basis, ensuring that salaries are charged to the respective account, DHS has implemented the following process: Provisional Payroll Codes are requested (1) Provisional Payroll Codes are requested prior to the close of the Fiscal Year by the Department of Finance through the Office of Management and Budget through the established process.(2)Once the codes are received, the Division of Human Resources will update the most current Personnel Distribution Sheets to reflect active employees. (3) The sheets will be submitted to Fiscal for certification by the CFO. (4) NOPA's are updated with the provisional codes.

Implement procedures to ensure supervisors’ approval of all federally funded timecards by a set deadline. HR will run a “missing timecard report” each pay cycle to ensure time cards are properly completed. Will conduct annual training on federal compliance requirements.

We acknowledge that the purchase of gift cards was not an allowable expense under federal grant guidelines. During the COVID-19 pandemic, our staff were tasked with responding to urgent and overwhelming public health demands, particularly as the New Mexico Department of Health became overextended. To recognize staff who went above and beyond to ensure timely case reporting and investigations for tribal communities, gift cards were used as a form of appreciation. Moving forward, we will ensure full compliance with federal grant requirements. Specifically: 1. We will adhere strictly to the cost principles and allowability guidance outlined in federal regulations and the terms of each Notice of Award. 2. In instances where the allowability of an expense is unclear, we will proactively seek guidance and written approval from our Federal Grant Management Officer before incurring the cost. 3. We will provide refresher training to program and fiscal staff on allowable costs under federal awards to prevent recurrence of similar findings. These corrective actions will ensure future expenditures are fully compliant with federal guidelines and that staff recognition practices remain appropriate, allowable, and consistent with award terms. • Immediate (Already in Effect): Ceased use of gift cards and other unallowable incentives. • Within 30 Days: Finance and program leadership will review current grant guidance and distribute a written summary of allowable/unallowable costs to all program managers. • Within 60 Days: Refresher training on federal cost principles (2 CFR 200) and Notice of Award guidance will be provided to all program and fiscal staff. • Ongoing: When ambiguity exists regarding allowable costs, staff will consult with the Federal Grant Management Officer prior to obligating or expending funds. Designation of Employee Position Responsible for Meeting Deadline Program Managers/Directors, Finance Officer, and Accounting Manager.

FINDING 2023-005 – Allowable Costs: Significant Deficiency over Internal Controls over Compliance Condition/context – In a sample of 25 payroll disbursements and 25 non-payroll disbursements, it was found that time and effort for 11 salaried employees were not supported by documentation for the allocation. The sample of non-payroll disbursements had 4 transactions without the documented methodology or support for the allocation between programs. Corrective Action Plan: • Implemented a formal time and effort reporting process (Allocation Method) for all employees whose salaries are charged to more than one funding source, in compliance with federal requirements. • Developing and enforcing a standardized cost allocation methodology for shared non-payroll expenses, ensuring documentation is retained for all allocation decisions. • Training program and finance staff on allowability and allocation requirements under 2 CFR Part 200. • Periodically reviewing cost allocations to ensure continued reasonableness and compliance with applicable grant terms. • Policy and Procedures updated/Staff Training on new Timesheet processes Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: Corrected: September 2025

Personnel Responsible for Corrective Action: Jim Keeney, CFO Anticipated Completion Date: Completed. Review and Approval continue consistently. Corrective Action Plan: Management has implemented a time and activity method that meets the requirements of federal regulations. It includes the use of JIRA Software and an Excel Spreadsheet. Staff are entering time on an ongoing and consistent basis, including both actual and allowable time, for federal and non-federal contracts/agreements. These tools are reviewed and approved by executive management before any billing has transpired. Management is providing ongoing training for existing staff and new staff on an annual basis. This includes review and analysis from the accounting department to ensure proper expense accrual and revenue recognition. Management has also written an improved and detailed policy and procedure on recording actual and allowable time.

During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and reporting needs. As part of this transition, we worked closely with our new payroll provider to implement job-costing functionality that will accurately track time across grants funded programs. In addition, we have established a process requiring department leads to review and approve all timesheets prior to submission. We also partnered with our new 3rd party payroll provider to set up time allocation for salaried employees.

Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization discontinued its prior payroll system when staff were laid off and shifted remaining personnel to contractor status. During this period, approval and payment of contractor invoices were processed through Ramp, with documentation maintained but not within a formalized payroll approval workflow. As CSforALL prepares for the 2026 rebuilding phase, management has re-established a structured payroll approval and documentation process aligned with audit recommendations. Corrective Action taken in 2025: Beginning in August 2025, the Organization transitioned to ADP, a trusted payroll service integrated with QuickBooks, in anticipation of restoring full payroll operations in 2026. Since implementation, payroll reporting and documentation have been maintained accurately each month by the Operations Manager and the Accountant, with formal approval granted by the Advisory Consultant. All invoices, payments, and payroll records are shared and stored bi-weekly as payroll is executed, establishing a consistent and documented approval trail. Corrective Action Planned for 2026: Beginning in January 2026, CSforALL will apply standardized supervisory approval procedures within ADP for all payroll transactions. Management will implement periodic monitoring of payroll records, ensure consistent use of the approved timekeeping and approval system, and maintain documentation of all supervisory approvals to ensure compliance with established internal controls throughout the 2026 operating year and beyond.

As noted above, we are working with consultants and our government partners to determine and define the requirements for each relevant program. We understand the recommendations offered and will review, and possibly revise, our policies and procedures, including supervisory review of documentation to support the allowability of costs charged to federal agreements. We will also review existing policies and procedures for preventing or detecting and correcting unallowable costs charged to federal agreements to ensure consistent application of those policies and procedures for all costs charged to federal agreements.

Finding 2023-002 – Allocation of Program Effort by Employees In response to the finding, GEM will institute controls and processes to document and allocate personnel time and effort to NSF program: A comprehensive manual for grants and federal funding has been developed, establishing clear written policies and procedures specific to the management of federal awards. With these documented guidelines now in place, our focus is on ensuring strong oversight and consistent adherence to the established policies across all applicable operations. GEM has implemented a new timekeeping system that will allocate time and effort via approved time and expense personnel reports and reconcile these the accounting records and NSF program charges. Anticipated date of completion: Process was implemented on December 31, 2023. Responsible party: Jamie Hicks, Senior Accounting Manager

Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section.

Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor’s approval and audit trail to reflect the work performed. Budget and Grants in conjunction with the program and Human Resources will implement a hindsight review of employee working hours with a certification by the employee and supervisor. Name(s) of Contact Person(s) Responsible for Corrective Action: Betsey Knapp, Director of Budgets and Contracts; Alvin Sinckler, Chief Financial Officer Anticipated Completion Date: November 15, 2025.

Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal process for preparation of the SEFA. Recommendation: Management should prepare a master tracking schedule for government grants which includes the source of funding and audit and reporting requirements. The schedule should be prepared by someone with knowledge of the grant agreements and reviewed by a leader in the accounting department to ensure completeness. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management has implemented a master tracking schedule for government grants that includes the source of funding and audit and reporting requirements. This tracker is a joint effort between finance and grants management teams. Anticipated Completion Date: December 31, 2025

Since January of 2024, CRA has done the following: Created a Human Resources Department, which did not exist before. Hired a Full Time Human Resources Director to oversee the department. Initiated a comprehensive Human Resources system where staff can review their pay, track their time, and review benefits. Initiated the process of uploading personnel information to our new system, while keeping backups secured in our Google Nonprofit workspace - including hiring documentation and change of status forms for employees.