Corrective Action Plans

U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by tracking and recording the actual hours each employee, regardless of position, spends working on each grant, on their time sheet or with a specific grant code, that specifies how many hours per day were spent on each federal and nonfederal activity. Alternatively, EFN can implement an after-the-fact review procedure to ensure the proper allocation of payroll expenditures to Federal and non-Federal awards, in accordance with 2 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Emergency Food Network (EFN) engaged a new audit firm for the 2024 audit. Before this year the EFN audit was administered by Johnson, Stone Pagano for 9 years. No deficiencies were previously reported or identified during those audits regarding time estimates for employees used for allocations including most of those specifically identified funding sources. In response to the 2024 audit finding by Clifton Larson Allen (CLA) in July of 2025, when the audit was conducted, EFN implemented an immediate individual employee time study that was approved by CLA to meet the recommendation. This time study methodology will be implemented twice per year on an ongoing basis with records retained and available for future audit verification. EFN has received written response from CLA that implementing this method meets all the requested requirements to be in compliance and mitigate future findings on this issue. Name of the contact person responsible for corrective action: Michelle Douglas, CEO Planned completion date for corrective action plan: August 2025 If anyone has questions regarding this plan, please call Michelle Douglas, CEO, at 253-208- 2962.

Personnel Responsible for the Corrective Action Plan: Darlene Sowell, President/CEO Anticipated Completion Date: December 31, 2025 Corrective Action Plan: Unleashing Potential will modify its internal procedures to track actual hours devoted to the program and perform a monthly review of actual hours incurred compared to the estimated amounts by individuals assigned to federal grant programs prior to requesting reimbursement from the funding course. The review will be performed by an individual other than the preparer of the reimbursement request, with knowledge of the federal grant program and will be formally documented.

The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ensure all employees' salary schedules are updated when we process the system-wide update. We will have an additional person to review and sign the new salary schedules before the first payroll is processed in the new fiscal year.

View of Responsible Official: The timesheet implemented in July 2024 properly reflects the actual vs budgeted hours for employees with multiple funding sources. We will continue to analyze discrepancies to determine if budget revisions are necessary. Finding resolved timeline: October 2025 Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President; Ricardo Colon Padilla, financial officer.

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of time spent on a grant monthly. These personnel have been informed of the proposed process and trained to promote consistent and accurate reporting relative to federal standards Anticipated completion date: October 2025 Contact person responsible for corrective action: Russ Chambliss

U.S. Department of Commerce, Philadelphia Works, Inc. 2024-1 Direct Labor Costs – Assistance Listing Number 11.307 Recommendation: We recommend that the PALM utilize a time management software which integrates with their payroll processing, to easily identify direct labor costs related to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented a new time management software in 2025 to track and manage direct labor costs relating to the administration of federal programs.

Continued training of cost center managers. Throughout the summer we have had the Finance Manager training Community Eds administrative team and responsible grant managers to get compliance with Time and Effort requirements.

Allowable Costs - Payroll Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof ensure monthly certifications of time allocations by employees and their supervisors are performed and documented on a consistent basis. In addition, we recommend Shatterproof retain approval of the payrates entered into the HRIS and used to pay employees and ensure controls exist to ensure the proper rates are used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • Time certifications for employees involved in federal grants are completed monthly and signed by both the employee and their supervisor. • Pay increases were historically reviewed and approved by the CEO in a final meeting with the CFAO and Sr. Vice President of HR but no formal approval was retained. Going forward, the CEO will document approval of salary changes via email after the meeting. Names of the contact persons responsible for corrective action: Ellen Duffey and Young Kim Planned completion date for corrective action plan: January 1st, 2025

REFERENCE No. 2024-002 Significant Deficiency in Internal Control Over Compliance, Other Matters Program Child Support Services (Assistance Listing Number 93.563) Identification Number(s) 18000 (2024) Finding Employee time and effort charged to the program did not agree with supporting documentation. For two of thirty-three employee timesheets selected for testing, the amount claimed for employee time and effort did not agree with supporting documentation. Employee payroll data was entered incorrectly when the claim was compiled, resulting in an underclaim of the amount charged to the program. Questioned Costs None. The error resulted in an underclaim. Recommendation The County should enhance its procedures and internal controls to ensure that employee time and effort charged to the program is accurate and agrees with supporting documentation. Corrective Action Plan The Finance division will be working with payroll and IT to assist in automating this process within the WorkDay system. Employee Function Codes drive the claiming process and currently it has been a manual process; however, the need to automate is important. Until a new process is in place, staff will be trained to spot these errors and if needed correct when found. In addition, Senior staff will be reviewing this process to also ensure its accuracy. Action Date September 5, 2025 (Meeting with staff) Final Implementation Date March 31, 2026 Name And Phone No. Of Person Responsible For Implementation Jennifer Cicero 631-854-9331

dLCV has refined our policies regarding review of timesheets to ensure that all timesheets are timely submitted and are reviewed and approved by designated staff. The policy revisions will be effective as of October 1, 2025

dLCV will implement a weighted direct bill process beginning October 1, 2025. Throughout the audit review, and as recently as one month before the final report, the auditors consistently reported to us that this was likely not a compliance issue. Additionally, the auditors were not able to provide any sample for any time period in 2024 showing the potential impact of changing from an hours allocation to a dollars allocation. The auditors did not inform us of their changed opinion until late August, 2025, making it impossible to make any adjustments in the current fiscal year.

Finding Number 2024-003: Activities Allowed or Unallowed; Allowable Costs/Cost Principles and Matching – Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action: In the immediate term, oversight of the manual process for preparing the Time & Allocation Excel Sheet and Request for Reimbursement (RFR) payroll calculations will be strengthened. Policies will be implemented to ensure quarterly attestations, timely budget-to-actual reconciliations, and documented review of reimbursement requests. Management will also work with the Payroll Service Provider to implement software upgrades that improve allocation accuracy and reduce errors through straight-through-process improvements. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, and Luz Gonzales-Toscano Anticipated Completion Date: January 2025 – immediate term and December 2026 software implementation.

We will continue to enforce and refine the internal controls implemented in April 2024. Records will be reviewed regularly to ensure compliance. This will be added to the finance and operation manual

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and pay raise letters for approvals. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

Effective January 1, 2025, employees are required to complete a monthly Personnel Activity Report (PAR) where the employees document the percentage of time they spent for each grant/program during the month with a brief description of the work performed for each project. The completed form is signed by the employee and their supervisor, then retained for our records. Effective September 1, 2025, monthly PARs will include contemporaneous certification by the employee that the distribution of hours worked is correct.

EPHC uses a third-party vendor to process payroll. This system does not have the capability to allocate salaried employees based on time spent on the program recorded in the time keeping system. Because of this, the hours worked in each program need to be converted into percentages before payroll is submitted for processing. To ensure accuracy, EPHC will have a second reviewer confirm the manual entry conversion from hours worked to percentage of time worked for salaried employees for the remaining duration of time in a third-party payroll system. Effective January 2026, EPHC will implement a new payroll system that will be processed in-house. This system has improved functionality that will eliminate the need to make this conversion and the potential for errors.

Condition In two instances, the amounts recorded in the General Ledger (GL) did not match the corresponding amounts recorded in the payroll system. Corrective Action Plan Corrective Action Planned: Efforts were taken to verify Dayforce is configured to allocate salary expenses to an employee’s home agency and department, regardless of where the employee assigns their hours in the timekeeping system. While the timesheet programmatic reflects the agency and department where hours and dollars are functionally charged, the payroll register aligns with the General Ledger based on home agency coding. As a result, the Payroll Register and General Ledger will reconcile with each other but may not align with programmatic reports, which are based on timesheet-level allocations. This system behavior is consistent with current configuration and financial reporting practices. The Payroll Department and the DHHS will meet in Q3 2025 to ensure grant/expense tracking activities are working as intended. Name(s) of Contact Person(s) Responsible for Corrective Action: Sue Drummond, Director Payroll & HRIS Interface Anticipated Completion Date: Completed January 2025.

For payroll, procedures will be implemented to ensure that payroll costs allocated to federal grants are supported by actual time. For nonpayroll, procedures will be enhanced to ensure proper allocation of nonpayroll costs to federal grants. Allocations will be reviewed and monitored on a monthly and quarterly basis to prevent misallocation and ensure compliance with the Uniform Guidance. Personnel Responsible for Implementation: Executive Director Christy Zamani, and Beaulieu Accountancy Corporation Date of Implementation: August 5, 2025

Management will update the entity’s accounting policies and procedures to include specific guidance on payroll allocation and documentation requirements for personnel expenses charged to Federal awards.

Planned Corrective Action: The District is in the process of reviewing and updating controls to ensure required time and effort logs are kept in the District's fiscal management system and routine submission of forms is enforced by the grant managers. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Marleni Bruner, Joanette Thomas, Lisa Robinson

Comments on findings and recommendations The organization concurs with the finding and agrees that after-the-fact time documentation is necessary to comply with federal requirements, even when employees' assignments and hours are consistent. Actions taken or planned The organization has performed a time-study during 2024 to support allocations to programs and has been implemented in 2025. Anticipated completion date January 1, 2025

Finding 2024-010 – Material Weakness – Allowable Costs/Cost Principles Condition The District supports time charged to federal awards via semi-annual certifications which are approved by the grant administrator or the building principal. In order for a cost to be supported at the time of final reimbursement, the semi-annual certifications should be approved by the grant administrator or the building principal. Title I Grants to Local Educational Agencies (ALN 84.010) The final reimbursement claim for the Title I Grants to Local Educational Agencies (Title I) program were due to Wisconsin Department of Public Instruction (DPI) on September 30, 2024; however, the final reimbursement claim for the Part A award was not submitted to DPI until November 18, 2024, and the CSI award was not submitted to DPI until October 1, 2024, due to an extension. Five of the 40 individuals sampled had their semi-annual certifications not approved timely and were approved after the due date of the final reimbursement claim, but before the date of the actual submission of the final reimbursement claim. An additional two individuals of the 40 sampled had their semi-annual certifications approved after the final reimbursement claims were submitted. Upon further review of all the spring semi-annual certifications for the Title I awards, there were an additional 50 individuals that had their semi-annual certifications approved by the principal after the due date of the final reimbursement claim but before the submission of the final reimbursement. Additionally, nine individuals had their semi-annual certifications approved after the final reimbursement date of the Part A award and another 59 individuals from Part A did not have their semi-annual certifications approved at all. Head Start Cluster (ALN 93.600) The final reimbursement claim for the program was submitted to the Federal agency on November 22, 2024. Four of the 40 individuals sampled had their semi-annual certifications approved by the Head Start administrator after the submission date of the final reimbursement claims. Upon further review of the all the spring semi-annual certifications, there was an additional individual that had their semi-annual certifications approved by the principal after the due date of the final reimbursement claim and another four individuals that did not have their semi-annual certifications approved at all. The samples were not statistically valid. Corrective Action Plan The Office of Finance agrees that it is important that certifications be completed in a timely manner and award reimbursements are submitted within the deadlines. The Office of Finance and the District as a whole is working on improving its internal controls system wide. We are committed to developing sound processes and procedures that are in full compliance with federal and state regulations. An example of a process improvement is to send out reminders on a regular schedule to school leaders and central office employees for programmatic compliance. These activities will be completed in advance of due dates going forward to ensure timely submission of grant claim reimbursements. Annual training for school leaders and central office staff is also part of the process improvement plan underway. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer, State and Federal Programs Director, Comptroller, Grant Accounting Manager Anticipated Completion: 06.30.2026

The Board of Health will adopt updated written policies periodically in accordance with the Uniform Guidance to help improve internal controls over federal compliance for the findings listed in this number.

Finding 2024-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, it does not maintain sufficient documentation to support the level of effort charged to the award, as required by federal regulations. While staff members are required to complete timesheets, the current format does not capture the level of detail needed to substantiate payroll allocations to federal programs. Additionally, there is no formal process for supervisory review and approval of these timesheets. Although no overcharges or double-dipping were identified, the lack of adequate documentation results in known and likely questioned costs due to noncompliance with documentation requirements. Corrective Actions Taken or Planned: The Organization will develop and implement a standardized timesheet template (Gusto) that captures employee name, pay period, hours worked by funding source, and supervisory approval. Provide mandatory training for all staff whose salaries are charged in whole or in part to grants on documentation and time allocation requirements. Require monthly reconciliation of time sheets to payroll records before submission to grants. The Organization will conduct quarterly internal reviews to ensure compliance and adjust as needed.

Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.