Corrective Action Plans

Management concurs with the recommendation to implement internal controls to ensure all costs charged to the program are accurate, allowable, and properly allocated in accordance with the terms of the federal award, and that there is proper review and approval.

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including review and monitoring of process and procedures. In addition, documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such expenses, will be retained in accordance with federal regulations.

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to implement internal controls over tracking of expenditures related to federal award grants, especially personnel costs, and the related reimbursed cost to ensure compliance with federal requirements.

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Group will reconcile budgeted and actual fringe benefit costs regularly to ensure continued compliance.

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate accounting of payroll costs incurred under the federal programs, including review and monitoring of processes and procedures. Documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such charges, will be retained in accordance with federal regulations.

Finding: 2024-057 - Insufficient documentation was available to support the manual transfer of time originally coded to another federal program to the TANF program. Questioned Costs: AL 93.558: $1,730 Assistance Listing Number: 93.558 Assistance Listing Title: TANF Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department does not agree with the finding. The Division of Public Assistance (DPA) met with CLA regarding the questioned costs which were explained and documented. For the sample selected, the employee did positive time keep to LDP U6615 - LIHEAP Policy for their time spent processing heating assistance applications. This was during a time when our Policy section was understaffed, and the administrative section absorbed programmatic duties. The division followed the State of Alaska’s payroll correction process. When IRIS-HRM (payroll) interfaced to IRIS-FIN (financial), the payroll transactions errored due to insufficient program budget. The Department of Administration, Division of Finance provides an erroring payroll transaction report. The departments are instructed to update the report with correct financial coding and send to a BOT email address. The BOT enters the correction in the State’s financial system and attaches the spreadsheet to document the update in coding. Department staff do not have permissions to add notes or additional attachments to the payroll transaction. DPA accounting staff reviewed the errored transaction and identified another allowable fund source to code these expenditures to. Therefore, the payroll expenses were adjusted and charged to the TANF program. Corrective Action (corrective action planned): Division of Public Assistance will enhance the process to review payroll transactions and document supporting information for changes. Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2025. Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner

The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. To ensure documentation of employees who are paid in full or in part with federal grant funds, DBH will enact a time and effort certification standard operating procedure (SOP) in conjunction with the Agency Operations Administration and Office of the Chief Financial Officer. The SOP will direct the supervisor to review a payroll report generated by the OCFO providing each employee’s percentage of time charged to the assigned fund source. A form will allow supervisors to certify the employee has performed the duties that align with the funding source. The certification will be required at least quarterly for employee’s funded 100% and at least monthly for employee’s funded by more than one funding source. Creation, execution and monitoring of SOP: Draft SOP, September 1, 2025 Contact: Michael Neff, DBH Chief Operating Officer Virtual training to all affected employees, September 15, 2025 Contact: Adran Reid, Agency Fiscal Officer, Department of Behavioral Health & Deputy Mayor for Health and Human Services Contact: Ryelle Roddey, Deputy Chief Operating Officer Anthony Baffour, Director of Financial Services Renee Evans Jackman, Director of Grants Management Estimated Completion Date: Operationalize, October 1, 2025 See Corrective Action Plan for chart/table

Corrective Action Plan June 26, 2025 U.S. Department of Health and Human Services Health Resources and Services Administration Rocking Horse Community Health Center and Affiliate respectively submits the following corrective action plan for the year ended December 31, 2024. Clark, Schaefer, Hackett & Co. 14 East Main Street, Suite 500 Springfield, OH 45502 Audit period: January 1, 2024 – December 31, 2024 The findings from the June 26, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS Department of Health and Human Services 2024-001 Health Center Cluster Program – ALN # 93.527; Grant No. H2E Significant Deficiency: See Finding 2024-001 Recommendation: Management should strengthen its internal controls over payroll charges to federal awards by ensuring consistent adherence to its time and effort certification policies as well as conduct periodic reviews of payroll documentation to verify compliance with established policies and federal requirements. Action Taken: We concur with the recommendation and will implement formal policies and procedures around obtaining time and effort certifications by June 30, 2025.

Finding 2024-002 – Allowable costs – payroll Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization charged payroll costs to the federal award programs using a set percentage based on budget and not based on employee’s actual time or effort amongst various programs. Recommendation: We recommend the Organization make changes overall its timekeeping processes to ensure that payroll costs accurately reflect the work performed and if budget estimates are utilized, that they are reconciled and trued up on a consistent basis. Action Taken: NFFCMH has made changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed. The Organization is acting upon different guidance it has received, and as of the date this audit is released, the contract this finding addresses is currently scheduled to end on 08/30/2025. NFFCMH will continue our current practice through the end of this same contract, and we will review any potential change to same upon renewal or extension of this contract.

Finding 2024-001: Internal controls and adherence to compliance were not followed with regards to an appropriate level of approval of management that is charged to the Coronavirus State and Local Recovery Funds and the Food Cluster Program. The Problem: CEO timesheets were not reviewed or approved by our Board of Directors in 2024 so proper oversight was not being done. Corrective Action: The procedure we had in place was that our Board Chairperson would review and approve our CEO timesheet entries each payroll period. This procedure was followed in prior years. In January 2024 the Chairperson changed to a new Chairperson and this person did not receive proper training on how to approve the CEO timesheet. When the auditors brought our attention to this situation in March of 2025, we immediately contacted the current and previous Board Chairs, HR Director, and Interim CEO. They worked together to train the present Board Chairperson on how to access the CEO timesheet entries, review them and approve them in a timely manner. This process is being used every pay period and our reports show that all timesheets are approved. We also printed out all timesheets going back to January and had the Board Chair review and sign those copies. Going forward we will be sure that proper training is done when there is a change in either the Board Chair or the CEO/Ed position.

2024-001 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Material Weakness in Internal Control Over Compliance and Noncompliance...., Inadequate Payroll Documentation B. Allowable Costs/Cost Principles Recommendation: The Auditors recommend that management ensure all employee timecards are signed or electronically certified by the employee in a timely manner. The Auditors also recommend a process be implemented to reconcile time charge to federal award to underlying payroll report. Internal controls should be reinforced to verify that no payroll costs are charged to federal programs without appropriate documentation and approval. Action Taken : We agree with the recommendation and updated our written policy in 2024 . The policy was reviewed by the Finance Committee and approved by the full Board of Directors in December 2024.

CORRECTIVE ACTION PLAN Year Ended June 30, 2024 Finding Number: 2024-001 Planned Corrective Action: Cleveland Play House has had difficulties with finding a long-term replacement for the Director of Finance roll and thus the position has experienced much turnover since June of 2023. During this time period, practices have been put in place for the reviewing of grant draws and the approval of time and effort logs. However, the turnover has led to inconsistency with the application of these practices. While the Director of Finance position remains temporarily staffed, there has been improvement in the following of industry best practice for the monitoring of time and effort and grant expenditures. Based on the reduction in questioned costs down from prior year findings and with the continued adherence to best practices for grant costs, Cleveland Play House continues to work towards a clean audit for the fiscal 2025 year ending June 30th, 2025. Anticipated Completion Date: June 30, 2025

Finding & Recommendation 2024-005: As per 2 CFR, part 430(i)(l) of the Office of Management and Budget's Uniform Grant Guidance, charges to Federal Awards for salaries and wages must be based on records that accurately reflect the work performed. The district did not complete Federal payroll certification until May 2024 and did not have sufficient internal controls in place to ensure the certification process was being performed. It is recommended the district's written procedures addressing internal controls with respect to the program requirements be followed to ensure the district tis in compliance at all times. Corrective Action: The district concurs and understands the importance of maintaining internal controls in accordance with 0MB Uniform Grant Guidance. By June 30, 2025, Assistant Superintendent Christopher Carballo will review the existing procedure for Federal payroll certification with Business Office staff to ensure compliance in the future.

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-013 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should update its procedures and controls and perform additional training over time and effort reporting to ensure that payroll costs charged to the program are based on actual time and effort and a combination code that is allowable under the program. The Department should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Action taken in response to finding: EOLWD Finance continues to address time and effort reporting compliance through targeted training and system enhancements. Ongoing training is provided for new staff to ensure they correctly enter combo codes that align with the activities performed. To strengthen oversight, a custom report has been developed to identify employees missing combo codes each week, allowing Finance staff to proactively follow up and ensure proper time charging weekly. Looking ahead, Finance will collaborate with departments in the upcoming fiscal year to update labor distribution profiles, ensuring that employees are defaulted to the correct combo codes for accurate and efficient time reporting. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Anna Yong, Vina Yung Planned completion date for corrective action plan: 12/31/2025

Views of Responsible Officials: Our Federal funds from January 1 to July 31, 2024, were subcontracts with two partners, NACCHO and ASTHO. Each was a flat fee agreement where we were not required to maintain timesheets for contracted work. Where more work was needed than covered by a contract, BCHC used other funds to cover salary. As of August 1, 2024, when we were in receipt of a direct Federal award, we did implement timesheets for effort tracking. While we do track hours work in accordance with what has been budgeted, we continue to supplement all projects (Federal and nonFederal) with additional funds. That said, we have revisited time tracking with our staff and anticipate enhanced accuracy of time capture. Further, from August to December we used a standardized 160 hours for monthly allocations as the denominator to determine payroll percentage per project. We have now started using actual hours per period for those pay periods that have more than 80 hours or months that have more than 160 hours. The implementation of a new allocation format is now in effect, and along with increased diligence on effort tracking across our team, we believe we will enhance accuracy.

Auditor’s Recommendation: Time and effort documentation be documented per Uniform Guidance requirements and used to review and adjust budgeted compensation and benefit costs charged to the award to be accurate, allowable, and properly allocated. Written policies and procedures should be designed and implemented for documentation of time and effort. Corrective Action: TEACH.org will write a policy regarding documenting required procedures to track employee time & effort charged to Federal grants. Each employee who charges time to a Federal grant will receive a copy of this policy annually. The policy will indicate that employees must provide signed time & effort tracking statements at least quarterly while they are charging time to Federal grants. Each statement will be signed by the employee, their supervisor, and the program director. These statements will be used to properly document time & effort charged to Federal grants and prepare invoices or claims for all Federal grants. Each invoice or claim will be compared to time & effort tracking and tied out to the amounts charged to the Federal grant. Responsible for Corrective Action: TEACH.org internal and external accounting staff will write the time & effort procedures with oversight from a TEACH Co-Executive Director. Once the procedures are approved, TEACH internal and external accounting staff will be responsible for identifying employees working on Federal grants and must supply them with a copy of the policy at least annually. Quarterly time & effort documentation forms will be prepared by internal and external accounting staff, and sent to employees, supervisors and program directors. TEACH internal and external accounting staff will be responsible for collecting and retaining all required time & effort documentation. TEACH program directors will be responsible for reviewing all completed time & effort documentation and reconciling time tracked to invoices or claims prepared for all Federal grants. Anticipated Completion Date: TEACH.org will write the time & effort tracking procedures, supply to all employees working on Federal grants, complete all time & effort tracking documents, and tie out to all invoices and claims retroactively to July 1, 2024. This work will be concluded by June 30, 2025, and starting July 1, 2025 the new procedures will be implemented for all Federal grants.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will review time certifications in comparison to salaries and wages recorded to federal programs. See 2024-005 for management's detailed action plan surrounding the time certification findings.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the maintenance, review, and approval of time certifications. See 2024-005 for management's detailed action plan surrounding the time certification findings.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the review and approval of time certifications. Action Plan:  Review current staffing for employees paid with federal funds: o To ensure accurate financial reporting, the Finance Team must establish a structured filing system within Google Drive/Team Sheets under Payroll with the following structure: [FY25 / Time Certifications].  Subfolder Structure:  Semi-Annual Time Certs  Monthly Time Certs  Time Certs Internal Audit o Time Certs Internal Audit  Download the Detail Distribution Report for the current year to date.  Add a column identify the Source of Funds based on budget unit coding.  Create a Pivot Table using the Source of Funds column, employee names, and amounts.  Time Certification Requirements: Employees paid with federal funds must complete time certifications.  Less than 100% federal funded: Monthly time certification required.  100% federally funded: Semi-annual time certification required.  One-time stipend from federal funds: No time certification required, but the offer letter documenting the stipend must be saved.  Anticipated completion date of May 15, 2025, with an updated monthly review.  Create, review, and secure signatures for time certs: o All time certifications must be created, reviewed, and signed by both the employee and supervisor as soon as possible.  If a time certification is not received, a payroll redistribution will be required to move the salary out of the federal fund – this is not ideal and should be avoided. o Timely completion ensures compliance and prevents unnecessary adjustments.o Anticipated completion date of May 15,2025, with an updated monthly review.  Conduct a quarterly audit of time certifications and federally funded payroll records: o As stated above, if a time certification is not received, a payroll redistribution will be required to move the salary out of the federal fund, which is not ideal and should be avoided. o The anticipated completion date is May 20, 2025, with an updated monthly review.

Recommendation We recommend that NIYC strengthen its payroll controls by: Implementing a secondary review of WEX timesheets prior to payroll processing, - Requiring all pay rate changes to be documented using standardized personnel action forms, and -Conducting periodic payroll audits to verify compliance with documentation and approval requirements. Management Response Corrective Action: NIYC will strengthen internal controls over payroll by implementing additional monitoring and review processes. Going forward, the HR Accounting Coordinator will be responsible for an annual review of all staff employment files to ensure that all required documentation is present and up to date. Furthermore, no changes will be made to any employee pay rate without prior written approval and documentation using the standardized personnel action form. Once the change has been made in the payroll system, all approvals and documentation for the change in pay rate will be given to the HR Accounting Coordinator to include in the employee's file. We have also implemented a secondary review of WEX timesheets by the Accounting Manager during the payroll process. This should find and correct any errors in the spreadsheet used to summarize the timesheets and process WEX payroll. Due Date of Completion: Implementing new internal controls starting June 1, 2025 Responsible Person(s): Accounting Manager, HR Accounting Coordinator

Recommendation Implement a centralized, access-controlled digital system for participant file storage. Additionally, management should require the use of a standardized eligibility checklist and conduct periodic file audits to ensure documentation completeness and compliance with WIOA requirements. Management Response Corrective Action: In response to this incident, we have reinstated the Eligibility Determination and Intake (EDIR) Form. This form clearly states the participant identification information, the characteristics tracked by our program data management tool (GPMS), and states what has been provided by the participant to determine their eligibility for the program. Provided in a check list format, the form clearly demonstrates what makes the participant eligible for our program services. The form also lists the documentation included in the application that has been provided by the participant. This form added to the program application and maintained in the participant's official record will ensure that all WIOA eligibility documentation has been received, reviewed, and approved at the time of intake. Due Date of Completion: Completed as of May 31, 2025 Responsible Person(s):Director of Programs and Development is responsible for re-instating the use of the form and the Field Office Managers and Job Developers are responsible for filling out the form and including it in the participant's official record.

FA 2024-001 Improve Control over Employee Compensation Compliance Requirement: Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program COVID-19-10.555 - National School Lunch Program Federal Award Number: 245GA324N1199 (Year: 2024), 225GA324N1099 (Year: 2024) Questioned Costs: $102,234 Prior Year Finding: 2023-004 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the employee compensation process as it relates to the Child Nutrition Cluster. Corrective Action Plans: The District is developing correction action to strengthen controls, policies, and procedures and ensure adherence through improved monitoring. Estimated Completion Date: June 30, 2026 Contact Person: Connie Walker, School Nutrition Executive Director Telephone: 678-676-1780 Email: Connie_R_Walker@dekalbschoolsga.org

Corrective action planned: In alignment with 2 CFR 200.430, Housing Connector will develop and implement a formal time tracking policy and procedure to ensure that personnel expenses charged to federal grants are supported by records reflecting the actual time worked on each award.

Finding Reference Number: 2024-007 Description of Finding: Lack of Semi-Annual Certifications for Special Education Personnel (Controls over Compliance - Special Education Cluster) Corrective Action Planned:The district has implemented new procedures for fiscal year 2025 to ensure that semiannual certifications are prepared, signed, and retained for all employees working solely on federal programs, including the Special Education Cluster (IDEA). A tracking system has been established, and staff training has been completed to reinforce documentation requirements. The district will continue to monitor compliance to ensure procedures are consistently applied. Responsible Contact Person: Patrick M. Faour, Interim Superintendent Anticipated Completion Date: August 30, 2025

To address this issure and ensure timely approval of time sheets, the following corrective actions have been implemented and will be maintained: 1. Recurring Communications on Payroll Deadlines: A structured communication schedule has been developed, through which both HR and the CEO will issue regular notices to staff and payroll supervisors. These communications will serve as timely reminders of payroll approval deadlines and emphasize the importance of compliance. 2. Ongoing Training and Support: Staff and supervisors will continue to receive training to address common barriers to timely approvals. On April 28, 2025, a leadership team training was conducted, which included all payroll supervisors. During this session, the importance of timely time sheet approvals was strongly emphasized. This training is part of our ongoing effors to ensure that all personnel involved in payroll processing understand their responsibilities and are equipped to meet them. 3. Escalation and Accountability: A clear escalation procedure has been established for instances where approvals are not completed by the deadline. Repeated non-compliance will result in disciplinary action, as part of a commitment to maintaining accountability. 4. Internal Processing Buffer: An internal buffer has been integrated into the payroll schedule. This allows additional time for finalizing approvals and ensures payroll can be processed accurately and on time. 5. Mandatory Immediate Action: In cases where time sheet approvals are not completed by the specified deadline, both staff and supervisors will be required to take immediate corrective action. This ensures delays are minimized and payroll operations are not disrupted.