Corrective Action Plans

Corrective Action Plan 2023-001: Management will implement a comprehensive time tracking review process that also extends to reviewing time for employees that choose to work remotely and will ensure that time not allocated to the grant is not included in the costs allocated to the grant. Management will revise the fringe benefit rate that gets charged to the hourly rates to ensure that none of the costs included in the fringe benefits are also direct expenses billed to the grant. The unallowable costs will be redirected to other allowable grant costs in 2024. Anticipated Completion Date: September 2024 Contact Person: Jay Konomos, Pillar Leader

Management’s response and corrective action is as follows: To improve the accuracy and timeliness of payroll processing, a revised payroll procedures manual will be developed and disseminated to all staff responsible for time approval. Additionally, mandatory training on the ExecuTime system will be conducted for these staff members to ensure they have the necessary skills for proper and timely time sheet approvals. Expected Implementation Date: June 2024 Contact person: Amanda Stanley, Chief WIOA Administrator, EmployBR

Management Response The eight selections were for salaried employees who worked more than 80 hours in the pay period. When a salaried employee has uncompensated overtime, the Garden must charge the documented hourly rate, adjusting hours for the uncompensated time against non-contract funding. This results in the actual paid dollars being billed to the federal award, as appropriate for cost reimbursement. The outcome being total hours on the timecard may be more than the paid hours reflected in the register. This is in accordance with the Uniform Guidance. The calculation of this adjustment was performed but not documented. Corrective Action Plan: Documentation of the salary allocation process has been completed. Anticipated Completion Date: Completed. Contact person(s) responsible for the corrective action: Jaime Kuczkowski, CPA Jaime@balancefm.com, Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org.

o As of June 30, 2024, LifeWire has implemented a new software package called VELA in which direct services staff enter their actual time worked to contracts, which is then reviewed and approved by their supervisors and reported to Finance staff for payroll processing. By December 31, 2024, the Finance staff will ensure all 2024 actual hours worked toward contracts have been reviewed and approved by all direct services staff whose time is billed and approved by their supervisors. o Name of Responsible Individual: Jeannette Biffle, Controller

2023-002 Allowable Activities/Cost Principles US Department of Education - AL #84.010 Title I Grants to Local Education Agencies Condition: The District was not in compliance wllh lhe Uniform Guidance as it was noted that management of the District was not preparing time and effort dastribution records and could not produce source documentation to support the time and etfort applied to payroll expense that was charged to Tatle I Grants to Local Education Agencies. Cause: The District's internal controls to identify and document employees that require support for time and effort charged to Title I Grants to Local Education Agencies were not effective for the year ended June 30, 2023. Auditor Recommendation: We recommend the District review their internal controls to strengthen processes and improve procedures. We recommend the District complete all required time and effort certilications in a timely manner. Plan of Action: Ashland School District wall identify administrative-level staff to oversee federal programs, including Title l, to ensure compliance with all relevant Uniform Guidance activities. Dastrict and building staff will review guidelines and documentation requirements for all federal programs to improve record keeping and to allow appropriate review of federal program activities. Date of lmplementation: lmmediately and ongoing. lf there are any questions regarding this plan, please contact Scott Whitman by email at Scott.Whitman@ashland.k12.or.us or by phone at 54 1 482-281 1.

1. Overview Organization Name form communities, Inc. Audit Period January 1 - December 31, 2023 Date of Audit Report 8/26/2024 Prepared By form communities, Inc. Date 8/26/2024 2. Summary of Audit Findings Finding #2023-001 Significant Deficiency and Other Noncompliance 3. Corrective Actions Finding #1: Significant Deficiency and Other Noncompliance ● Description of Issue Based on procedures performed, the auditor identified payroll expenditures allocated among federal award programs that were not supported by the time and effort allocation certifications. As a result, verification documentation of payroll allocations across federal award programs was not obtained. ● Root Cause Analysis Lack of documentation to support payroll allocations across federal award programs. ● Corrective Actions These findings were for 2023, but were not documented in the audit until August 2024. As of January 2024, we’ve already redoubled our efforts to improve time-keeping across programs and funding lines. Today, everyone assigned to projects that require this level of time-keeping must sign-off on a monthly basis asserting that they’re spending at least the minimum amount of time required on relevant project activities. ● Responsible Party The corrective actions are being led by our Program Management Office which ensures that allocation documents are collected for each individual, for each relevant project. ● Timeline The corrective actions have been implemented as of January 2024; however, additional levels of hourly tracking were requested. New payroll software is being implemented to facilitate this level of tracking, shifting from 30 ADP to Proliant. The kick-off meeting for this transition is scheduled for August 28, 2024 with a goal of having a full transition before January 1, 2025. ● Resources Required SignNow: Digital signature collection tool to automate the collection of signatures for all records. Proliant: new timekeeping and payroll software. ● Monitoring and Evaluation PMO should set a goal of receiving 100% of all required allocation documents on a monthly basis. ● Expected Outcome With improved procedures for tracking and reporting of time allocations across federal award programs, we should achieve full compliance with the compliance requirements and terms and conditions of federal awards starting in August 2024. 4. Implementation and Monitoring ● Implementation Plan ○ Starting in January 2024: Consistent collection of monthly allocation plans, and automated signature requests for all relevant individuals ○ Starting in August 2024: Shifting to a new payroll and timekeeping system to increase the level of detail that can be monitored ● Monitoring Plan ○ PMO team will monitor to ensure we have received all required allocation documents ● Responsibility for Monitoring ○ April Jacob from the PMO team 5. Reporting and Documentation ● Reporting: PMO team will create a Slack channel focused on allocations where we will have open tasks to: create allocations, load allocations, and receive notifications when all allocations have been signed. PMO team will be responsible for reporting in that channel when we’ve received 100% of the required allocation documents ● Documentation: The Corrective Action Plan will be stored in the same Slack channel as the allocations, and any relevant questions to the plan can be addressed in that channel, accessible by organizational leadership and PMO team. 6. Conclusion An audit of our 2023 program identified a lack of consistent documentation for 2023. In 2024, we started to archive our monthly allocation plans, and automated the collection of signature documents from our employees so that we have at least two levels of information. As part of our audit process, we determined that it would also make sense to move to a new payroll and timekeeping system, with a goal of full deploying the system by January 1, 2025. The result should be that, for most employees, we have at least 2 levels of awareness for all project involvement. 7. Signatures Name: Eric Estrada Name: Peter McClain Title: Executive Director Title: PMO Lead Date: 08/27/2024 Date: 08/27/2024

Views of Responsible Officials: Management currently approves all payroll registers immediately upon receipt and before payroll is processed. The Center intends to create a policy outlining payroll allocation methodology and other procedures. Name and Title of Responsible Official(s): Rebecca Montiel, Accounting Manager Anticipated Completion Date: December 31, 2024

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2023-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations

U.S. Dream Academy, Inc. submits the following corrective action plan for the year ended December 31, 2023. The finding from the schedule of findings and questioned costs dated August 23, 2024 is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 Internal Controls and Compliance over Allowable Costs and Activities - Payroll (Significant Deficiency) Recommendation: We recommend the Academy establish policies and procedures to reconcile the percentage of hours charged on time slips to the budget estimates used to bill the Federal grantor. This should be in conjunction with quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Academy’s fiscal year). Corrective Action: On November 20, 2023, U.S. Dream Academy entered into a contractual agreement with ADP Comprehensive Services to move electronic time cards from Attendance on Demand to ADP Time & Attendance. This change in software will allow program and grant allocations made by employees on time cards to be directly imported into payroll processing as is, eliminating the need to manually enter the summation of all hours worked over the pay period and manually breaking down the allocation for entry into the general ledger. The Time & Attendance software went “live” with the pay period ending May 18, 2024. Each pay period, the Financial Controller will reconcile actual time worked (as per time card) against budgeted salary allocations. The Chief Financial Officer will review these reconciliations prior to grant reporting and at year end closings. Responsible Parties: Phylicia Buie, CFO and Chris Moore, Financial Controller Date Corrected: August 23, 2024 If there are any questions regarding this plan, please contact Phylicia Buie pbuie@usdreamacademy.org or Christine Moore at cmoore@usdreamadacemy.org .

Boston Fire Department (BFD) has implemented additional procedures to ensure all pay rates are accurate, and evidence of approval exist. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) has revised their policies and procedures for timekeepers to timely report any system issues related to department time summary reporting. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) has updated its’ training and guidance for timekeepers. Timekeepers participated in enhanced trainings during August of 2024 in preparation of the new school year. Anticipated Completion Date: August 31, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) has updated its’ training and guidance for timekeepers. Timekeepers participated in enhanced trainings during August of 2024 in preparation of the new school year. Anticipated Completion Date: August 31, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Immunization Cooperative Agreements, ALN #93.268 Criteria: According to 2 CFR 200.430 i(i)(vii) charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and there should be support to the distributions of the employee’s salary or wages among specific activities or cost objectives if the employee works on more than one Federal award. Condition: In gaining our understanding of controls over allowable costs for payroll, we noted that the Organization did not have proper documentation of time and effort analysis to support charges to the grants. Cause: The Organization used the grant budget to charge salaries to the grant but did not have any documentation showing an analysis of actual time worked on those grants. Effect: The hours charged to a program could be under stated or overstated if the actual hours differed from the grant budget hours. Auditor’s Recommendation: We recommend implementing the use of time sheets with grants or personnel activity reports that document actual hours worked by personnel on each grant. Management Response: Management will implement time sheets for all employees that work on grants that specify what grants they are working on, number of hours for each for all payrolls in 2024 to correct this problem going forward. In addition, the timesheets will include what functions those employees worked on if they do work that was to be outsourced.

Corrective Action: The district concurs and understands the importance of maintaining internal controls related to Education Stabilization Fund requirements. However, due to turnover of half the Business Office staff in June 2023, the district procedures could not be effectively followed. That said, by September 1, 2024, the Assistant Superintendent for Business will, together with the pertintent Business Office staff, review the existing procedures for these internal controls to ensure all are being implemented properly for the coming fiscal year. Additionally, the Assistant Superintendent for Business will have monthly reviews with the Treasurer to ensure these internal control processes are being correctly followed.

City’s Corrective Action Plan: The City of Stockton has performed a review of the data for payroll and performed isolated testing in fiscal year 2023-24 that concludes the issues have been corrected. The City has hired a grant manager to assist with the periodic reconciliation of grants to the general ledger as well as establishing policies and procedures over the annual process. Finance, Budget and Payroll staff will communicate and work with the grant contacts to ensure proper documentation is maintained and allocation of salaries charged by program are approved and documented. Responsible Person: Queen Gray (Assistant Chief Financial Officer over Payroll), Imelda Arroyo (Budget), and Jennifer Winn (Grants Manager) Expected Implementation Date: September 2024

Management acknowledges the importance of ensuring that payroll costs charged to the program are consistent between the payroll system and the employee’s timesheet. The City continues to monitor its internal control process to ensure thorough review procedures are being followed. Timesheets are reviewed, bi-weekly, by payroll and adjusted to reflect actual hours as they relate to a specific activity. The City was able to hire a permanent accountant hiring who will provide additional oversight of these processes ensuring that hours worked are both reported correctly on the timesheets and are following the funding allocations that are approved by the grant.

The Superintendent and the grant coordinator are no longer employed by the Mountain Pine School District. The District Treasurer will no longer pay any employee without a proper timesheet signed by the employee and appropriate supervisor. The District Treasurer will confirm that the time sheets turned in for off contract are truly hours worked outside the employees' contract.

ALN: 84.010, Corrective Action Plan: Inadequate Supporting Documentation - Title 1 - OPI - The Montana Office of Public Instruction management will provide staff training on how to track time and effort functions in the manner required. The training will be performed by the Centralized Services Manager and Payroll Manager. Person(s) Responsible for Corrective Measures: April Grady, Chief Financial Officer, Montana Office of Public Instruction, Target Date: 10/31/2024

Views of Responsible Officials: Due to the nature of our operations, we have a multinational payroll carried out in our subsidiaries. The timekeeping records are produced by the employees and reviewed by managers, are received by the finance team once the month is closed and the salaries being paid. To distribute the payroll data to grants as per the allocations in the timekeeping data there is an unavoidable manual aspect which is open to human error. Additional internal controls will be put in place to eliminate human error as far as possible in future.

Finding Number: 2023-001 Allowable Costs/Cost Principles - Compliance and Internal Control Summary of Finding: The Code of Federal Regulations 2 CFR 200.303, Internal Control, requires the nonfederal entity to establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-federal entity is managing Federal awards in compliance with Federal statutes, regulations, and other terms and conditions. During the audit, we noted an instance for which an employee was reinstated and received retro-active payment for the months of September through November 2022 for which we were not able to substantiate the allowability of the payroll charges. Response to finding: This was an unusual and isolated incident. Management is working to ensure the appropriate procedures are in place to address this type of transaction in the future to comply with all internal controls. Corrective Action: Management will review current procedures and update to ensure compliance with our internal controls. Individual(s) Responsible for Corrective Action Plan: o Name: Melissa Ells o Title: Controller o Phone number: 312-660-1667 o Anticipated Completion Date: September 2023

Auditor's Recommendation: We recommend that the accounting department reconciles the general ledger for receivables to their billing system in totals on a timely basis. Action Taken: A new process to record revenue and receivables was implemented during April 2023, which records earned services at a more accurate rate and provides more timely supporting documentation for those balances. Management believes this new process has aUeviated the problem of receivables and supporting documentation.

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. Department of Health and Human Services Pass-Through Entity: None Criteria: Per 2 CFR 200.430(i), personnel costs charged to federal grants are required to be supported by documentation including time records. Per 2 CFR 200.303, a non-federal entity must establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Condition: Our audit procedures over the calculation of COVID patient days used to allocate the payroll cost to the PRF/ARP federal program disclosed the amounts were not properly calculated. Cause: The Medical Center has controls in place to review the calculation; however, the control did not operate to identify an error in the calculation of COVID patient days. Effect: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Questioned Costs: None Perspective: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Medical Center implement additional internal controls over compliance in order to properly identify any errors in calculation. Management’s Action Plan: The Medical Center will implement additional internal controls over compliance. Such controls will include verification of all calculations used by two parties, the Director of Finance and CFO as well as signoff on calculations. Name of Person Responsible for the Plan: Mallory Ginn, CFO Anticipated Completion Date of the Plan: 7/31/2024

Item 2023-002 - Activities Allowed and Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Repeat Finding No Action Taken As of July 20, 2024, we have added the Payroll Summary by grant to the grant draw down packet. In addition, we have changed the procedure to reflect that the payroll summary must have either the CFO and/or CEO approval signature prior to grant draw. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079.

CORRECTIVE ACTION PLAN (Concerning Finding 2023-002) Contact Person Responsible for Corrective Action: Rhonda Casey, Business Manager Corrective Action: The Millinocket School Department will take the following actions to address finding 2023-002: The School Department will complete semi-annual wage certifications every six months to ensure that time certifications are completed at the period end and that all charges reflect an accurate account of the employee’s time devoted to the program. Anticipated Completion Date: January 31, 2024