Corrective Action Plans

Corrective Action: The district will strengthen internal controls on the employee contract and employee board approval process. There will be checks and balances between Human Resources and the Business Office before any recommendations are presented to the board. Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: February 18, 2025

CORRECTIVE ACTION PLAN March 19, 2025 U.S. Department of Health an-d Human Services Employee & Family Resources, Inc. respectfully submits the following corrective action plan for the year ended 06/30/24. Name and address of independent public accounting firm: BerganKDV, Ltd.; 220 Park Ave South; St. Cloud, MN 56301 Audit period: July 1, 2023 - June 30, 2024 he finding from the scheduleoflindmgs and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Federal Award Finding Significant Deficiency Finding 2024-001: Proper Support for Payroll Cost Allocations Recommendation: We recommend that the Organization utilize the time and effort reporting system that ensures payroll costs are charged to federal awards based on actual hours worked and to train employees to properly code their hours. If actual hours are not used, management should review and adjust salary allocations periodically to align with documented time records. Action Taken: We concur with the recommendation. Information from the time and effort reporting system will support the payroll costs for the year July 1, 2024 - June 30, 2025. Beginning July 1, 2025, payroll costs charged to federal awards will be based on actual hours worked during the calendar month. Additional training has been conducted with staff and supervisors. Questions regarding this plan can be addressed to me at 515.471.2360. Sincerely, Tammy Hoyman CEO

Food Distribution Cluster US Department of Agriculture / Oregon Department of Human Services Federal Assistance Listing Number: 10.565, 10.568, 10.569, 10.182 Federal Program Name: Food Distribution Cluster, Local Food Purchase Assistance Cooperative OFB’s View on Finding: OFB acknowledges the finding and agrees with the auditors' assessment Responsible Party: Katie Kenton, Interim Co-Director of Finance (Strategic Finance); Nan Wang, Interim Co-Director of Finance (Operational Finance); Rut Martinez-Alicea, Director of Equity People Culture and Administration; Starr Yurkewycz, Director of Partnerships and Programs; Nathan Harris, Director of Community Philanthropy; Shannon Oliver, Interim Director of Operations Corrective Action Plan: Finance will collaborate with key stakeholders to develop and implement a time and effort reporting system that meets federal documentation standards. This plan will identify impacted personnel and tailor reporting processes based on different funding sources. This effort will be cross departmental, roll out may include iterations of testing and refining and require training adoption and monitoring. These actions will strengthen internal controls and ensure personnel costs are accurately recorded and appropriately allocated. The anticipated completion date is: Employee review & certification of time and effort estimates - June 30, 2026 Implementation of software solution for time and effort documentation - June 30, 2027

University System Response/Corrective Action Plan North Dakota State University: Agree. North Dakota State University agrees to certify federal payroll expenses in a timely manner. North Dakota State University implemented a new payroll certification system which went live Spring 2024. Previously, North Dakota State University utilized a manual effort reporting process as part of PeopleSoft. The new payroll certification process was built into Novelution Research Management System, which supports multiple aspects of grant management. Novelution allows PIs to review salary information and certify within the software, provides automated reminder emails, and provides a better tracking mechanism for compliance. There has been a learning curve in utilizing the new system, and during FY2025 we continued to refine the process and implement additional mechanisms to improve compliance. University of North Dakota: Agree. In accordance with University of North Dakota’s policy, we will remind pre-reviewers and certifiers of University of North Dakota's requirement for timely certification. As outlined in the policy, we will invoke the consequences for failing to timely certify, including removing uncertified payroll from a project. Contact Person: North Dakota State University: Karin Hegstad, Associate Vice President Finance & Administration University of North Dakota: Lauren Pite, Director Grants & Contracts Anticipated Completion Date: North Dakota State University: June 30, 2025 University of North Dakota: March 31, 2025

Information on the federal program : Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Context : For 18 selections, in a sample of 40 payroll transactions, the School Corporation based the employees’ time charged to the grant on an annual time and effort log. The employee’s time was split with a non-federal fund. The School Corporation allocated the employee’s time based on a time and effort log completed in September of each year which was reviewed by the Superintendent. The School Corporation did not complete time and effort logs more frequently than annually to ensure the amounts being charged to food service were based on worked performed for each payroll period. Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of doing a time study, we will fully implement an analysis of percentages paid by the school lunch program on a monthly basis. Anticipated Completion Date: Beginning of April 2025, fully implemented and corrected by the end of May 2025.

We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work. The employee records this allocation at least weekly within a time keeping software system. Employees and supervisors are now required to review and acknowledge payroll allocations across grants by signing weekly timesheets. Timesheets will be retained and used as backup by the Grants Department when invoicing the Grantor for expense reimbursement. In addition, we have updated our Policy and Procedures Manual to reflect this policy. An additional policy was implemented in November 2024 requiring one Accounting staffer and one Grant staffer review employee timecards versus invoices prior to submission. The Policy and Procedures Manual has been updated to reflect this policy. Responsible Parties: Kimberly Yoo, CFO Whitney Gillis, Director of RD Mary Guzman, Accounting Supervisor Date Corrected: November 2024

Corrective Action Plan: The Division will implement a more detailed and precise review process to ensure the accuracy and completeness of the reimbursement request. Anticipated Date: April 2025 Name of Person Responsible for Implementation: Al Agpoon, Controller

Context: For 4 selections, in a sample of 40 payroll transactions, the School Corporation did not have time and effort logs to support the portion of the employees’ time charged to the grant. The employees’ time was split with a non-federal fund; however, the School Corporation did not have support for the allocation of the time charged to the ESSER III fund. The sample amount charged to the grant for split-funded employees without time and effort logs was $1,375. Contact Person Responsible for Corrective Action: Serena Francis, Business Manager Contact Phone Number: 765-985-3891 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will implement time and effort logs for all split-funded employees. Currently we do not have any split funded employees. Anticipated Completion Date: 3/1/2025

2024-001. Payroll (Allowable Costs/Cost Principles) United States Department of Education, Passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States ALN: 84.027 Condition: Subpart I, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the performed. The documentation should support the distribution of the employee’s compensation among specific activities if the employees work on more than one Federal award, or a Federal award and non-Federal award. The preparation of personnel activation reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, it was noted that in some instances, the District’s payroll verification forms were either not reviewed or signed by either the employer and employee, and they did not accurately reflect the actual allocation that was charged to the grant in order to comply with Subpart I, 2 CFR §200.430. Planned Corrective Action: The District acknowledges the finding and will thoroughly review and maintain the federal personnel activity reports to ensure each employee’s salary, or other forms of compensation, are properly approved and signed off by employer and employee. Additionally, the District will ensure that the amount charged to the grant corresponds to the federal program to which the employees’ earnings were allocated, based on time and effort, in compliance with Subpart I, 2 CFR §200.430. Responsible Contact Person: Jean Mingot Assistance Superintendent for Business Southampton Union Free School District 70 Leland Lane Southampton, New York 11968-5089 Anticipated Completion Date: June 30, 2025

FINDING 2024-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Linda Zaborowski, CFO Contact Phone Number and Email Address: (219) 881-5536 lzaborowski@garycsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Gary Community School Corporation is committed to strengthening internal controls to ensure compliance with federal regulations governing the Child Nutrition Cluster programs. To address the deficiencies identified in the audit, we will implement a structured system for reviewing and approving all financial transactions related to the food service program. Moving forward, all invoices submitted by the Food Service Management Company (FSMC) will require detailed supporting documentation before payment is processed. The Food Service Director will conduct thorough reviews to verify the accuracy and allowability of costs, ensuring that only eligible expenses are charged to the program. Additionally, a standardized checklist will be developed to confirm compliance with federal cost principles. To address payroll-related deficiencies, all employees whose salaries are funded by the Child Nutrition Cluster will be required to maintain detailed time and effort records that document their work on federal and non-federal activities. The Payroll Department will not process payments from federal funds without proper documentation, and approval from the CFO/Food Service Director. To prevent future occurrences of questioned costs, the Business Office Coordinator will carefully review all FSMC invoices to verify that adequate documentation is provided, and any unallowable costs, including sales tax, are identified and excluded before payment is made. Moving forward, internal procedures will include a detailed verification process to ensure that only allowable costs are charged to the program. Anticipated Completion Date: Gary Community School Corporation will implement this procedure by July 2025.

Auditor’s Recommendation: We recommend the University strengthen the controls in place to provide assurance that proper review occurs and retain documentation needed for an audit. Views of Responsible Officials and Planned Corrective Action: Management agrees that there have been significant challenges with the Paycom system and the approval of the contracts. We are currently working on signature workflows to ensure proper approval for our student, staff and faculty employees. We have begun a team effort among staff in following offices : HR , ORSP, BO, AA, ITS and VPFA. We are working to ensure that all personnel in the chain of the workflow know what signatures are required on different types of contracts. We plan to train relevant staff to recognize when appropriate approvals are not in place and return contracts and timesheets for proper approval. Supervisor training is planned for January 27, 2025 to ensure that supervisors as well as employees take responsibility. In regards to the time and effort, we need a software solution that automatically generates these reports for us and payroll information ties to the payroll system and general ledger. At this time the majority of all the reports generated out of Paycom require intensive manual work in multiple offices. The BO and ORSP will be working on IDC identifying issues and determining solutions. Timeline and Estimated Completion Date: Changes will be implemented in January to be completed by June 30, 2025. Responsible Party: Office of Research and Sponsored Projects, Comptroller and Director of Human Resources

Recommendation We recommend that for hourly employees, both the employee and the supervisor sign the timecard, either manually or electronically, to provide evidence that the employee takes responsibility for the hours worked and the supervisor can attest to the hours worked. Management Response Corrective Action: The District has actively been working with staff and management to review and sign their timesheets before processing payroll. Due Date of Completion: June 30, 2025 Responsible Party(ies): Business Manager

MMUUSD Preliminary Corrective Action Plan (Concerning Finding 2024‐001; Activities Allowed and Allowable Costs) Contact Person Responsible for Corrective Action: Nicole Fortier, Director of Finance and Operations Corrective Action: During our audit there was one instance identified where MMUUSD overpaid an employee under the Food Service program at a rate of pay different than the stated rate for a Food Service Substitute. To be more specific, the Food Service substitute rate was transposed and the employee was paid $16.62 ($0.10 more) instead of the stated substitute rate of $16.52. The first step in our corrective action plan was a review with our Senior Payroll Specialist of the error, and to reiterate the importance of verifying the correct hourly rate being input for our substitutes. This step has already been completed. Additionally, we are in the process of implementing a more thorough payroll review process, which will include a preliminary review by Christal Clark, Accountant in the Business Office. Given that the payment of substitutes is such a manual process and we cannot utilize our employee timesheet software for paying them, we will also perform periodic reviews of all substitute payments to verify that the rate of pay is in line with the Sub Pay agreement for that respective Fiscal Year. If any discrepancies are noted, the employees will be made whole ASAP. We are currently performing periodic reviews of all substitute payments to verify the correct rate of pay is being used as of January 2025. We are in the process still of developing a payroll review process that works for us and is efficient. With Christal Clark being more involved in the payroll process on a biweekly basis, we are assessing whether this should be a post‐payroll review or mid‐payroll review. Anticipated Completion Date: 07/01/2025

FINDING 2024-006 Contact Person Responsible for Corrective Action: Rachel Dutoi Contact Phone Number: 574-254-4503 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: The Business Departmental staff going forward will work with the Payroll department to account for all individuals that are to be paid from Federally Funded Grants and other funding sources. From these lists of employees, the Business Department staff will designate the individuals being paid from federally funded grants and other local or state funds. Time and Effort records will be kept for all employees along with documents listing the impacted employees. These lists will then be reviewed during the certification process by the person creating the listing with Payroll personnel, the Assistant Director of Business Services and the Director of Business Services to ensure that all employees are accounted for. Anticipated Completion Date: This new process will begin with the next impacted payroll cycle.

During the year a new timesheet process was put in place. There were a couple of instances during the initial implementation of this new process where timesheets were reviewed and approved without the employee endorsement. The Organization believes that this inconsistency has since been addressed.

Views of Responsible Officials: Upon reviewing the audit finding, Gads Hill Center (GHC) acknowledges the importance of maintaining accurate and compliant documentation for personal services charged to federal and non-federal awards. To strengthen internal controls and ensure proper time reporting, GHC has implemented enhanced procedures to align with federal requirements. These measures are designed to ensure that all salaries allocated to federal and non-federal awards are appropriately documented and substantiated based on actual work performed. Corrective Action Plan: In response to this finding, Gads Hill Center has immediately implemented a structured procedure to ensure compliance with federal regulations regarding time and effort reporting. Effective February 2025, the following corrective actions have been established: • Monthly After-the-Fact Time Reporting: Employees whose salaries are allocated to federal and non-federal awards must complete monthly time reports that accurately reflect the actual time worked on each funding source. • Review Process: These time reports are reviewed and signed by both the employee and their direct supervisor to confirm accuracy and compliance with the documented allocations and make any necessary adjustments. • Internal Monitoring and Compliance: GHC’s finance and program leadership teams will conduct periodic reviews to ensure adherence to this procedure and make any necessary refinements to maintain compliance with federal guidelines. By implementing these enhanced controls, Gads Hill Center is committed to ensuring accurate documentation of personal services and maintaining compliance with all federal funding requirements. Completion Date: Implemented and fully operational as of February 2025.

Reference # and title: 2024-002 Internal Control and Compliance over Title I Payroll Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Title I Grants to Local Educational Agencies #84.010A 2024 Condition: For an employee who works in part on the consolidated administrative cost objective and in part on a Federal program whose administrative funds have not been consolidated or on activities funded from other revenue sources, an LEA must maintain time and effort distribution records in accordance with 2 CFR section 200.430(i)(1)(vii) that support the portion of time and effort dedicated to (a) the consolidated cost objective, and (b) each program or other cost objective supported by non-consolidated Federal funds or other revenue sources. Employee pay should be reviewed to ensure that payment amount is correct. Employee attendance should be documented on a consistent basis. In testing 25 payroll transactions for the Title I program, the following exception were noted: 2 exceptions noted in which there was inadequate attendance records; 9 exceptions where time records were not initialed or signed by the employee; 2 exceptions where one employee was not paid in accordance with the salary schedule, which resulted in under payment. 14 exceptions where time certifications were completed, but not in a timely manner. Corrective action planned: During the year, there was staff turnover within the Title 1 department. The School Board will ensure that new personnel are properly trained in necessary internal controls over payroll transactions moving forward. Person responsible for corrective action: Mrs. Nicia Bamburg, Chief Financial Officer Mr. Waylon Bates, Assistant Superintendent of Curriculum and Academic Affairs P.O. Box 2000 Benton, Louisiana 71006-2000 Phone: (318) 549-5000 Anticipated completion date: June 30, 2025

2024-001 Allowable Costs Research and Development Cluster: National Institutes of Health: Institutional Career Development Costs (ALN 93.350, grant number 5 UL1 TR001866) Corrective Action Plan: In April 2024, University management became aware that a full-time employee of the University was concurrently employed at Duke-NUS Medical School in Singapore since early 2021. This former employee did not disclose his affiliation at Duke-NUS Medical School on his conflicts of interest forms that the University requires all researchers to complete annually. This former employee’s salary was covered by several National Institutes of Health (NIH) grants. An investigation was conducted by external legal counsel, during and after which the University took several actions. First, the employee’s employment ended. Second, the University stopped drawing the NIH grant funds for this employee’s salary soon after becoming aware of the situation. Third, the University conducted a financial conflict of interest review for the period 2019 through 2024 to determine if any conflicts beyond his employment at Duke-NUS Medical School existed. No further conflicts were identified. Fourth, the University informed NIH of the matter and recommended that the University repay half of the amount of this employee’s salary, fringe benefits and indirect cost recovery charges during the time period from January 2021 through May 21, 2024, which amounts to $299,805. After discovering the issue, we promptly initiated an investigation. Our findings confirmed that this employee was employed by our institution, and our institution including his supervisor was unaware that he was concurrently employed at Duke-NUS Medical School. As a result of these findings, we have taken decisive steps, as follows: 1. End of Employment: The employee’s employment was ended. 2. Investigation and Reporting: We investigated the matter and reported the findings to and have cooperated with NIH. 3. Enhanced Oversight: In response to this incident, we are enhancing our hiring practices and conducting more thorough background checks, especially for positions working on government grant awards. 4. Training and Education: We are implementing mandatory training sessions for all staff on ethical practices, compliance with Uniform Guidance, and the importance of reporting any suspicious activities. 5. Compliance Review: We are conducting a comprehensive review of our compliance with Uniform Guidance to identify any areas for improvement and ensure that our policies are robust and effectively communicated to all employees. 6. Conflict of Interest Disclosure Training and Education: At least annually and at the time of the just in time period (and if there is no just in time period, at the time of award), the University will continue to require University investigators through its certification and recertification process, to attest to the accuracy of their financial conflicts of interest in research disclosure forms pursuant to applicable, long-standing University policies. Contact Person: As to: #1, 3, 4, 5 above: Michael P. Vitale, CPA – Controller Email: vitalem@rockefeller.edu Phone: 212-327-8704 As to: #2 and 6 above: Deborah Y. Yeoh Email: yeohd@rockefeller.edu Phone: 212-327-8071 Anticipated Completion Date: June 30, 2025

Name of Contact Person Responsible for the Corrective Action Plan: Larry Hammel, CFO Changes will be made to the standard operating procedure (SOP). To ensure that timesheets are completed correctly, signed, and reviewed prior to submission for payment. In addition, the principal for each school will be responsible for onboarding/resignation/transfer for all employees at the school location and reporting to Human Resources to process. The training for the new SOP will be completed by April 2025.

Context: For 5 selections, in a sample of 40 payroll transactions, the School Corporation did not have time and effort logs to support the portion of the employees’ time charged to the grant. The employees’ time was split with a non-federal fund; however, the School Corporation did not have support for the allocation of the time charged to the ESSER II and III funds. The sample amount charged to the grant for split-funded employees without time and effort logs was $6,759. Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The newly hired Grant Specialist and Corporation Business Manager will maintain time and effort logs for any personnel whose salary is split between funds. Anticipated Completion Date: July 2025

We were previously found to be compliant with time and effort based on a single annual survey, although DEW’s guidance states it should be done semi-annually. We will be changing time and effort reporting to at least twice annually, resolving this issue. One was completed September 2024 and another will be completed by February 2025.

Management will enhance procedures and controls to ensure that payroll costs charged to the grant are adequately documented.

Context: For 5 selections, in a sample of 5 payroll transactions, the School Corporation did not have time and effort logs to support the portion of the employees’ time charged to the grant. The employees’ time was split with a non-federal fund; however, the School Corporation did not have support for the allocation of the time charged to the School Lunch fund. Contact Person Responsible for Corrective Action: Chris Scott Contact Phone Number: 765-544-2246 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will implement a formal time and effort reporting system for all employees whose salaries are partially funded by federal grants. Our Café department has since revised our process and no longer charge any SES employee payroll to the Café Account for cleaning. As a result, this issue has been fully addressed and should not recure in future reporting periods Anticipated Completion Date: July 2024

2024-002: Payroll Timecard Approval Federal Departments: Department of Health and Human Services Assistance Listing #: 93.612 and 93.959 Compliance and Internal Controls Significant Deficiency Category of Finding – Allowable Costs/ Cost Principles Name of contact person – Sharon Day, Executive Director Corrective action – IPTF has hired and assigned an experienced individual within the organization who has the responsibility of reviewing and approving the Executive Director's timecard prior to processing. Completion date – Management and the Board of Directors implemented the above as of February 2024.

Cross training will occur between the BA, Assistant BA and the Senior Accountant. In the event of extended vacancies or absences, multiple staff members will be trained on filing correct final reports.