Corrective Action Plans

Management Response and Corrective Action Plan 1. Automatic payments for recurrent utility services are covered by blanket approval to ensure timely remittances. Individual utility invoices are not individually approved but are reviewed by agency location by the Operations department during their monthly finance meeting. Management has elected this method as most efficient for the volume and timeliness required. Documentation of the review during the meetings will be kept as evidence of review of these expenses. 2. Management allocates payroll for exempt salaried employees on an hourly basis to fund sources based on the 80-hour period for which they are compensated. Any hours worked in excess of 80 hours by these employees are not compensated nor charged to fund sources. Exempt salaried employees have been directed to report only compensated time on timesheets. 3. We concur with this finding. Changes in pay rates for staff who perform multiple roles will be redefined to include all possibly affected program fund sources that staff may impact. Contact person(s) responsible for the corrective action: Lisa Brabo, Chief Executive Officer, lbrabo@fsacares.org Denise Cicourel, Chief Operating Officer, denise@fsacares.org Jaime Kuczkowski, Chief Financial Officer, jaime@balancefm.com Anticipated Completion Date: Education and documentation on the above have already started and will be completed by June 30, 2025.

Invest in Kids updated its human resources system to ensure timesheets accurately reflect time allocated across various funding sources and cost objectives. Additionally, all staff attended the organization’s annual financial management and internal controls training in October 2024, that included updated policies and a focus on accurate submissions of time and effort. Policy reviews have also been completed by management.

Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and staff to access and review.

Name of Responsible Individual: Marchon Jackson, Associate Vice President for Research, Brenda Willis, Senior Executive Director of Financial Grants & Contracts, Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations Corrective Action: A new office is being developed to address the timeliness of the personnel payment request forms. In Phase I, CRAs will be assigned to high-volume research colleges to provide support for costing allocations. Phase 2 will encompass existing departmental administrators who will gradually transition into more centralized research workflows supported by CRAs. A shared services model for the remaining colleges is planned for FY26. Quarterly checklist and updates outlining cost allocation statuses will be completed with Deans and Associate Deans to determine the process needed to complete cost allocations timely. Anticipated Completion Date: July 1, 2025

We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two instances of missing approvals identified in the audit were due to human error rather than a lack of controls. To prevent such occurrences in the future and reinforce our existing procedures, we will continue implementing and strengthening the following controls: • Proactive Timesheet Approval Monitoring – Reports are regularly run to identify missing timesheet approvals before payroll is processed. Employees and supervisors with outstanding approvals receive reminders to ensure further action as needed, including notifying program directors about missing timesheet submissions or approvals resulting in out-of-compliance with federal awards and Uniform Guidance. • Real-Time Payroll Processing Checks – During payroll processing, additional reminders are sent to employees and supervisors who have not yet approved their timesheets, further reducing the likelihood of omissions. • Additional Approval Outside the System – In response to BDO’s recommendation, we will require managers to email Payroll at the end of every pay period affirming that they have reviewed and approved all timecards. This additional layer of approval ensures that even if a manager forgets to approve a timesheet in the system, there is still documented confirmation of their review. • Post-Payroll Compensating Control Implemented in FY24 – To mitigate any risk of over/undercharging grants due to miscoded time from unapproved timesheets, a compensating control was introduced in FY24. This process requires Program Management to review and approve a post-payroll report identifying any discrepancies in time allocations, ensuring that all time charged to grants is accurate and properly approved. • Documentation and Continuous Improvement – VOAWW provided attestations to BDO where available and acknowledges that the compensating control was not fully implemented during FY23 but was in place for most of FY24. Moving forward, we will ensure that this control is consistently applied across all programs. By maintaining and strengthening these controls, including the additional email approval process, we are confident in our ability to ensure proper timesheet approvals while mitigating any risk of inaccurate grant charging. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

We acknowledge the auditors’ recommendation regarding the need for a more arm’s-length approach in determining rent charges between entities. To address this finding, we are making adjustments to our rent allocation methodology to enhance transparency and ensure compliance with best practices. As part of our corrective action plan, we will implement the following measures: • Transition to an Actual Expense Allocation Methodology – VOAWW will modify the rent allocation process to allocate actual expenses incurred, ensuring that charges between entities reflect true costs. This approach eliminates the need for a year-end true-up process while maintaining fairness and accuracy. • Implementation of a True-Up Process for FY25 – While transitioning to the new methodology, we will conduct a true-up process for FY25 to reconcile any discrepancies and ensure that rent allocations align with actual expenses. These actions will help strengthen our internal controls and ensure that inter-entity rent allocations are handled in a compliant and equitable manner. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

UPS-AIDS has always used the budget allocations for wages and salaries in the past until this year that it becomes an issue. The finding was not corrected because management did not have sufficient time to prepare for the subsequent year after the previous year was submitted in a very short period of time. Nevertheless, we have agreed to comply as they have requested. However, we have agreed to comply with 2 CFR 200.430. Ive Pierre, Chief Financial Officer, will implement a time study by June 30, 2025.

2024-018. USU Extension Extra Services Compensation Program Non-Compliance with Uniform Guidance State Agency: Utah State University Research & Development Federal Agency: Various 1) Potential Financial Impact USU retained Huron Higher Education Consulting to conduct a Uniform Guidance compliance review of compensation costs charged to federal sponsors. Huron Consulting routinely works with Carnegie R1 institutions to review research compliance issues. Huron conducted a detailed review of an extensive data set for ESC payments made to USU employees, focusing on employees who had salary charged to federal grants or designated as a grant cost share. This review identified limited instances (1) when salaries directly charged to sponsored projects included extra service compensation in the institutional base salary and (2) when extra service compensation was charged to federal sponsors. Overall, the review found that the vast majority of USU ESC payments (referred to as secondary payments in the internal audit) were not charged to federal sponsored awards. Out of a total population of $5.8 million ESC payments reviewed, the unallowed compensation costs related to ESC is approximately $140,000. USU is in the process of addressing the unallowable compensation costs by removing unallowable charges on open awards and refunding unallowable charges on closed awards. 2) Policies and required documentation for ESC. ESC Policies: USU is reviewing its policies associated with ESC and institutional base salary (IBS) (both currently defined in USU Policy 376: Extra Service Compensation). A working group has been established that includes the Provost’s Office, the President’s Office, the Office of Research and Human Resources to develop updated procedures for requesting ESC. Once in place, a new Extra Service Compensation website will be rolled out that will provide guidance on the policy, acceptable uses of extra-service Compensation, and training materials. In conjunction with the website development, a communication plan to inform stakeholders, especially approving department heads and administrators, will be developed. Institutional Base Salary Policy and Procedures: USU will create and implement an Institutional Base Salary policy that aligns with federal requirements and industry best practices and specifically defines salary components and the associated pay codes that are included and excluded from an employee’s institutional base salary. USU will also update its time and effort certification system with correct institutional base salary mapping. 3) Internal controls for sponsored program compensation USU will implement the following improvements in its internal controls: Revised ESC Form. USU has revised its ESC Form to include documentation / calculation demonstrating payment is commensurate with institutional base salary. Revised ESC Application and Approval Process: USU has already updated the internal ESC review process to include appropriate controls to ensure that all ESC requests are reviewed for Uniform Guidance and USU policy requirements. In this regard, all ESC requests at USU are now reviewed by the Office of Sponsored Programs in the context of all funding sources associated with the applicant (including cost share indexes). This change directly addresses prior routing based on the source of funding which resulted in the Office of Research/Sponsored Programs being bypassed for state-funded ESC requests. Certification language has been inserted at appropriate approval levels to ensure that employees are not receiving ESC related to their primary position/workload. Improved Definitions of Primary Work Statement: USU has initiated a collaborative effort between Human Resources, the Provost’s Office, and the Office of Research to clearly define the primary work assignment for faculty via the role statement or annual work plans to clarify the full workload associated with the IBS. Increased Compliance Monitoring: After-the-fact monthly review of ESC payments is being collaboratively performed between the Office of Research and Provost’s Office. Additionally, USU has reorganized its operations to house post-award research administrators within the Office of Research and added an additional supervisory position to manage post award compliance and management. USU will charge central-post award research administrators with monitoring salary charges to sponsored awards and cost share accounts as a secondary internal control. Research Incentive Programs: The Office of Research will establish permissible conditions and components for research incentive programs and any and all proposed programs will be reviewed and approved by the Office of Research before implementation. 4) Adequate training to university personnel regarding sponsored programs compensation compliance. Uniform Guidance training for faculty and staff: USU is building and incorporating new training modules for those managing federal awards which will include guidance on allowable compensation costs and determining institutional base salary. ESC Training: USU has developed a new required annual training for anyone requesting or approving ESC from all types of funding sources at USU (delivered via USU’s Learn Blue system). This training addresses requirements for ESC and employees’ role and responsibilities for compliance requirements. Additional training regarding time and effort certification will be developed. Pay Code Training: USU will provide additional training and education for departmental and payroll staff responsible for coding and processing salary across the institution. Responsible Person: Lisa M. Berreau Vice President for Research Utah State University 435-797-3509 Anticipated completion date of corrective action plan: Actively in progress and full completion by Jan. 1, 2026.

Federal Agency Name: Corporation for National and Community Service Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) section 200.430 provides that records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Amounts for certain personnel costs were not reimbursed at the correct pay rate for certain employees. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. While current year differences were immaterial and resulted in a slight underbilling, we have implemented a secondary review process of all calculations of hourly payrates to ensure consistency in the payrate calculation. Anticipated Completion Date: Ongoing

The District is aware of the importance of maintaining documentation that demonstrates expenditures charged to a program are allocable and allowable. The District will review existing procedures related to the review of temporary workers to ensure that documentation is available to demonstrate charges to programs comply with federal guidelines and regulations. The District also recognizes the importance of timely approval of time and effort in compliance with federal regulations. While the District does perform regular reconciliations of expenses to ensure allowability, the District will review and update procedures, as necessary, to continue to improve and document timely supervisory approvals after each bi-weekly payroll is processed in relation to finding 2024-01 in the District’s Report on Internal Controls and Compliance.

Management agrees with the finding related to effort certifications. Dartmouth-Hitchcock published a new effort policy on February 11, 2025, for all research staff to emphasize the importance of Principal Investigators and Research Staff certifying their efforts on grants promptly. Management will begin implementing and enforcing the policy starting with the quarter ending March 31, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: March 31, 2025

2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable and properly allocated. Condition: During our testing of the Sheriff Department’s compliance with allowable costs/cost principles requirements, we noted that thirty-three (33) of forty (40) overtime cost calculations were miscalculated. Cause: Equitable sharing funds may not be used for salaries, except under certain provisions outlined in Section V.B.3 of the Equitable Sharing Guide including overtime. The Sheriff’s Department calculates the allowable portion of personnel salaries using a separate template that contained a formula error which inaccurately calculated the total salaries costs allocated to the program. The Sheriff’s department did not have internal controls in place to ensure that the allowed salaries were being calculated correctly. However, the error was detected after the 5th out of 6 months in which these types of costs were allocated to the program. Effect: Salary costs were allocated to the program in an incorrect amount. Questioned Costs: Our testing resulted in questioned costs in the amount of $3,550. However, the total questioned costs for the total population was $23,409. Context/Sampling: A sample of forty (40) individuals were selected from a population consisting of (840) payroll transactions. Repeat Finding from Prior Years: No. Recommendation: We recommend the Sheriff’s Department establish and maintain internal controls to ensure the overtime calculations are being accurately allocated to the program. Management Response and Corrective Action: 1. Person Responsible: Tiffany Mui, Fiscal Administrator 2. Corrective Action Plan: a. Staff corrected the formula error in the Overtime (OT) calculation workpapers. Detailed workpapers, including formulas, will be reviewed by Fiscal Administrator. b. Updated desk procedures for Sheriff’s Narcotics task will include updated OT calculation change. Procedures will be reviewed and initialed by Fiscal Administrator and Sr. Fiscal Manager. 3. Anticipated Implementation date: March 2025

Condition: The documentation to support reasonable assurance for salaries and wages consisted of documentation of when employees completed a therapy session but no clear documentation of how much time when employees were on-call or completed case notes for this grant. Recommendations: We recommend The Center remind its employees complete a personnel activity report that show all of the hours employees spend on the grant not rely just hours documented in the Center system used to track therapy sessions. Management response: Management agrees with the finding and has already put a process in place for documenting time spent on grant-funded activities. Management is working with our Chief Compliance Officer to ensure that the process encompasses all necessary steps to ensure complete and accurate records of the grant-related activities by those who have the time covered by the grant funds.

Contact person(s) responsible for corrective action – Lisa Lawson, Sr. Accountant Corrective action planned – KMHS will move forward with billing benefit expenses as actual as of January 2025 contract billing. All employee and employer benefit costs will be billed out per the actual benefits enrolled and received. Anticipated completion date – 1/31/2025

2024-002 - LACK OF WRITTEN FISCAL POLICIES AND PROCEDURES As of March 27, 2025, scaleLIT has updated its fiscal policies and procedures to reflect all the federal guidelines required by the Uniform Guidance. The scaleLIT Board Treasurer has reviewed and approved the updates.

2024-001 – MATERIAL WEAKNESS IN INTERNAL CONTROLS OVER FINANCIAL REPORTING In July 2024, scaleLIT switched accounting firms. This engagement has led to a more robust monthly close-out process to ensure accurate and complete class allocations. The Director of Operations meets with the firm weekly to review accounts receivable, expense and income coding and allocations, and other activities related to billing and invoicing. The Director of Operations and Executive Director meet monthly with another accounting team member to review monthly financial reports. PART III - FEDERAL PROGRAM AUDIT FINDINGS 2024-001 – MATERIAL WEAKNESS IN INTERNAL CONTROLS OVER FINANCIAL REPORTING As stated above, scaleLIT is now working with a new accounting firm, Jitasa. Jitasa tracks all grants on separate ledgers. scaleLIT meets with Jitasa weekly to ensure that all income and expenses are correctly allocated. scaleLIT is implementing time studies for staff beginning on April 1, 2025, to become more detailed with the staff time spent on federal contracts.

2024-001. 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: IDEA Part B ALN: 84.027 Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Education Preschool Grants: IDEA Preschool ALN: 84.173 Special Education Preschool Grants: IDEA 619 ARP Allocations ALN: 84.173X Condition: Subpart E, 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 work performed.” The documentation should support the distribution of the employee’s compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PAR) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District prepared periodic certification equivalents, but it did not comply with Subpart E, 2 CFR §200.430. Planned Corrective Action: The District will adopt procedures that ensure that time performed will be used to support costs charged to the federal award, and comply with Subpart E, 2 CFR §200.430. Responsible Contact Person: Michael I. DeVito, Esq. Assistant Superintendent for Finance and Operations Long Beach City School District 235 Lido Boulevard Lido Beach, New York 11561 Anticipated Completion Date: June 30, 2025.

FINDING 2024-004 Finding Subject: A sample of 14 payroll population from the School's ESSER disbursement population was selected for testing to verify if the transactions were for allowable costs. An employee was paid 50% of the ESSER grant and no documentation was provided. Contact Person Responsible for Corrective Action: Greg Elkins, CFO Contact Phone Number and Email Address: (317) 485-3100, greg.elkins@mvcsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The school is assuming that time & effort documentation was required for the one individual paid 50% with ESSER funds. That is occurring now, and always has with the only current federal fund that partially pays for staffing (Title 1.) It is unknown why this individual did not archive this information as they served as the Title 1 director as well during this time. No corrective plan is needed. The grant is closed, no funds are available, no further transactions will occur from this grant. Anticipated Completion Date: 3/11/2025 (the grant is closed)

Action taken in response to finding: Program staff will continue to ensure that all timesheets are signed by the division head Name(s) of the contact person(s) responsible for corrective action: Janet Antonellis, CDBG Administrative Assistant, Svetlana Taksa, Fiscal Manager, and Lara Kritzer, Director of Housing and Community Development. Planned completion date for corrective action plan: This has been and will continue to be implemented with all future timesheets.

2024-002 Allowable Costs Recommendation: We recommend the School ensure policies and procedures for payroll expenditures for grant programs be charged to the federal grant based on approved hours worked in the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For federally funded employees, CFO will complete semiannual certifications to validate federal grant based payroll expenses. Time and Distribution logs will be used for any part time federally funded employees. Name(s) of the contact person(s) responsible for corrective action: Deborah S. Czmiel Planned completion date for corrective action plan: 05/31/2025

Management has historically maintained robust timekeeping procedures to ensure time is allocated as accurately as possible based on projected activities. However, we recognize the need for a more timely process for making adjustments from estimated to actual time worked. To address this, the new program director scheduled quarerly meetings with our external accountant, beginning in April 2025, to review and update time allocations based on actual activity> We have also requested that fringe benefits be allocated in a manner consistent with how salalries are charged to the federal grant and will review to verify. These steps will ensure that both time and fringe benefit allocations more closely reflect actual effort and remain in alignment with federal grant requirements.

The Department will conduct a formal review of its processes and policies to identify potential weaknesses in the payroll timekeeping and approval process, and will update its policies and procedures to align with the roles and responsibilities of those involved in rostering and timekeeping. The department has already taken corrective action to ensure that duty chiefs are finalizing the rosters before the end of their shift and making it the responsibility of the timekeeper to initiate action when finalization by the Duty Chiefs has not occurred so the timekeepers review process can be completed.

a. Name of Contact Person Responsible for Corrective Action: Jarrad Robinson Director of Federal Programs b.Corrective Action Planned: All employees whose salary is specifically funded with federal monies including federal grants, will be required to complete either a personal activity report (PAR) and/or a semi annual report. c.Anticipated Completion Date: Currently ongoing

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (1 instance). b) Calculation errors for expenses allocated to the grant (3 instances). c) Employee tracked 2.7 hours under the federal program and a nonfederal program line in ClickTime (1 instance) causing it to be double counted. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. An employee entered 8 hours of PTO into ClickTime for two days each; however, the employee was only paid for 4 hours of PTO for each day. The calculation errors were due to the use of a wrong employee’s allocation percentage and a keying error for payroll expenses for an employee. The secondary review of the employee ClickTime timecards did not identify the incorrectly tracked hours and double tracked time. Also, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Project Directors (Rebecca McCrackin, Missy Martini), Project Accounts Manager (Marsha Bomgaars) and CEO (Dan Ries) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 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 work performed.” The documentation should support the distribution of the employee's compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District had not prepared periodic certification equivalents for all employees. Planned Corrective Action: The District will monitor procedures to ensure that documentation to support salaries and wages charged to federal awards is in a format that complies with the requirements of the Uniform Guidance Subpart E, 2 CFR §200.430. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.