Corrective Action Plans

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting details.

Finding 2023-039 – Corrective Action Plan Auditee Views: The charging of a former employee’s payroll costs in full to SFRF for five pay periods after the employee separated from service in the Pandemic Recovery Office (PRO) was not due to any errors or omissions on the part of PRO. PRO never included this employee on the Master Time Sheet for the office in any of these pay periods nor did PRO review and approve the timesheets of this employee during the five pay periods in question. All necessary actions were taken by PRO to demonstrate that the employee in question was no longer an employee of PRO and the failure to pay this employee from the proper account (not SFRF) lies with the entity that is responsible for the processing of the Department of Administration’s payroll and not PRO. The employee within the Division of Purchases was a Division of Purchases FTE that was dedicated to SFRF. SFRF was used to pay this employee, but the employee did not appear on the Pandemic Recovery Office’s (PRO) Master Time Sheet because they were not a PRO FTE. This employee did show up on the Division of Purchases Master Time Sheet and their timesheets were reviewed and approved by Division of Purchases supervisory staff to ensure that only time and effort dedicated to SFRF were paid for by SFRF. The Director of PRO acknowledges that they had a responsibility to review and approve the timesheet of this employee and did not do so. It would not be possible, however, for PRO to include this employee on PRO’s Master Time Sheet as the employee was not an FTE in PRO. The current policies relating to timesheet collection are not within the control of the Pandemic Recovery Office (PRO). PRO is an office within the Department of Administration and adheres to the timesheet protocols for the department, including, but not limited to, timesheet collection. As part of these departmental protocols, every employee must submit an amended timesheet on the Monday following the workweek for which the timesheet is submitted to accurately reflect the actual hours worked should that be different from those recorded on the original timesheet submission. Amended timesheets are reviewed by the Director of PRO for accuracy before final submission. Thus, PRO supervisory reviews of time and effort reporting are accurate and complete under current DOA time sheet protocols. Corrective Actions: Request report from payroll team and conduct regular reconciliation and monitoring of payroll charges to PRO records to improve documentation and support for personnel costs charged to federal programs. The State’s new Enterprise Resource Planning (ERP) system will have improved approval controls and timeliness of reporting for time and effort of employees. Implementation of the ERP system should resolve any other issues that impact time and effort reporting by employees and the subsequent review of such time and effort reporting by PRO supervisory staff. Anticipated Completion Date: July 1, 2025 Contact Person: Paul L. Dion, Ph.D., Director, Pandemic Recovery Office, Department of Administration paul.l.dion@doa.ri.gov

Finding 2023-033 – Corrective Action Plan RIDOH agrees with the finding and recommendation. Corrective Actions: 1. Complete a SFY23 Qtr2 reconciliation adjustment for the individual discovered to not have had charges reconciled according to time reported. This is possible because the relevant funding sources still are open; this will resolve the Questioned Costs for ELC. Anticipated Completion Date: April 30, 2024 2. Review and improve RIDOH internal Time and Effort Reporting policies and procedures and provide training to staff and supervisors to assure all staff understand requirements for dual-signatures on all Time and Effort reports. Anticipated Completion Date: September 30, 2024 3. Review and improve Time and Effort Reconciliation policies and procedures and provide training to all staff that prepare Time and Effort Reconciliation adjustments, to assure all finance staff understand the procedures for appropriately assessing Time Sheet Workbooks and the need for adjustments. Anticipated Completion Date: June 30, 2024 4. Develop and implement appropriate internal controls to test and monitor if compliance with revised Time and Effort policies and procedures is being achieved. Anticipated Completion Date: December 31, 2024 5. Assess the Department-wide usage of generalized time sheet Programs/Activities, including Departmental or Division Management & Leadership, Finance & Operations, and/or Administrative Assistance. Develop strategies to minimize use of these categories by staff charged to federal grants and to appropriately document time charged to grants. Anticipated Completion Date: September 30, 2024 6. Implement processes to add specific descriptions of work performed under any activation of the Incident Command System (ICS) to the Time Sheet Workbooks of any staff participating in an ICS activation (each workbook will be edited manually). The ICS placeholders cannot be eliminated entirely due to the need to have an immediate way to record work for an emergency response situation. Anticipated Completion Date: June 30, 2024 Contact Persons: Alisha Colella, Chief Financial Officer, Rhode Island Department of Health alisha.colella@health.ri.gov Carla Lundquist, Deputy CFO / Federal Grants Manager, Rhode Island Department of Health carla.lundquist@health.ri.gov

2023-003 Allowable Cost- Payroll Recommendation We recommend that the schools develop internal controls and procedures to ensure the documentation is consistently maintained and readily available to support compliance with grantor’s requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: 1. Requirements to support documentation of payroll expenditures will be reviewed with school staff annually as part of grant support visits, resource materials provided and other technical assistance sessions. 2. As part of Spring 2024 site visits to be completed prior to June 30, 2024, Title I specialists will review with school staff requirements for documentation to support payroll expenditures using Title I funds. Documentation of stipend and temporary staff payroll will be collected and saved in the school’s grant monitoring folder. This activity will also occur in September 2024 for summer stipend/temp staff payments. 3. Charter schools utilizing Title II and/or Title IV funds will continue to participate in twice annual monitoring by the Office of Data Monitoring and Compliance to review support documentation for any stipend/temporary staff payments. 4. Schools leveraging ESSER funds in SY23/24 for stipend/temporary staff payments will be requested to upload support documentation to a district established SharePoint site prior to June 30, 2024. 5. By April 30, 2024 requirements for payroll expenditure documentation will be reviewed with district offices implementing grant funded district initiatives. These meetings include Title I, Title II, Title III, Title IV, Perkins and COVID relief grant funds. All district offices will be required to save support documentation for stipend and temporary staff payments for district level and/or district coordinated activities to a SharePoint folder to ensure accessibility for future monitoring activities. The district staff person from the Office of Data Monitoring and Compliance assigned to support the federal grant will review uploaded materials to ensure the documentation supports payroll expenditures. Name(s) of the contact person(s) responsible for corrective action: Kimberly Hoffmann Planned completion date for corrective action plan: June 2024.

The Director of Finance and Operations will work with staff to ensure that proper documentation is provided and approved, per CVSU process / procedures, for every invoice: not just ESSER related. Chris Locarno, Director of Finance and Operations, is responsible for implementing this corrective action plan. We plan to rectify all actions by June 30, 2024

Agency will implement as after-the-fact review for salaried employees. Timecards are actual time worked on project as instructed by Cal OES. Paycor allocations (which are budgeted allocations) are driving the salaried employees' allocations to the labor distribution report. Salaried employees, regardless of their time worked, are allocated 86.67 hours per pay period and by percentage of their labor allocation. Agency will review timecards to labor distribution and make the necessary adjustments after posting the Payroll Import by creating a journal entry to ensure that the project is charged accurately. Timecards are never altered as they are approved with 2 approvals.

Agency will ensure that payroll time sheets are correct prior to processing and importing payroll. If an error on time sheet is found, employee and manager will be notified for employee to make correction. If the error is caught after payroll is processed a Journal Entry will be processed with proper documentation and approval.

Response to Deficiency: Concur. The control has been added effective January 1, 2024. Corrective Action Plan: The current process has been modified to add internal audit to process for adding grant codes to allocation tables. Audit will be conducted by staff accountant who is not a part of the code input process. Internal auditor will review allocation tables to ensure new grant codes are properly included and communicate compliance to requestor and the CFO. Preventative Action Plan: All finance team members will be retrained regarding addition to the current process. Responsbile Personnel: Priya Sarathy, Chief Financial Officer Date: 4/11/2024

During the 2022-23 fiscal year, Ha:San had employee turnover in several key management positions and, unfortunately, the 2023 management team was not aware of all charter school finance compliance requirements which resulted in the findings noted in the single audit report. Ha:San has hired a new management team for the 2023-24 fiscal year who are knowledgeable of charter school finance and compliance requirements and are predicting no repeat findings in the 2023-24 audit. Ha:San and subsidiary will obtain contracts and employment agreements with all staff. Further, a records retention policy will be enforced. Finally, timecards with sufficient detail of federal project participation will have documented approval by the appropriate level of management throughout the year.

Finding 2023-002: Allowable Costs/Cost Principles (Material Weakness and Noncompliance) Condition: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or that the actual time spent was used as a basis for allocating personnel charges to the grant. In addition, there was no evidence that actual incurred expenditures were used as a basis for allocating indirect costs to the grant using the negotiated indirect cost rate. Corrective Action Planned: • With input from the Human Resources Department, the Social Services Department and the Grant & Contract Accountants, Management will identify a process for timekeeping for all employees that are allocated to grant/contract budgets. • Once the time-keeping process has been determined, the Grant & Contract Manager and the Divisional Contracts & Grants Compliance Manager will work in tandem to document policies and procedures to ensure employee timekeeping, the salary and wage allocations to the grant, and allocation of indirect costs are charged to the grant using an appropriate base. The written policies and procedures will include, but are not limited to, step-by-step instructions for employees and supervisors, a review/approval process, document retention, and a communication plan. Anticipated Completion Date: June 30, 2024 through September 30, 2024 Name of Contact Person Responsible for the Plan: Elizabeth Sergel

Views of Responsible Officials: Management is committed to having a strong internal control structure that supports compliance with both internal and external policies and procedures. A system for continuous monitoring of the salary allocation process in the Ukraine field office will be implemented after additional training is provided. We will provide ongoing support and guidance to staff as they implement the newly acquired ERP system. Management will also conduct periodic evaluations to assess the impact of the training program on internal controls surrounding the salary allocation process.

The City recognizes the importance of internal controls and plans to enhance procedures to ensure payroll expenditures related to grants are properly captured, documented, and charged to that grant. Covid interruptions with related illnesses, early retirements, and hiring difficulties all contribute to a negative impact on productivity.

Finding 2023-001 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-001 - ACTIVITIES ALLOWED OR UNALLOWED / ALLOWABLE COSTS/COST PRINCIPLES Type: Material Weakness in Internal Control / Noncompliance Program: COVID 19 Education Stabilization Fund (ALN 84.425D – ESSER II Formula, ESSER II Section 98c Learning Loss, ALN 84.425U – ESSER III Formula) Condition: The District was unable to provide documentation that identified wages, by employee, that were charged to Education Stabilization Fund grants. Corrective action to be taken: Payroll transactions will be recorded at the most granular level to ensure accuracy and transparency in the resulting outcomes. The issue at hand was a result of an overarching labor transfer at the top level of the labor expense accounts. The errant transfer neglected to properly align the underlying transactions, at the employee weekly payroll level, with the correlating expense totals being transferred between grants (i.e. each individual employee expense of the same General Ledger expense code structure comprising the total expense of the given General Ledger) and resulted in the disparity noted in the finding. Adherence to this corrective action will ensure strengthened internal control(s) and future grant compliance. Corrective action timeline: The corrective action is effective immediately and applicable to all stakeholders with data entry access to the CHSD financial accounting software platform. District leader responsible for Corrective Action Plan: The Finance Director will be responsible for ensuring compliance with this corrective action and work product of the Finance Director will have a similarly robust check and balance via transaction review and verification by a knowledgeable second source, normally the Account Payable Administrator or the Superintendent. Respectfully submitted, Marc Forrest, Director of Finance

The Department of Human Services (DHS), Central Office Payroll group will run reports biweekly to determine if any employees are on a leave without pay status greater than 10 days. This added reporting function will ensure that all DHS employees who are on a leave of absence without pay beyond 10 days have their PMIS histories updated upon each extension and return to work. COMPLETION DATE/ CONTACT PERSON March 26, 2024 Maureen Taylor (609) 292-6106 Maureen.Taylor@dhs.nj.gov

Contact Person Responsible for Corrective Action: Nicole Fortier, Director of Finance and Operations Corrective Action: During our audit it was identified that MMUUSD overpaid an employee for four charges under the Food Service program and charged the work to the program that was not specific to Food Service. To be more specific, Food Service subs were paid at a higher rate ($.50 higher) than the stated rate for a Food Service substitute. Additionally, there were instances noted where a maintenance substitute was charged to a Food Service budget unit. The first step in our corrective action plan was a review with our Senior Payment Specialist of the importance of slowing down and 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. Once Christal has completed her review, this will go to Nicole Fortier, Director of Finance for a final, high‐level review and sign off. We are hopeful to begin the process at the end of FY24, with full implementation in FY25. Anticipated Completion Date: 7/01/2024

Finding Number: 2023-002 Planned Corrective Action: The City concurs with the finding and will take the following actions in response: Provide training in the Department of Development (DOD) that reminds applicable staff of the department’s policy that all personal activity reports/work logs are to be reviewed and signed by the supervisor within one week of the completion of a pay period. Modify current financial management internal controls to indicate that if a work log is not signed by the supervisor at the time DOD Fiscal Office completes the quarterly ‘tru up’, a ‘tru up’ for unsigned activity reports/work logs shall not be done at that time, thereby reducing the risk of ineligible expenses, and all worklogs must be signed by the time designated by DOD Fiscal Office near the end of the fiscal year; and DOD Fiscal Office staff shall review signature timeliness as a part of the quarterly ‘tru up’ process and provide a report to department leadership who shall determine the appropriate next steps if activity reports/work logs are unsigned. Anticipated Completion Date: 4/30/2024 Responsible Contact Person: Bill Webster, Deputy Director Alex Cofield, Development Program Coordinator/Compliance and Data Analytics

2023-002 - Allowable Costs/Cost Principles – Internal Control and Compliance over Payroll Expenditures (Significant Deficiency) Condition: Community Development Block Grants-Entitlement Grants Cluster We determined the City did not comply with federal requirements for direct payroll charges. Payroll costs for all eight employees tested were allocated to programs based on percentages provided by management. These allocations were not supported by approved time samples or updated cost allocation methods/plan, nor were they reconciled to actual time spent on the various programs. Employee timesheets did not record the actual labor efforts expended on these grants. In April 2023, the City has required all Housing Department staff to retrospectively fill out timesheets pertaining to actual hours worked on the program during fiscal year 2023, The City performed reconciliation on Housing Department staff payroll charges to reflect actual hours worked. However, the admin supporting staff did not use the same method due to the low percentage of the payroll charges to the grant. Housing Voucher Cluster We determined the City did not comply with federal requirements for direct payroll charges. Payroll costs for all five employees tested were allocated to programs based on percentages provided by management. These allocations were not supported by approved time samples or updated cost allocation methods/plan, nor were they reconciled to actual time spent on the various programs. Employee timesheets did not record the actual labor efforts expended on these grants. In April 2023, the City has required all Housing Department staff to retrospectively fill out timesheets pertaining to actual hours worked on the program during fiscal year 2023, The City performed reconciliation on Housing Department staff payroll charges to reflect actual hours worked. However, the admin supporting staff did not use the same method due to the low percentage of the payroll charges to the grant. Management Comment. City Response and Corrective Action: Management has enforced the existing policy, which mandates that employees funded by federal grants document the actual time they spend working on those grants. The staff responsible for reporting the actual time spent on federally funded programs dedicate a significant portion of their time to these programs. However, there are administrative staffs that provide support towards these programs, and tracking their time spent towards the time spent on the program would require more time and effort than the minimal allocation the City allocated for each administrative staff as appropriated in the Adopted Budget. The minimal cost allocated towards the program is significantly less than the actual time spent as well as being below the 10 percent de-minimis indirect rate as mentioned in Note 4 on the FY 2022-23 Single Audit. Management will have supporting administrative staff to keep track of their actual work hours moving forward and/or establish an indirect cost allocation plan moving forward. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Rose Tam, Director of Finance Albert Trinh, Accounting Manager

In order to ensure accurate record keeping of hours charged to salaries and wages, the time keeping software has been restricted to prevent education hours and standard hours to duplicate the hours charged to salaries and wages. Time-sheet signoff by supervisors require a review of education hours to ensure hours are properly recorded. Person(s) Responsible: Payroll Administrator/Director of Finance Timing for Implementation: Effective December 1, 2023

Ref. No. Compliance and Internal Control over Compliance Findings 2023-006 Allowable Costs – Significant Deficiency Recommendation We recommend the County follow their internal control process to ensure that adequate documentation supports the accumulation of costs charged to the Program as required by 2 CFR §200 Subpart E. View of Responsible Officials and Planned Corrective Action Management agrees with this finding. The Department of the Prosecuting Attorney’s office has reviewed and agreed a detailed line item report and Payment Request/Approval form did not accompany the respective RFF. The Department has already corrected these deficiencies to ensure each expense has an Expense Approval form with justification and that each RFF is accompanied with a detailed line item report and backup documentation for each expense being requested for reimbursement. Each payroll and non-payroll monthly invoices submitted clearly shows the breakdown. With each invoice submitted, it will state, as an example, “VOCA-SNAP 21-V2-01 Report & Attachments MM/YY”. A sample of this was submitted on March 25, 2024 with response. In short, the necessary back-up requested going forward is and will be available to submit for future audits or reviews. Anticipated Completion Date: 3/27/2024 Responding Person(s): Robert Nadal Grant Management Specialist Phone No. 808-270-7608

In order to ensure accurate record keeping of hours charged to salaries and wages, the time keeping software has been restricted to prevent education hours and standard hours to duplicate the hours charged to salaries and wages. Time-sheet signoff by supervisors require a review of education hours to ensure hours are properly recorded. Person(s) Responsible: Payroll Administrator/Director of Finance Timing for Implementation: Effective December 1, 2023

Views of Responsible Officials and Planned Corrective Action: The Board agrees with this recommendation and will review internal procedures relating to data that will support the allocation of personnel costs.

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

Finding 2023-004 Federal Agency Name: U.S. Department of Labor 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

Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation. Additionally, CFR Section 200.430 states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and are supported by a system of internal control which provides reasonable assurance that the charges are accurate and allowable. The Florida’s Division of Accounting and Auditing Reference Guide for State Expenditures states that supporting documentation shall be maintained in support of expenditure payment requests for cost reimbursement contracts including that approved timesheets support the hours worked on the project or activity must be kept. During our testing of payroll disbursements, we noted that seven of the 120 payroll expenditures selected for testing did not have a properly approved timecard for the pay period selected. Corrective Actions Taken or Planned: All of the timecards noted in the finding above have been reviewed for accuracy and retroactively approved by the Chief Talent Officer. The following corrective actions are in the process of being implemented: • CHS’s Payroll and Talent teams will conduct a review of timecards completed after July 1, 2023. The accuracy of any unapproved timecards identified will be verified and retroactively approved by the designated supervisor, or the Chief Talent Officer if the designated supervisor is no longer available. • After each payroll period, a list of unapproved timecards will be provided to the Talent Team so the respective Talent Business Partner may follow up with corrective action with those supervisors who have two or more repeat occurrences. Such corrective action will include: o A thorough review with the supervisor of the CHS policies and practices relative to supervisory duties regarding the management and approval of employee timecards. o Mandatory refresher education and training on the supervisory timecard review and approval process in the CHS HRIS, Paylocity. In addition, CHS is formally implementing a new HRIS, UKG PRO, in July 2024. This system has advanced notification and tracking features that will assist supervisors in proper management and approval of timecards. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Vogel, Chief Talent Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2022 – 06/30/2023 Contract Number: FSCWJ00302 Award Year: 2022 – 2023 Comments on Findings and Recommendations: Finding 2023-001—Certification over payroll cost allocation (Control Finding)— Envision Unlimited allocated staff salaries and related fringe benefits to the federal program based on budgeted estimates, which were determined before the services were provided. There was no employee certification or documented review of actual time and effort incurred for the payroll costs charged to the grant at the time audit procedures were performed. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) 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 which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken- Employee certifications were obtained and reviewed by supervisors for all grant payroll costs charged during the award year and were provided to the auditors. A new process is in place for quarterly certifications to follow 2CFR 200.430(i). The required corrective action for Finding 2023-001 for the period 07/01/2022 – 06/30/2023 was completed in December 2023. The person now responsible for completion of the corrective action plan is Dennis James, Chief Financial Officer.