Corrective Action Plans

Dear Mr. Waguespack, Please find below the University's management response to the audit finding titled "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards." Management Response: The University partially concurs with the finding. The audit finding states that UL Lafayette did not perform time and effort certifications for the period January 1, 2024, through June 30, 2024. However, we clarify that these certifications were not intentionally omitted. As outlined in our prior response, the University has been transitioning from a manual to an electronic effort certification system. In the transition, we had opted shifting from a fiscal year-based reporting framework to a calendar-year-based framework. The effort certifications for the period in question are scheduled for completion by April 15, 2025, at which point they will fully support that salaries and wages charged to federal awards are based on records accurately reflecting work performed. Corrective Actions: • The University has developed a structured plan to complete the January 1, 2024 — June 30, 2024 effort certifications, ensuring compliance with 2 CFR §200.430(i), which requires after-the-fact confirmation of personnel costs. • The Standard Operating Procedure (SOP) will be updated to require biannual effort reporting, enhancing monitoring of personnel effort. • The University will retain the full calendar-year effort reports (January 1, 2024 — December 31, 2024), including the January 1, 2024 — June 30, 2024 period, electronically on file for audit and compliance purposes. Planned Actions: • Completion of Effort Certifications: The University will finalize and retain the calendar-year effort reports for January 1, 2024 — December 31, 2024, by April 15, 2025, ensuring compliance with federal regulations and addressing audit concerns. • Transition to Biannual Effort Reporting: Effective FY 2025, UL Lafayette will implement biannual effort reporting to enhance compliance and personnel effort monitoring. The updated SOP will reflect this change. • The University will make every effort to secure effort certification for Key personnel leaving the university prior to their departure. The University remains committed to making continuous improvements and appreciates your understanding and support as we address these challenges.

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office’s findings related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address the findings and provides the following response and corrective action plan. Recommendation: Management should ensure they have adequate controls over time and effort certifications, purchases, and reimbursement requests. In addition, management should ensure adequate segregation of duties covering approvals of all transaction types. Response and Corrective Action Plan: Effective FY25, LSUHSC-S has implemented an electronic Time & Effort certification system through PeopleSoft in conjunction with New Orleans. Training in the new system was provided by the New Orleans IT Department to all departmental Business Managers. Technical support questions are addressed by OSP Post Award and New Orleans IT Department. LSUHSC-S Administrative Directive 4.4 will be revised to include the new electronic process. The Office of Research Administration will hold Post-Award Monitoring meetings with all principal investigators and designated departmental staff on a quarterly basis. These meetings will begin in March 2025. During these meetings, Grant Managers from OSP Post Award will review grant ledgers to ensure that all grant accounts are reconciled monthly. Departmental Business Managers will sign off on the completed monthly reconciliations. Personnel expenditures will be included in this monthly review. Discrepancies will be reviewed with the PI and business manager for accuracy and possible corrective action plan. Prior to submission, OSP Pre-Award will provide the RPPR to the PI and Business Manager for review and certification, to ensure time and effort allocations match the current budget and PER report. OSP Pre-Award will aid Business Managers as needed. A new PER electronic system was implemented and the AD for Cost Transfer is being revised and approved. The revised AD will require greater detail in the justification for changes in source funding for salaries. Justification must meet the requirements in the revised AD. A new Standard Administrative Procedure will be implemented in March 2025 that requires all salary changes on grant accounts to be made no later than 90-days after the effective date. All requests that are greater than 90 days will be evaluated through a rigorous review process and may or may not be approved. LSUHSC-S Research Administration will ensure accurate information is available and provided to auditors upon request in a timely manner. LSUHSC-S will explore the implementation of additional PS module vendor transaction utility, such as adding more approvers, to ensure adequate segregation of duties for approval. The removal of the ability for self-approval of requisitions within the PeopleSoft requisition workflow will prevent a requestor and an approver from being the same person. A monthly report will be auto-generated and emailed (ad-hoc ability as well) to the Director of Purchasing and the Executive Director of Financial Operations. The report will list detailed requisition information to include the requestor names and approver names of requisitions created for that period for review to ensure the approval process is properly working. Name of Contact(s) Responsible for Action Plan Ramey Benfield, Chief Financial Officer, Vice Chancellor for Research Administration Jen Katzman, Vice Chancellor, Administration and Budget (with Departmental Business Managers) Tracy Calvert, Associate Director, Office for Sponsored Programs Post Award William Haacker, Assistant Director, Office for Sponsored Programs Post Award Steven McAlister, Associate Director of General Accounting Anticipated Completion Date: Continuous

Allowable Activities and Costs Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a process to review changes to salary and wage information as changes are made or identified.. Action taken in response to finding: The process has been changed as of July 1, 2024 and will continue forward. Name(s) of the contact person(s) responsible for corrective action: Daria Sztaba, CFO Planned completion date for corrective action plan: July 1, 2024

Views of Responsible Officials: We acknowledge the audit finding regarding the documentation of personnel time. To address this issue, we have implemented the following corrective actions and will continue to enhance our process: 1. Enhanced Training: We are providing comprehensive training to all relevant staff on the importance of accurate timesheet entry/review and the proper procedures for documenting and allocating personnel expenses. 2. Improved Internal Controls: We have strengthened our internal control procedures to ensure that timesheets are completed accurately, reviewed thoroughly, and retained properly. Allocations are additionally entered into the payroll system for further accuracy. These are reviewed and approved then entered into the accounting system. This is then reconciled to the payroll system for further accuracy. 3. Regular Audits: We are conducting regular internal audits of timesheet and payroll records to ensure ongoing compliance with documentation standards and to identify any areas needing improvement. 4. Accessible Records: We have established a system for the retention of allocation documentation in a readily accessible format to facilitate future audits and ensure transparency. 5. Addressing Turnover: We recognize that high turnover rates within the finance and program departments have contributed to these issues. To mitigate this, we will continue to focus on improving staff retention through enhanced support, training, and development opportunities, ensuring continuity and consistency in our documentation processes.

TASC of Southeast Ohio is currently reviewing all personnel files to ensure that all approved rates are included in the files. Internal controls surrounding the documentation of approvals of timesheets and pay raises are currently being implemented.

Immunization Cooperative Agreements – Assistance Listing No. 93.268 During our testing, we noted the Chapter charges benefits to the programs based on an estimated allocation calculated based on the percentage of salaries as determined in the contract budget. However, we noted the Chapter does not have internal controls in place to provide a review of the actual fringe benefits incurred. Recommendation: We recommend Pennsylvania Chapter, American Academy of Pediatrics establish a process for periodic after-the-fact reviews of interim charges made to federal awards based on budget estimates. Based on the review, management should make any necessary adjustments to the interim charges based on the results of the periodic reviews. This would ensure that the final amount charged to the federal award is accurate, allowable, and properly allocated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Chapter will implement a process for the review of interim charges made to federal awards and make any necessary adjustments that ensure the final amount charged to the federal award is accurate, allowable and properly allocated. Name(s) of the contact person(s) responsible for corrective action: Annette Myarick, Executive Director Planned completion date for corrective action plan: The planned corrective action will be completed by June 2025.

The Treasurer will ensure that the appropriate documentation supporting the time spent on a federal grant, in accordance with the Service Center’s Policy 6116 for Time and Effort, for all employees having wages and/or benefits charged to federal grants.

Finding 2024-003 – Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles 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 employee’s 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: Brad DeRome Contact Phone Number: 765-747-5222 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all payroll amounts recorded to food service are reviewed to ensure they represent food service payroll activity only. Anticipated Completion Date: March 2025

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Allowable Costs/Cost Principles compliance requirements. Context: During testing of the Allowable Costs/Cost Principles compliance requirements, there were two vendor vouchers in a sample of 60, where the School Corporation was unable to locate any supporting documentation. These two selections totaled $1,530 charged to the grant. It was further noted that during our testing of payroll costs charged to the COVID-19 – Education Stabilization Fund, for 2 selections in a sample of 40, the School Corporation was unable to provide any support to validate the amount of payroll charged to the grant. These two selections totaled $414 charged to the COVID-19 – Education Stabilization Fund. Corrective Action Plan: The School Corporation will establish a system of internal controls to ensure that documentation is maintained and that expenditures charged to the grant comply with the grant agreement and are allowable. Person responsible for implementation and projected implementation date: The Business Manager will be responsible for overseeing the implementation of the corrective action plan, which will go into effect immediately.

iv. Management Response and Corrective Action Plan: Program staff allocate their time spent at work each day based on their client load and recurring weekly activities, e.g., case conferencing meetings. Staff must allocate their daily time and activity hours on their timesheets corresponding to the project/s each client is enrolled in. Leave allocations should reflect each payroll period’s project time and activity actual percentages. Staff must manually record this information on complicated timesheets and consequently errors are made as not all staff are equally administratively adept. While there are multiple levels of review over timesheets, as the company has grown, it has become apparent that NBCC must integrate a more reliable method of always ensuring accurate allocation calculation of regular and leave hours. The expectation was that our new payroll solution provider, Paychex, was going to custom tailor a system that prevented such calculation errors, but this has not been the case thus far. Therefore, NBCC is actively once again researching payroll companies in an effort to find a solution better aligned with our timesheet needs. In the interim, management will work to edit our existing timesheet template to create a more user-friendly timesheet tool that auto-calculates where necessary and as appropriate so as to avoid misallocation. Management will also conduct additional timesheet trainings with staff as necessary. The end goal will be to secure a new payroll solution provider with system functionality that eliminates this kind of human error. v. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Victoria Garfield, Grants Administration Director, vgarfield@sbnbcc.org Michael Dzierski, Finance Director, mdzierski@sbnbcc.org vi. Anticipated Completion Date: The anticipated completion date of the first step of editing our existing timesheet and retraining all staff as necessary is June 30, 2025. The anticipated completion date of the second step of having an integrated new payroll system with a new payroll solution provider will be dictated by the identification of a new vendor, and the subsequent development and implementation process of the new system, with an estimated completion date of December 31, 2025.

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services 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 (PARs) 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 monitor procedures that ensure that time performed as reported to comply with Subpart E, 2 CFR §200.430, be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. The District will also see that sufficient details exist regarding the duties performed by the employees whose compensation is reimbursed by federal awards. Responsible Contact Person: Reza Kolahifar Assistant Superintendent for Human Resources and Personnel Connetquot Central School District 700 Ocean Avenue Bohemia, New York 11716 Anticipated Completion Date: June 30, 2025.

Condition: Of the testing population of 40 payroll transactions tested, for 10 transactions the Center was unable to provide a timesheet or other documentation to substantiate the application of the individual's time for that period. Corrective Action Plan: The Center will implement updated personal activity reports to substantiate each employee's time allocated to the grant for each pay period. Anticipated Completion Date: June 30, 2025 Responsible Individual: Andy Navarro, Senior Accountant

Boston Public Schools has updated its’ training and guidance for timekeepers. Timekeepers participate in enhanced trainings annually in August in preparation of the new school year. Anticipated Completion Date: August 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools has updated its’ training and guidance for timekeepers. Timekeepers participate in enhanced trainings annually in August in preparation of the new school year. Anticipated Completion Date: August 31, 2025 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

2024-007 A/B. Allowable Costs and Cost Principles/Activities Allowed or Unallowed Administrative Cost Grants for Indian Schools FFAL #15.046 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified six expenditures where payroll was not paid in accordance with employment letter Responsible Individuals Trevor Gourneau, Superintendent Corrective Action Plan: The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. Anticipated Completion Date: June 30, 2025

2024-008 A/8. Allowable Costs and Cost Principles/ Activities Allowed or Unallowed Indian School Equalization FFAL #15.042 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary:During the course of the engagement, Eide Bailly identified several expenditures where payroll was not paid in accordance with employment letter. Responsible Individuals:Trevor Gourneau, Superintendent Corrective Action Plan:The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. Anticipated Completion Date: June 30, 2025

Finding 2024-003 Name of Responsible Individual: Tamara Hill, AVP Research Operations and Finance Corrective Action: We concur. We are identifying personnel that will be allocated to federal awards to ensure all effort reports are reviewed and certified timely. During the next effort reporting cycle, the school will transition to a new automated system, Cayuse effort reporting. This will give the Office of Grants & Contracts Faculty and Staff increased visibility into the personnel allocated to federal awards in a more efficient manner. We will complete the corrective action no later than June 30, 2025. Anticipated Completion Date: June 30, 2025

Plan: 1. Internal Control Review: Fiscal staff must upload appropriate documentation, such as an invoice, for each expense entered into QuickBooks. Each of these expenses is then reviewed by a member of the executive team, making sure allocations are appropriately recorded. 2. Training and Awareness: OBT has provided training to all relevant personnel, especially those involved in procurement, expenditure documentation collection, and allocation designation to ensure they understand the requirements of federal awards and the importance of proper documentation. 3. New Technology: OBT Has purchased new technology to better support documentation collection and allocations for all orders made. 4. Continuous Monitoring: OBT is continuously monitoring compliance with allowable cost principles, identifying any gaps, and taking corrective actions as needed. Name of Contact Person: Greg Rideout, Co-CEO Target Date: OBT will implement all four steps within this plan by March 31, 2025, with ongoing monitoring and improvement.

Finding 2024-002, Timesheet – Timekeeping (Assistance Listing 16.575 and 93.696) Persons Responsible: Irene Math, Chief Financial Officer, Jessica Schneibolk Controller Comment: Per 2 CFR § 200.430 requires that the distribution of salary and wages charged to federal awards be based on actual employee activity as reflected in personnel activity reports (timesheets), prepared after-the-fact, and includes the total activity for which employees were compensated. Response: In January 2025, WJCS implemented an automated time and attendance system for staff to track time which integrates with the payroll and financial systems to ensure appropriate allocations to Federal awards. Prior to implementation of the new system weekly manual timesheets were used to track staff time and attendance on Federal contracts. However, these manual timesheets were not integrated into a standard agency-wide payroll processing system. The new system enhancements to payroll tracking will allow WJCS to completely and accurately allocate payroll costs to grants with fewer mechanical steps which increase the risk of miscalculations. Estimated Completion Date: The agency-wide time and attendance system was implemented in January 2025.

2024-001 - Allowable Costs/Cost Principles – Internal Control and Compliance over Payroll Expenditures (Significant Deficiency) Condition: Community Development Block Grants-Entitlement Grants Cluster During the audit period, the City has required all Housing Department staff, including administrative support staff, to fill out project activity timesheets reflecting the actual hours worked on the program. The City performed reconciliation on the staff payroll charges to reflect actual hours worked. However, not all staff members have fully complied with this policy. Payroll costs for the fourteen (14) out of forty (40) payroll samples tested were allocated to programs based on percentages provided by management. These allocations were not supported by approved time samples or updated cost allocation plan, nor were they reconciled to actual time spent on the various programs. Employee timesheets did not record the actual labor efforts expended on the grant. Housing Voucher Cluster During the audit period, the City has required all Housing Department staff, including administrative support staff, to fill out project activity timesheets reflecting the actual hours worked on the program. The City performed reconciliation on the staff payroll charges to reflect actual hours worked. However, not all staff members have fully complied with this policy. Payroll costs for the thirteen (13) out of forty (40) payroll samples tested were allocated to programs based on percentages provided by management. These allocations were not supported by approved time samples or updated cost allocation plan, nor were they reconciled to actual time spent on the various programs. Employee timesheets did not record the actual labor efforts expended on the grant. Management concurs. Corrective Actions: 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 City is in the process of implementing an indirect cost allocation plan to allocate the administrative staff time and anticipates this will be in effect in fiscal year 2025-26. In the meantime, staff will make every effort to document the actual time spent working on the grants. Name of Responsible Person: Ron Garcia, Director of Community Development Ryan Mulligan, Housing Manager Rose Tam, Director of Finance Albert Trinh, Accounting Manager

Planned Corrective Action: The two employees are no longer with America’s Finest Charter School (AFCS). However, AFCS will ensure that all Title I employees responsible for reviewing the Semiannual Certification Form will certify it after the pay period. We will continue to provide training for all employees funded by federal programs and for the HR Manager regarding the requirements for federal time accounting under 2 CFR §200.430. We will also review payroll records to ensure that payroll is accurately charged to the correct programs on a semimonthly basis.

Department: Administrative and Financial Services Title: Internal control over monitoring of employee classification and compensation needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The procedure referenced in 5 M.R.S. Sec. 7061(4) is laid out in 18-389 C.M.R. Ch. 4. The Department complies with these written policies and procedures as required by federal and state law. Section 7061(4) was last updated in 2023, with an effective date in October 2023. Pursuant to the JSC on Appropriations, Section 7061(4)(A) requires a review every five years of the state compensation plan for each class or position in the classified service. The FJA process is not related to the compensation plan, however, it is administered under a separate internal control structure that is in place and operating effectively and ensures that the compensation for individual employees is reasonable for the services rendered. The requirement for review of each classification through the FJA process is covered under Section 7061(4)(C) and is required to be reviewed every 10 years. It is also important to note that the Department has conferred with the OAG, who determined that Section 7061(4)(C) is not retroactive, meaning the Department has another 8.5 years to complete a review of all classifications. Additionally, salary studies conducted on State employee wages have shown that the salary and wages of job classifications paid by the State are consistently lower than industry averages, removing the risk that the utilization of these salary schedules as a component of payroll costs will cause overcharges to Federal grants. Completion Date: N/A Agency Contact: Michael J. Dunn, Acting State Human Resources Officer, Bureau of Human Resources, DAFS, 207-287-4651

Finding Number: 2024-001 Planned Corrective Action: Meals on Wheels of the Monterey Peninsula (MOWMP) will address the finding by taking the steps outlined below: 1. Expenditure Allocation: Controller and/or bookkeeper will allocate expenditures based on the number of meals prepared each month and the percentage of meals prepared for each program and funding. Yearly reviews of the allocation process will be conducted to ensure accuracy and relevance. Adjustments may be made based on changes in meal demand, program requirements, funding sources, or other factors affecting meal preparation costs. 2. Payroll Reporting: On a yearly basis, Managers and/or Directors will allocate the amount of time each employe works based on tasks performed and the amount of time worked on federal award activities. This allocation will be expressed as a percentage of total work hours performed. Periodic adjustments to time allocations may be necessary to reflect changes in project priorities, staffing levels, or other factors affecting workload distribution. Person Responsible for Corrective Action Plan: Leadership Oversight – Christine Winge, Executive Director Operational Oversight – Kay Smith, Controller Anticipated Date of Completion: MOWMP will complete the Corrective Action Plan by June 1, 2024 and these new policies and procedures will be in full effect throughout fiscal year 2025 and beyond. We will continue to review effectiveness and make changes as necessary.

Concur. To help ensure the County’s policies and procedures include a process for reconciling budgeted payroll allocations to actual time spent on grant activities and provide sufficient documentation to support the actual time worked on the grant program, the County has revised its process for tracking the actual time spent on grant activities in order to provide sufficient documentation to support the actual time worked on the grant program and a reconciliation process to adjust these charges to reflect the actual effort expended on the grant projects. The recommended solutions include strengthening its comprehensive internal control policies and procedures to ensure that payroll costs charged to federal award are accurate, allowable, and properly supported. Additionally, the County will implement a process to reconcile the budgeted payroll allocation with actual time spent on grant activities. The County’s goal is to meet and complete recommendations by the end of fiscal year 2025-26.

Concur. To help ensure the County’s policies and procedures include a process for reconciling budgeted payroll allocations to actual time spent on grant activities and provide sufficient documentation to support the actual time worked on the grant program, the County has revised its process for tracking the actual time spent on grant activities in order to provide sufficient documentation to support the actual time worked on the grant program and a reconciliation process to adjust these charges to reflect the actual effort expended on the grant projects. The recommended solutions include strengthening its comprehensive internal control policies and procedures to ensure that payroll costs charged to federal award are accurate, allowable, and properly supported. Additionally, the County will implement a process to reconcile the budgeted payroll allocation with actual time spent on grant activities. The County’s goal is to meet and complete recommendations by the end of fiscal year 2025-26.