Corrective Action Plans

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Corrective Action Plan for Current Year Findings June 30, 2024 Finding 2024-001: Activities Allowed or Unallowed Research and Development Cluster Award Period: July 1, 2023 – June 30, 2024 Responsible Person: Karen Miller, Controller 609-771-2203 Jeanette Vega, Director of Grant Financial Administration 609-771-2847 Corrective Action Plan: For the fiscal year ending June 30, 2024, the College had 7 employees with a combined total of 10 payroll instances with no effort verification form certified for any of the transactions from July 1, 2023, to December 31, 2023, in the fiscal year being audited. The effort was certified after the fiscal year, as part of the year-end process which was not in line with the semi-annually time frames as historically done with guidance in our Effort Verification Operating Policy. The College recognizes the importance of ensuring that labor costs charged to federal awards are based on accurate and timely records and certifications, as required under 2 CFR 200.430(g). The timing delays occurred due to staffing vacancies and knowledge transfer of current staff as well as misalignment of staffing. Once the staffing was realigned, trained, and vacant positions filled, the time and effort certification for the fiscal year labor costs were completed. This task occurred during the months between August 2024 and November 2024 which was outside the policy time frames. The College is committed to improving its internal controls over time and effort reporting for research and development grants to ensure compliance by taking corrective action steps to improve monitoring and oversight, strengthen training and communications, and develop an action plan for corrective timing. The College implemented part of the corrective action on August 01, 2024, retroactive to July 1, 2023, and will complete the remaining items by the end of the next fiscal year. Anticipated Completion Date: June 30, 2025

Corrective Action Plan – Kansas Health Science University Identifying Number: 2024-002 Finding: Improper Controls Over Personnel Expenses Applicable Regulation: Uniform Grant Guidance (2 CFR 200.430(g)(1)(i)) states 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. Finding: A KHSU supervisor did not properly document approval for one employee’s personnel activity reports. Corrective Action Taken or Planned: Upon being notified by the auditors of this specific issue, the organization took immediate steps to address the finding. The missing documentation for the personnel activity report was located and the supervisor provided retroactive written approval. The updated Personnel Activity Report was submitted to KDADS. This corrective action resolved the specific instance during the audit. In addition, the following will be implemented: 1. Development and Implementation of a Standard Operating Plan • A SOP for reviewing and documenting approvals of personnel activity reports (PARs) will be developed. • The procedure will include detailed steps for supervisors to review, approve, and retain documentation of PARs. 2. Training for Supervisors • All supervisors responsible for approving PARs will have one-on-one training on the new SOP by the Chief Financial Officer, emphasizing the importance of proper documentation to comply with internal controls and audit standards. • Training sessions will be scheduled. 3. Implementation of Monitoring Controls • A secondary review process will be introduced to ensure compliance with the new procedures, including review by the Principal Investigator. • The Grants Management Office or an equivalent oversight body will conduct periodic audits of PAR documentation to verify proper approvals. Contact Person: Matt Ankenbrandt, Chief Financial Officer mankenbrandt@kansashsc.org Anticipated Completion Date: 2/15/25

Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. Moving forward, any employee who has time split between multiple grants or Federal and non-Federal activities will be expected to complete a personnel activity report. This report will record actual time spent working on eligible activities for each fund. If the employee has a regular schedule, the employee’s schedule will suffice as their personnel activity report, as long as it follows the guidelines. The personnel activity reports will be requested each month during the reimbursement request process and will be signed by the employee and their supervisor.

Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. Moving forward, any employee who has time split between multiple grants or Federal and non-Federal activities will be expected to complete a personnel activity report. This report will record actual time spent working on eligible activities for each fund. If the employee has a regular schedule, the employee’s schedule will suffice as their personnel activity report, as long as it follows the guidelines. The personnel activity reports will be requested each month during the reimbursement request process and will be signed by the employee and their supervisor.

Auditor recommendation: The auditor recommends that the City implement a final review for potential duplicated costs prior to approving reimbursement requests, and adjust the general ledger for any such items noted. Views of Responsible Officials and Planned Correc􀀁ve Ac􀀁on: The City agrees with this finding. A reimbursement request was submi􀀂ed 3/18/24 in the amount of $634,532.45. It was later iden􀀁fied that the reimbursement request included duplicate payroll expenditures in the amount of $2,694. One of the duplicated items, totaling $1,115, was iden􀀁fied through internal review within the City of Santa Fe a􀀃er the reimbursement request was submi􀀂ed. A credit memo has been processed in the FAA’s Delphi system and the City has repaid the $1,115 amount that was duplicated. The other item, totaling $1,579, was iden􀀁fied through the external audit. The City will process an addi􀀁onal credit memo and repay the $1,579 amount promptly. The Finance Director, the Accoun􀀁ng Officer, and the Grants team are working with the Airport team to strengthen policies and procedures and ensure a full review of the general ledger for the federal program to ensure no duplicate costs are charged prior to reimbursement requests being submi􀀂ed. A secondary review by the Finance Department of all Airport requests for reimbursement is now occurring prior to submission to FAA. In addi􀀁on, we have started using employee pay advices as addi􀀁onal suppor􀀁ng documenta􀀁on for reimbursement requests. In the past excel spreadsheets were used as suppor􀀁ng documenta􀀁on, and the Finance Department review some􀀁mes happened a􀀃er the reimbursement request was submi􀀂ed. Vacancies in key posi􀀁ons resulted in a lack of robust review of reimbursement requests prior to submission. These key posi􀀁ons have now been filled. The City now has an Airport Manager with substan􀀁al experience managing municipal airports and overseeing federal funding for airports. The Accoun􀀁ng Officer, Grants Manager and Accoun􀀁ng Financial Analyst posi􀀁ons in the Finance Department have been filled, and the Grants Division is now fully staffed. More robust staffing is allowing Finance to work more closely with the Airport team. One of the primary du􀀁es of the new Accoun􀀁ng Financial Analyst in the Grants Division is to support the administra􀀁on of Airport grants. The City is in the process of contrac􀀁ng with a vendor to assist the Airport with federal compliance and provide training for Airport staff on relevant Uniform Guidance requirements. The vendor’s scope of work will include helping with developing and documen􀀁ng policies and standard opera􀀁ng procedures for requests for reimbursement. Addi􀀁onally, the Airport Department plans to create a Grant Accountant posi􀀁on which will be responsible for reconciling grant expenditures monthly and processing reimbursement requests quarterly. The Finance Department will con􀀁nue to perform a secondary review of Airport requests for reimbursement prior to submission to FAA. In CY25 the City plans to provide Uniform Guidance training for staff which will include internal controls related to ac􀀁vi􀀁es allowed and allowable costs. Responsible Official: Emily Oster, Finance Director, James Harris, Airport Manager, Matthew Bonifer, Accounting Officer, Erika Lujan, Grants Manager Timeline and Es􀀁mated Comple􀀁on Date: June 30, 2025

View of Responsible Officials: We have implemented a new payroll recording feature that captures all staff time including overtime.

Reference Number: 2024-004 Proper review of payroll charges to grant funds Corrective Action Plan: The District will review the current policies and procedures of internal controls over payroll charges related to federal awards and implement controls that will adequately monitor the activity charged to programs. Contact Person: Vicki Perez, CFO Implementation Time Frame: August 31, 2025

Information on the federal program: Subject: Education Stabilization Fund - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U, 84.425W Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013, S425W210015 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness, Other Matters Context: For 1 selection, in a sample of 40 payroll transactions, the School Corporation did not have time and effort logs to support the portion of the employees’ time charged to the grant. The employees’ time was split with another federal grant; however, the School Corporation did not have support for the allocation of the time charged to the Education Stabilization Fund grant. Contact Person Responsible for Corrective Action: Andrew J Nicodemus, Business Manager Contact Phone Number: 765-362-2342 x6 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the controls over Activities Allowed or Unallowed and allowable Costs/Cost Principles for the Education Stabilization Fund. After this review, we will implement a system to ensure that the proper procedures are completed and fully integrated into our internal control structure. We will implement additional training for all staff involved and will have a designated place where this support is kept. The School Corporation will also implement procedures to determine proper splits for employees who are not paid from one singular Federal Grant and completion of appropriate Time and Effort Reporting. Anticipated Completion Date: We expect this Corrective Action to be implemented as of the current date due to this grant being completed and the School Corporation is not expected to have these grant funds in the future.

Information on the federal program: Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010A Federal Award Numbers and Years (or Other Identifying Numbers): S010A210014, S010A220014, S010A230014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness, Other Matters Context: For 5 selections, in a sample of 40 payroll transactions, the School Corporation did not have time and effort logs to support the portion of the employees’ time charged to the grant. The employees’ time was split with another federal grant, however, the School Corporation did not have support for the allocation of the time charged to the Title I grant. Additionally, for three selections, the School Corporation charged a higher percentage to the Title I grant than what the time and effort log percentage showed. Contact Person Responsible for Corrective Action: Andrew J Nicodemus, Business Manager Contact Phone Number: 765-362-2342 x6 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the controls over Activities Allowed or Unallowed and allowable Costs/Cost Principles for the Title I Program. After this review, we will implement a system to ensure that the proper procedures are completed and fully integrated into our internal control structure. We will implement additional training for all staff involved and will have a designated place where this support is kept. The School Corporation will also implement procedures to determine proper splits for employees who are not paid from one singular Federal Grant and completion of appropriate Time and Effort Reporting. Anticipated Completion Date: We expect this Corrective Action to be implemented by the end of the current 6-month period in June 2025.