Corrective Action Plans

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over payroll transactions in order to comply with laws, regulations, and grant agreements. Additionally, the pass-through entity has increased its documentation requirements which helps the Organization ensure that it possesses compliant payroll documentation. Further, the Organization plans to review its personnel files to ensure that adequate documentation exists to support approved rates of pay. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Partially implemented. Personnel file review anticipated completion December 31, 2024.

Views of Responsible Officials and Planned Corrective Action - The County will create a documented process in the new policy and procedures manual for federal guidelines and charging of administrative costs for documented time spent on grants with supporting calculations will be documented for clarity and consistency. Responsible Official - Andrea Montoya, Deputy County Manager and Robert Placencio, Finance Director Timeline and Estimated Completion Date -November 2024.

The City has implemented the recommendation first contained in 2022-007. There is a process in place where supervisor review and approval of timesheets is completed and documented. That process continues and will be in place for the entirety of the fiscal year ending June 30, 2024. Responsible Person: Kevin Saycocie Expected Implementation Date: 07/01/2024

Management Response/Corrective Action Plan: Going forward the School Nutrition staff will keep a spreadsheet documenting meals reimbursed previous fiscal years, and in each month to compare to the number of meals calculated for the current billing month.

We appreciate the auditor's identification of the material weakness in our internal controls over the documentation of approved pay rates related to our federal award. We understand the importance of maintaining adequate internal controls to prevent, detect, and correct misstatements on a timely basis. 1. Documentation Process: We will implement a documentation process to ensure that all employee pay rates related to our federal award are documented and approved by management. Specifically, we will: a. Assign responsibility for documenting and approving employee pay rates related to our federal award to a specific staff member. b. Establish a process for documenting and approving employee pay rates related to our federal award, including the use of a standardized form. c. Ensure that all employee pay rates related to our federal award are documented and approved before payroll is processed. d. Investigate and resolve any discrepancies identified during the documentation and approval process related to our federal award. e. Document the documentation and approval process related to our federal award and ensure that all documentation is maintained. 2. Internal Controls: We will strengthen our internal controls over the documentation of approved pay rates to ensure that misstatements are prevented, detected, and corrected on a timely basis. Specifically, we will: a. Establish a process for reviewing all employee pay rates by management. b. Ensure that all staff members responsible for documenting and approving employee pay rates are trained on the new process and the importance of maintaining adequate internal controls. c. Document the new process and internal controls in a written policy and procedure manual. 3. Personnel: We will ensure that personnel changes do not impact our internal controls over the documentation of approved pay rates. Specifically, we will: a. Cross-train staff members to ensure that there is adequate coverage for all employee pay rates. b. Establish a process for documenting and communicating changes in personnel responsibilities related to the documentation and approval of employee pay rates. We believe that these corrective actions will effectively address the material weakness identified by the auditor and strengthen our internal controls over the documentation of approved pay rates. We are committed to ensuring the accuracy and integrity of our financial reporting and maintaining the trust of our stakeholders. Person Responsible: Anthony Jayesingha Date Corrected: 7/31/2023

We appreciate the auditor's identification of the material weakness in our internal controls over the review of payroll registers for allowable costs and activities and period of performance related to our federal award. We understand the importance of maintaining effective internal controls to provide reasonable assurance that we are managing federal awards in compliance with statutes, regulations, and the terms and conditions of the award. Documentation Process: We will implement a documentation process to ensure that payroll registers are reviewed for accuracy by management on a timely basis and that the review is properly documented. Specifically, we will: 1. Assign responsibility for reviewing payroll registers for accuracy by management to a specific staff member. 2. Establish a process for reviewing payroll registers for accuracy by management, including the use of a standardized form. 3. Ensure that all payroll registers related to our federal award are reviewed for accuracy by management on a timely basis and that the review is properly documented. 4. Investigate and resolve any discrepancies identified during the review process related to our federal award. 5. Document the review process related to our federal award and ensure that all documentation is properly maintained. Person Responsible: Anthony Jayesingha Date Corrected: 7/31/2023

Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and implemented procedures to ensure appropriate documentation of personnel costs is complete and accurate. The prior year's finding was corrected with the pay period ending 9/23/2023, which resulted in this repeat finding for the year ended 12/31/2023. Hourly staff are clocking into the appropriate cost center and salaried staff are submitting hours to payroll to ensure the proper tracking of time. Contact Person(s): Heather Hintz/Kathy Dams Anticipated Completion Date: 10/1/2023

2023-002. Allowable Costs/Cost Principles United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: The Organization charged costs for staff time without source documentation that complied with Uniform Guidance. Recommendation: The Organization should maintain Personnel Activity Reports (PAR) or equivalent documentation. This reporting of time will allow each employee to accurately reflect the time work is performed, for compensation which is funded by a federal award. Corrective Action: The Organization will modify procedures to have time records reflect actual time worked by employees on PAR equivalent documentation, which will serve as support for personnel expenses funded by a federal award. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

JVS will implement a process before December 31, 2024, whereby each payroll period, a JVS Payroll department employee will 1) independently review all employee timesheet allocations, as approved by their supervisor and 2) make necessary modifications to the budgeted allocations reflected in its payroll ERP module (Paylocity). In this manner, program labor distributions and resulting cost allocations will align to actual time incurred and permit accurate reporting for billing purposes. JVS is also researching a technological solution that will reduce the amount of time required from the above laborious effort.

We will implement procedures to maintain accurate timecards or time studies for employees who have payroll claimed under the federal programs beginning in October 2024. This is a repeat finding from last year’s audit. We did not receive the corrective action plan for this audit until February of 2024 to know to implement changes. In pulling these items, the same findings would be noted due to not knowing those changes needed to be made during 2023.

Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.

Corrective Action: ABHS plans to optimize technology to improve the month-end closing process and allow for reconciliations to be performed on a consistent basis. Person Responsible: Alethea Velasquez, Chief Financial Officer, and CLA Estimated Completion Date: December 31, 2024

Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensuring that staff are well-informed about federal regulations and their implications for our grant management processes. The Controller will ensure the calculation of payroll costs are based solely on the actual hours worked and certified by grant personnel. This practice will help maintain accuracy and accountability in our financial reporting. In addition, the Technical and Internal Controls Accountant will conduct quarterly internal reviews to monitor and verify that payroll costs reported on cost reimbursement invoices are consistent with the actual hours certified by grant personnel. These regular reviews will serve as a critical check to uphold the integrity of our financial processes and ensure compliance with federal guidelines. Through these initiatives, management aims to foster a culture of compliance and accountability, equipping our team with the knowledge and tools necessary to effectively manage grant funds.

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024

Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to the Director of Finance. The Director of Finance reviews time and effort reports and compiles the data to allocate personnel expenditures, however, the time stamp of approvals was not effectively documented during 2023. The Foundation has implemented procedures to effectively time stamp the review and approval process, each month. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.

Personnel Responsible for the Corrective Action Plan: Darlene Sowell, President/CEO Anticipated Completion Date: November 1, 2024 Corrective Action Plan: Unleashing Potential will modify its internal procedures to track actual hours devoted to the program and perform a monthly review of actual hours incurred compared to the estimated amounts by individuals assigned to federal grant programs prior to requesting reimbursement from the funding course. The review will be performed by an individual other than the preparer of the reimbursement request, with knowledge of the federal grant program and will be formally documented.

Columbus Neighborhood Health Center, Inc. dba PrimaryOne Health Corrective Action Plan Year Ended December 31, 2023 Contact Information: Charleta B. Tavares, Chief Executive Officer 614. 859. 1946 ctavares@primaryonehealth.org Audit period: January 1, 2023 – December 31, 2023 Finding 2023-001 – Allowable Costs (Time and Effort) Recommendation: Management should establish policies and procedures that are consistent with the Uniform Guidance administrative requirements with regards to compensation and allowable costs which includes ensuring time and effort charges are based on records that accurately reflect the work performed. Action planned/take in response to finding: 1. Implementation of Time and Effort Reporting System: The organization has begun to establish and implement a robust time and effort reporting system in compliance with 2 CFR 200.430. This system will: a. Accurately reflect the distribution of employee time across different federal grants. b. Track employee hours worked, allocate wages based on grant activities, and ensure the proper alignment of salaries to the work performed. c. Provide documentation supporting time allocation between different federal and non-federal activities. 2. Training for Payroll and Grants Management Staff: All payroll, human resources, and finance staff will undergo mandatory training on: a. Time and effort reporting requirements under federal guidelines. b. The correct procedures for allocating wages to federal grants, including compliance with Uniform Guidance (2 CFR 200). 3. Updating Policies and Procedures: The organization will update internal policies to reflect compliance with the Uniform Guidance, particularly regarding payroll documentation and time and effort allocation. This will include: a. Establishing written procedures on tracking employee work hours and effort reporting. b. Implementing monthly or quarterly reviews to ensure payroll costs are appropriately charged to federal awards. 4. Periodic Internal Audits: The organization will conduct periodic internal audits to ensure continued compliance with federal requirements, especially as it relates to payroll and time tracking. Any discrepancies will be promptly corrected to avoid future findings. Planned completion date for corrective action plan: December 31, 2024

The certification process for the year ended December 31, 2023, is expected to be completed by October 31, 2024. For the period from January 1, 2024, through September 30, 2024, the certification process is expected to be completed by November 15, 2024. Communication has been disseminated to employees that certifcations will occur in accordance with the policy for the remainder of 2024 and beyond. Any material differences identified in the allocation of salaries and fringes will be corrected for the year ended December 31, 2024. Cheri Sash, Director of Grants & Financial Contract Compliance Compliance will oversee the certification process.

Corrective Action: Management is in the process of updating its written procedures to ensure that allowable costs and cost principles comply with 2 CFR 200.403. This includes Grants Accounting implementing a manual process that empowers program employees to submit and approve Time & Allocation Excel Sheets. These sheets include attestations certifying actual labor costs monthly. This information is then taken to input by the grants accounting team into the Request for Reimbursement (RFR). This measure ensures that labor costs are accurately reflected and compliant with regulatory requirements. In addition, Management will implement policies and procedures regarding regular review of allocations for workers compensation and other similar expenses to ensure accuracy. Name of Responsible Individual(s): Jason Brenier and Judy Bokhari Anticipated Completion Date: December 2024

Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, and Luz Gonzales-Toscano Anticipated Completion Date: December 2025

Corrective Action: Management, in the immediate term, will review its oversight and controls on the manual process Grants Accounting implemented for obtaining Time & Allocation Excel Sheet and calculating payroll and benefits costs accurately onto the Request for Reimbursement (RFR). Furthermore, management plans to collaborate with its Payroll Service Provider to capitalize on software upgrades, aiming to enhance the accuracy of Time & Allocation to grants and reduce errors by designing straight-through-process improvements. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, and Luz Gonzales-Toscano Anticipated Completion Date: October 2024 – immediate term and December 2025 - software implementation.

Planned Corrective Action: NFF revised current year SEFA for expenses which did not meet the compliance requirement. In addition, management implemented review control whereby the expenditures will be reviewed to ensure compliance with federal agency requirements. Beginning in August 2024, NFF will update its time and effort management and review of employees who perform work related to federal grants. This includes circulating a tracking spreadsheet monthly to relevant staff to certify their time and effort spent on eligible activities allowable for grant expenditure relative to their overall work performed, which will be used for salary and benefit allocations. The Finance team will circulate the spreadsheet first to relevant staff members for certification, and then department heads for management review and approval. For department head time and effort review and approval, the executive suite will review and approve. The spreadsheet and approvals will be saved as back up for the allocations each month.

In response to this finding, it is important to note that the proposed measures were already considered upon the transition of the CFO. ElderSource will continue to follow policies and procedures in place, which include the CFO or a designee in their absence reviewing the payroll journal, along with a written confirmation of approval. According to this letter, the corrective action has been completed. It will be monitored by the CFO, James Lee.

Significant Deficiency 2023-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration: Substance Abuse and Mental Health Services Projects of Regional and National Significance Passed Through Vibrant Emotional Health: National Suicide Prevention Lifeline: 988 National Chat and Text Backup 93.243 S23-SM84816-048 988 National Backup Chat and Text Subnetwork 93.243 S24-SM84816-048-CTP 988 National Phone Backup 93.243 S23-SM84816-048 988 National Backup Phone Subnetwork 93.243 S24-SM84816-048-PB Disaster Distress Helpline: Disaster Distress Helpline Online Peer Support Center 93.243 S23-SM84816-048 Disaster Distress Helpline Online Peer Support Center 93.243 S23-SM84816-049 Disaster Distress Helpline Online Peer Support Center 93.243 S24-SM84816-048-DDH OPS Condition: Time records prepared by employees reflect the total hours worked for the day, but do not reflect the actual time spent on programs funded by a federal award, rather they are based on budgeted hours. Recommendation: The Organization’s use of Personnel Activity Report (PAR) equivalent documentation, should allow each employee to accurately reflect the time work is performed, and serve as support for personnel expenses, funded by a federal award. Corrective Action: The Organization will modify its procedures for PAR equivalent documentation to reflect actual time worked performing duties funded by a federal award. Responsible Contact Person(s): Meryl Cassidy, Executive Director Response of Suffolk County, Inc., - P.O. Box 300 - Stony Brook, New York 11790 Anticipated Completion Date: December 31, 2024.