Corrective Action Plans

The payroll department will be trained on the proper calculation of salary and compensation rates.

The payroll department will be trained on the proper calculation of salary and compensation rates.

Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Infinity Health’s current policy to support compliance with time and effort requirements is to obtain a statement from each employee with any time allocated for a grant, certifying the time spent on grant activities on a quarterly basis. Beginning 12/1/2023, Infinity Health has implemented a new electronic document management system which will improve our ability to track and monitor timely completion of time and effort statements each quarter. Name(s) of the contact person(s) responsible for corrective action: Kyle Ahlenstorf, CEO, and Michelle Leonard, CFO. Planned completion date for corrective action plan: June 30, 2024

The Alliance has reinstituted an hourly timesheet format in order to account for positions with multiple funding sources.

Grants and Finance Teams have already implemented tracking time and effort by actual hours versus budgeted allocated and reconcile each quarter before recording into our general ledger application. To compile with the finding recommendation will require combining two separate award periods for the HRSA HTC Grant to coincide with CIBD's fiscal reporting period.

Time and Effort sheets will be completed and maintained in personnel files and federal program records.

Finding 2023-002 Material weakness in internal controls over compliance and instances of noncompliance related to allowable costs. Repeat Finding Yes. 2022-04 Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: We agree that all awards should be charged the actual allocation percentages of time and effort. It is our assessment that staffing turnover did contribute to challenges with the set-up and deployment of Paylocity in Fall of 2022. We are committed to improving our time and effort system. Currently, we are in the process of migrating accounting and payroll functions to new systems. Additionally, we have dedicated a fiscal staff member’s time to review all payroll expenditures and adjust as needed prior to our next draw. Anticipated completion date: April 30, 2024.

CORRECTIVE ACTION PLAN April 1, 2024 Victim/Witness Assistance Progam respectfully submits the following corrective action plan for the year ended December 31, 2023. Cognizant or Oversight Agency for Audit: Commonwealth of Pennsylvania Commission on Crime and Delinquency Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: January 1, 2023 – December 31, 2023 The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. Findings – Financial Statement Audit #2023-001 – Significant Deficiency – Authorization and Approval Procedural Controls Recommendation We recommend delegating the approval of the Executive Director’s timesheet to another member of management involved in regular office procedures. View of responsible officials and planned corrective action Effective immediately, the Assistant Director signs the biweekly timesheets of the Executive Director. Findings – Federal Award Programs Audit See Finding 2023-001 If the Commonwealth of Pennsylvania Commission on Crime and Delinquency has questions regarding this plan, please call Victim/Witness Assistance Program Executive Director Amy Rosenberry at 717-780-7078. Sincerely, Amy Rosenberry Executive Director

Human Resources educated the leadership team on February 28, 2024 on ADP timesheets and stressed the importance of getting the proper timesheet approvals, as well as additional training on the ADP payroll system and barriers that can effect timely approvals. HR will be doing an additional check on Fridays of timesheet weeks to make sure employees are submitting timesheets to their supervisors on time. Any instance of approvals not being done will result in the employee's paycheck being held until proper approvals are submitted. HR will also provide individual education sessions with the timecard supervisor and/or employee to those that didn't submit approvals on time. Person(s) Responsible: Human Resources, Crystal Harting Timing for Implementation: Effective immediately as of 5/31/2024

Personnel Responsible for the Corrective Action: Steven Rosenzweig, Chief Financial Officer Anticipated Completion Date: Prior to the beginning of the next federal grant program Corrective Action Plan: Senior leadership will design a system to track the actual hours worked by staff that are specific to each separate federal grant program. The time tracking data will be periodically reviewed and approved by the senior leader, who will ensure the data is maintained in organizational records to support the final report of the federal grant program expenditures.

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process to document time and effort associated with research and development cluster and it’s federal grants. All employees that work with the Challenger Learning Center will continue to have their hours worked documented in the Paycom payroll software. Payroll is processed on a biweekly basis, and therefore on biweekly basis the payroll costs from the Challenger Learning Center will be reimbursed to the University from the various Challenger Learning Center bank accounts. This will be done as a percentage of time worked for the NIH Grant, the NASA Grant, and the general Challenger Learning Center functions. Anticipated Completion Date: June 2024

Views of Responsibte Officials and Planned Corrective Actions: The School District will immediately begin collecting the time and effort documentation for the impacted grants for the current fiscal year (FY24) and into future periods as required. lf the Oversight Agency has questions regarding this plan, please call Amanda Dupont, lnternal Auditor, at 978-674-2102

Finding Number: 2023-003 – Procurement/Full and open competition Anticipated Completion Date: April 2024 Responsible Contact Person: Jocelyn Lombardozzi Planned Corrective Action: In response to this finding, an analysis of 2023 labor charged to awards was conducted. The results of the analysis revealed that a net amount of $35,238 more could have been charged to the awards which the Company will not pursue charging to the awards. An analysis of labor charged to awards active in the first quarter of 2024 has also been performed to ensure that active awards are being charged according to employee’s actual pay. As of April 1, 2024, the Company has transitioned to a new accounting system. This system is configured to require employees working on sponsored projects to utilize percentage of effort and effort certification functionality for tracking actual time and actual labor costs to awards. Budgeted labor rates are no longer being used as of April 1, 2024.

At this time, the Foundation can confirm all employees have rate of pay documentation in their employee files. The Foundation is working to adopt stronger policies around contractors engaged with the organization with oversight to contractors’ pay provided by the staffed CEO.

The Organization will implement policies and procedures to ensure payroll costs charged to federal programs are based on timesheets that reflect the actual work performed. The timesheets will be signed by employees and approved by a supervisor prior to allocation of payroll cost to the federal program.Effective April 26, 2024 – all staff will submit timesheets for the two week period ending on April 26, 2024 and will continue to do so. Anticipated Completion date - April 26,2024 Responsible Contact Person -Joe Diamond, Executive Director

Upon review of the finding, we acknowledge the importance of accurately documenting personnel expenses by the requirements outlined in the cited regulation. We recognize that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed and that these records must support the distribution of an employee's salary or wages among specific activities or cost objectives when applicable. In response to this finding, we will take the following actions: 1. Review and strengthen our current procedures for documenting personnel expenses to ensure compliance with Section 2 CFR Part 200.430 (i). 2. Provide additional training and guidance to relevant personnel responsible for documenting time and effort across different activities or cost objectives. 3. Implement enhanced monitoring mechanisms to regularly assess and validate the completeness of personnel expense documentation. 4. Designate a responsible individual or team to oversee and coordinate the implementation of these corrective actions. We are fully committed to addressing this finding promptly and effectively to ensure ongoing compliance with federal regulations. We welcome any further guidance or assistance from your team to facilitate this process.

The District will require a PAR form from any employee covering a shift in Child Nutrition whose main job is not in the Child Nutrition Department. • The Director of Child Nutrition, Syed Zaidi, will identify and provide a PAR form for those employees providing services to the Child Nutrition Department in a substitute situation. To be established as of 6/30/2024.

Views of Responsible Officials: Management will develop appropriate documentation to support when an employee charges a program that is funded by various donors. A consistent and reasonably methodology which may be based on awards budgets should be the basis of the ending allocation. This corrective action will also be included in an updated time allocation policy.

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

Recommendation: We recommend that controls be reviewed and revised to ensure that time and effort distribution records are prepared for staff who are charged to federal programs. These records should also be reviewed, approved, and maintained by administrative personnel. Action Taken: The Harrisburg Area YMCA's Compliance Officer has created a tracking sheet that will allow employees to keep track of their tasks and hours as related to grant programs. The employee will sign off on each sheet.

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 payroll and other records.

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.