Corrective Action Plans

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Finding 2023-004 Federal Agency Name: U.S. Department of Labor Pass-Through Entity: State of Washington – Service Washington, State of California – California Volunteers, State of Kentucky – KY Cabinet of Health and & Family Services Assistance Listing Number: 94.006 Program Name: AmeriCorps State and National Finding Summary: Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) section 200.430 provides that records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Amounts for certain personnel costs were not reimbursed at the correct pay rate for certain employees. Responsible Individuals: Reid Cox, CFO Corrective Action Plan: Acknowledged. While current year differences were immaterial and resulted in a slight underbilling, we have implemented a secondary review process of all calculations of hourly payrates to ensure consistency in the payrate calculation. Anticipated Completion Date: Ongoing

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

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

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has received the finding titled “Weakness in Controls over Payroll.” The finding noted DCFS employees and supervisors did not timely certify and approve time and attendance records and supervisors did not approve or reject leave requests before the end of the applicable pay period. Although DCFS has procedures in place for both the employee and appointing authority or designee to approve, reject, and certify payroll and attendance records by utilizing the electronic time sheets in the Cross-Application Time Sheets (CATS) system, we concur with the finding that some were not completed timely. DCFS continuously strives to improve processes and controls and has taken corrective action. As part of our continuous improvement plan, we provided time administrators with instructions and reminders on how to review the eCertification Report (ZP241) in LaGov HCM each pay period to identify time statements that have not been certified and approved and to provide appropriate follow up with staff. DCFS Human Resources will continue to send periodic notices to all DCFS employees regarding the eCertification process including a reminder of the importance of all employees being vigilant and compliant in completing the process to ensure time reporting is accurate and complete. The contact person for Payroll is Marion Creft-Jackson, Human Resources Supervisor, and she can be reached at (225) 342-3146 or Marion.Creft-Jackson.DCFS@la.gov.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2024, regarding a reportable audit finding related to inadequate controls over payroll for the following programs in the Office of Public Health (OPH): Public Health Emergency Preparedness (PHEP) and HIV Prevention Activities (HIV). LDH appreciates the opportunity to provide this response to your office's finding. Finding: Inadequate Controls over Payroll - OPH Recommendation: OPH should ensure employees comply with existing policies and procedures, including properly certifying and approving electronic time statements. LDH Response: LDH concurs with the finding and concurs with the recommendation. Corrective Action: As part of a comprehensive agency-wide plan to address this finding, OPH is developing a corrective action plan to enact control measures and monitor the certification and approval of electronic time statements. The below corrective measures have been put in place or will be put in place to prevent future findings. OPH implemented an updated Time Entry Policy in place in April 2023. This policy includes employee, supervisor, and time administrator responsibilities regarding the certification and approval of electronic time statements. This policy will be redistributed agency wide. Each pay period, LDH Human Resources sends all LDH and OPH time administrators an email containing Time Administrator payroll timelines and reports that must be run each pay period. Included are reports indicating errors requiring corrections prior to payroll close and the eCertification Report used to identify any electronic time statements that have not been certified or approved for follow-up. Each pay period, LDH Human Resources emails the OPH Assistant Secretary reports of time statements not certified and/or approved. These reports are sent to all areas of OPH to ensure corrective measures are taken. OPH will also set earlier internal deadlines for employees and supervisors to certify and approve their timesheets. This will allow Time Administrators to run reports sooner to identify electronic time statements that have not been certified or approved and allow time for follow-up. OPH will implement a new procedure requiring Time Administrators to conduct an orientation with any new hires or transfers within the first week of hire or transfer. The Time Administrator will review the entry of time, the entry of leave requests, and the deadlines for approval and certification. You may contact Devin George, Deputy Assistant Secretary, by telephone at (225) 342-2655, or by email at devin.george@la.gov.

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office's finding related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the concerns/issues identified by your staff. LSUHSC-S concurs with the recommendation for addressing the finding and provides the following response and corrective action plan. Recommendation: Management should monitor, investigate, and obtain justification from department personnel for untimely time and effort certifications, untimely adjustments, and lack of supporting documentation for adjustments to enforce established policies. Response and Corrective Action Plan: To continue to strengthen the institutional internal controls within award management, LSUHSC-S is addressing the organizational structure. LSUHSC-S historical organizational structure reflects the award management of grants administration and grants accounting functions separately. In contrast, the prevailing model at peer institutions is centralized management, aiming to enhance communication and transparency across grants administration and finance. In response, LSUHSC-S is actively taking steps to consolidate these functions under joint authority. The chancellor has approved an organizational restructuring of award management resulting in the creation of the Office for Sponsored Awards Management (SAM). This office will operate under a Director reporting jointly to the Vice Chancellor for Research and Chief Financial Officer. The institution is initiating the recruitment of a SAM Director and Associate Director of Grants and Contracts Accounting to further strengthen the research infrastructure. In addition, the following processes are under revision and /or implemented to enforce award management requirements. Time and Effort Reporting. LSUHSC-S Administrative Directive 4.4: Time and Effort Reporting and Certification will be updated to reflect the on-line process that is being developed through our Peoplesoft IT Group and with the LSUHSC- New Orleans functional users. Once operational, Office for Sponsored Awards Management (SAM) will evaluate the time and effort reporting procedures, along with associated forms used to report supporting evidence, ensuring accurate documentation and recertification of time and effort for each personnel action as reported on active grants. SAM will also monitor and maintain time and effort certifications to ensure alignment of cost transfers with award terms. Cost Transfers. Effective July 2023, LSUHSC-S implemented new policies, specifically Administrative Directive 1.1.8: Closing Out Grants and Contracts and Administrative Directive 1.1.9: Elimination of Grants and Contracts Account Overdrafts, outlining procedures to facilitate the closure of grants and contracts accounts and to eliminate overdrafts within such accounts. These directives include the establishment of a matrix detailing responsibilities and timelines for closing out grants. The policies offer procedural guidance to rectify overdrafts beyond the approved budget. A feature in PeopleSoft is activated to restrict personnel expenditures exceeding budget limits or extending beyond the performance period. Such expenditures are recorded in a suspense account, subject to review by departmental business staff for the identification of alternate funding sources. To prevent non-personnel expenditures beyond the performance period, LSUHSC-S assigns end dates to sponsored awards. Training. LSUHSC-S continues to conduct and improve training sessions and educational meetings that cover federal, state, and institutional requirements. Mandatory annual training for all employees involved or planning to engage in research includes a module on time and effort certifications and expense monitoring. In addition to the annual training, supplementary education consists of one-on-one departmental meetings held by the Office for Sponsored Programs, continuing education for department business managers and administrative staff, and specialized sessions designed for research personnel. Examples of such educational opportunities include a New Grant Award Meeting and additional training sessions publicized in the Research Matters Newsletter. Emphasis is placed on grant management organizational podcasts and classes for seasoned and new business staff, principal investigators, and institutional grant and contract support staff. Name of Contact(s) Responsible for Action Plan Marcia Scarmardo, Chief Advisor to Chancellor Jen Katzman, Assistant Vice Chancellor for Administration and Finance (with Departmental Business Managers) Bill Haacker, Assistant Director of Grants Accounting Steven McAlister, Associate Director of General Accounting Annella Nelson, Assistant Vice Chancellor for Research Development Anticipated Completion Date: Continuous If you have questions or require additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.

Dear Mr. Waguespack: Please find below our management response to the audit finding "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards.” The University concurs with the finding results. As you may recall, FY 22's finding prompted us to create an effort reporting policy and system in draft mode and tested it starting at the end of FY 22 and FY23. This audit has brought to the attention of the office of Sponsored Programs Finance Administration and Compliance (SPFAC) that there are deficiencies in our adopted system, particularly in the generation of effort reports, which regrettably missed some key personnel and required information. Your identification of these shortcomings underscores the urgency of our need to enhance our internal controls and procedures to ensure compliance with federal regulations. Regarding the draft policy calling for quarterly effort reports, we have carefully considered your recommendation and in light of our operational capacities have decided to proceed with an annual, calendar year (CY) reporting time frame. We believe that an annual reporting cycle aligns better with our current operational resources. We will ensure that this chosen reporting cycle is rigorously adhered to and supplemented with additional measures as needed to enhance accuracy and timeliness. Moving forward, we are committed to the following actions to address the identified deficiencies: 1. Enhancing Internal Controls: We will review and strengthen our internal control framework to ensure that all required information is captured accurately and comprehensively in our effort reports. 2. Annual Time & Effort Certification: We will revise our Time & Effort Certification policy to reflect the decision to adopt an annual reporting time frame. This will involve refining our processes to ensure that annual certifications provide a thorough and accurate reflection of personnel effort on federal awards as required by federal regulations. The annual reports will be processed on a calendar year (CY) basis. To allow for a fresh start for CY 2024, the next effort reporting cycle will cover July 1, 2023, through December 31, 2023. 3. Monitoring and Oversight: We will establish robust monitoring mechanisms to track changes in personnel effort and ensure that any deviations from approved thresholds are promptly identified and addressed. To further assist with correction of this finding, the University has engaged Ellucian Banner to apply the Effort Certification Module which is a systematic certification process for us to review, validate and certify the work effort performed by faculty and staff in support of sponsored research. The module is expected to go in test mode in 2024 and anticipated to go live in 2025. The director of SPFAC will oversee the implementation of this action plan.