Corrective Action Plans

Finding Number: 2023-001 Allowable Costs/Cost Principles - Compliance and Internal Control Summary of Finding: The Code of Federal Regulations 2 CFR 200.303, Internal Control, requires the nonfederal entity to establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-federal entity is managing Federal awards in compliance with Federal statutes, regulations, and other terms and conditions. During the audit, we noted an instance for which an employee was reinstated and received retro-active payment for the months of September through November 2022 for which we were not able to substantiate the allowability of the payroll charges. Response to finding: This was an unusual and isolated incident. Management is working to ensure the appropriate procedures are in place to address this type of transaction in the future to comply with all internal controls. Corrective Action: Management will review current procedures and update to ensure compliance with our internal controls. Individual(s) Responsible for Corrective Action Plan: o Name: Melissa Ells o Title: Controller o Phone number: 312-660-1667 o Anticipated Completion Date: September 2023

Auditor's Recommendation: We recommend that the accounting department reconciles the general ledger for receivables to their billing system in totals on a timely basis. Action Taken: A new process to record revenue and receivables was implemented during April 2023, which records earned services at a more accurate rate and provides more timely supporting documentation for those balances. Management believes this new process has aUeviated the problem of receivables and supporting documentation.

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. Department of Health and Human Services Pass-Through Entity: None Criteria: Per 2 CFR 200.430(i), personnel costs charged to federal grants are required to be supported by documentation including time records. Per 2 CFR 200.303, a non-federal entity must establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Condition: Our audit procedures over the calculation of COVID patient days used to allocate the payroll cost to the PRF/ARP federal program disclosed the amounts were not properly calculated. Cause: The Medical Center has controls in place to review the calculation; however, the control did not operate to identify an error in the calculation of COVID patient days. Effect: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Questioned Costs: None Perspective: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Medical Center implement additional internal controls over compliance in order to properly identify any errors in calculation. Management’s Action Plan: The Medical Center will implement additional internal controls over compliance. Such controls will include verification of all calculations used by two parties, the Director of Finance and CFO as well as signoff on calculations. Name of Person Responsible for the Plan: Mallory Ginn, CFO Anticipated Completion Date of the Plan: 7/31/2024

Item 2023-002 - Activities Allowed and Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Repeat Finding No Action Taken As of July 20, 2024, we have added the Payroll Summary by grant to the grant draw down packet. In addition, we have changed the procedure to reflect that the payroll summary must have either the CFO and/or CEO approval signature prior to grant draw. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079.

CORRECTIVE ACTION PLAN (Concerning Finding 2023-002) Contact Person Responsible for Corrective Action: Rhonda Casey, Business Manager Corrective Action: The Millinocket School Department will take the following actions to address finding 2023-002: The School Department will complete semi-annual wage certifications every six months to ensure that time certifications are completed at the period end and that all charges reflect an accurate account of the employee’s time devoted to the program. Anticipated Completion Date: January 31, 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Rhonda Casey, Business Manager Corrective Action: The Millinocket School Department will take the following actions to address finding2023-001: The School Department will ensure that each employee’s classification is identified in his/her Letter of Contract and that each contract appropriately outlines job duties and responsibilities as they pertain to each funding source. Additionally, the School Department will revise times sheets to reflect hours worked under each funding source. Anticipated Completion Date: July 1, 2024

Management acknowledges that it is necessary to more specifically itemize employee time that is applicable to the federal grants and contracts that partially fund broad programs and services and has instituted infrastructure to ensure that this is done and documented correctly in the future. The previous year’s finding was received after FY23 was substantially complete and making the necessary changes was not possible, resulting in recurrence. The necessary codes are in place in our payroll system and guidance and leadership of the timesheet process will be provided by all program executives (EVP, VP) to all staff that are impacted, with oversight by the Chief Financial & Operating Officer and Sr. Director of Finance. This is in place as of the date of this corrective action plan.

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, a new policy was implemented that requires employees to record their time as a percentage across all grants in which they work. The employee records this allocation at least weekly within a time keeping software system. Employees and supervisors are now required to review and acknowledge payroll allocations across grants by signing weekly timesheets. Timesheets will be retained and used as backup by the Grants Department when invoicing the Grantor for expense reimbursement. In addition, we have updated our Policy and Procedures Manual to reflect this policy. Responsible Parties: Kimberly Yoo, CFO Whitney Gillis, Director of RD Mary Guzman, Accounting Supervisor Date Corrected: 7/1/2023

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations based on employees’ time and effort records. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

Finding 2023-002 Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files The PRDOH agrees with the finding. However, PRDOH has implemented several corrective actions. The PRDOH established an internal control to ensure that the required documents are recorded in the files. The Director of Human Resources presented a work plan, in order to implement an effective procedure for reviewing files. A control sheet of documents required to the active records was established in which the Human Resources Officers of the regions and Hospital were requested to verify the employee’s files for the require documentation that is need it in the files. Responsible Official Lcdo. Luis Rivera Villanueva Secretario Auxiliar de Recursos Humanos 787-765-2929 ext. 4273 Mrs. Luz S. Ramos Pedroza Specialist 787-765-2929 ext. 4273 Mrs. Maribel Zayas Payroll Officer Director 787-765-2929 ext. 4209 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.

DEPARTMENT OF PUBLIC HEALTH 2023-034 Opioid – STR - Assistance Listing No. 93.788 Action taken in response to the finding: We are currently working on implementing training during on boarding as well as annual refresher training for these key fiscal requirements including time and effort reporting and plan to have these trainings in place by the end of the 2024 calendar year. In the interim the BSAS grants office will work with Grant PIs to train staff on time and effort reporting, correct any issues with duplicative effort reporting, and ensure staff are allocated to grants in proportion to their actual time worked. This is being corrected by the BSAS grants director and all corrections have been documented through PARS reports. This particular finding was in relation to an Interdepartmental Service Agreement ISA (815 CMR 6.00) with The Dukes County Sheriff’s Office (department) for which we do not have direct access to their payroll. We will be including in future ISA agreements, language that states that monthly detailed payroll reports associated with ISA funds must be submitted to the BSAS ISA office for review. These records will be reviewed by the BSAS ISA manager, and any corrections required will be relayed to the ISA child agency by the BSAS ISA manager via email for documentation. If any child agency is repeatedly non-compliant we will work with them on a corrective action plan for their site. If the issues are not resolved we will review the status of their agreement, and our continued relationship with them. All related records will be kept in the BSAS ISA offices Teams files for the child agency. Name of the contact person responsible for corrective action: Shannon McEneaney-Farron, BSAS Fiscal Director Planned completion date for corrective action plan: Ongoing. This process will commence as of July 1, 2024.

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-010 WIOA Cluster, Employment Service Cluster – Assistance Listing No. 17.258, 17.259, 17.278, 17.207, 17.801 Action taken in response to the finding: EOLWD Budget and Human Resources (HR) will update procedures and controls to ensure all new staff are notified and trained to comply with entering Self-Service Time and Attendance (SSTA) combination codes on their timesheets. As programs are assigned unique combination codes, EOLWD Budget and HR will annually remind staff that SSTA combination codes are required when entering timesheets and, if none are entered, timesheet approvers are required to reject timesheets and notify staff to comply with the requirement. Additionally, a weekly Data Mart report will be created to identify timesheets entered without SSTA combination codes so HR can send notifications to staff to update timesheets for compliance. Name of the contact person responsible for corrective action: Steve J. Wong, Budget Director, and Cheryl Stanton, Secretariat Human Resources Officer Planned completion date for corrective action plan: December 31, 2024

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements an adequate review process to ensure costs charged to the grant are reasonable, accurate, and properly allocated. We recommend the Authority perform and document this review quarterly at minimum. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Budget division will continue to send an annual summary at the beginning of the fiscal year for all employees who have split funding for federal and non-federal funds. During the MSS process there will be a coding added if the payroll certification is required by a comment in the system. Monthly the Budget and Payroll Division will have a monthly review of all MSS employee changes during the month to evaluate the payroll certifications for the changes are accurate. Name(s) of the contact person(s) responsible for corrective action: Jared Cummer, CFO and Olivia Hunsinger, Controller Planned completion date for corrective action plan: Progress has been made and full completion is expected 06/30/2024.

Federal Agency Name: Department of Education and Passed through State of South Dakota Department of Education Program Name: Twenty-First Century Community Learning Centers Federal Financial Assistance Listing #84.287C Finding Summary: Our auditors identified two instances where timesheets or bi-weekly activity reports were unable to be provided, three instances where the employee’s paid time off and holiday pay was not allocated nor submitted for reimbursement under the Federal program which was inconsistent with other pay periods, and one instance where support did not agree to the amount and time allocated. The Club’s controls did not detect or correct the errors identified. Responsible Individuals: Jody Hernandez, Chief Executive Officer; Darcie Bien, Chief Financial Officer Corrective Action Plan: For all grant-funded payroll, all time allocated through the payroll software will be compared to the bi-weekly activity reports for consistency and accuracy prior to submitting for reimbursement. In addition, a second review of the reimbursement requests by a member of the management team, other than the CFO who prepares the reimbursements, will be done. Anticipated Completion Date: July 2024

Recommendation: The auditor recommends the City strengthen policies and procedures to ensure a review of the general ledger for the federal program to ensure no duplicate costs are charged prior to reimbursement. Additionally, the Finance Department should provide secondary review on all requests for reimbursements. Action Taken: The City agrees with this finding. When this issue was brought to the attention of the Finance Director and Accounting Officer as material noncompliance, the schedule of expenditures of federal awards (SEFA) was revised to remove the duplicated expenditures. Management proposed an adjusting journal entry prior to the completion of the audit to record the amount of the reimbursement for duplicated expenditures as a liability “due to Federal Government”. The City will work with the awarding agencies to return the funds that were reimbursed incorrectly. When this reimbursement request was done the payroll expenditure data that was used to calculate the reimbursement request was compiled manually by combining multiple reports. This was a manual process. The process has changed, so that now the Airport Administrative Manager gets one report directly from the Payroll Division that contains all Airport payroll expenditure data. In November 2022 (about 5 months into FY23) the City hired a new Airport Manager with substantial experience managing municipal airports and overseeing federal funding for airports. In CY24 the Finance Director and the Accounting Officer will work with the Airport staff to strengthen policies and procedures to ensure a review of the general ledger for the federal program to ensure no duplicate costs are charged prior to reimbursement. Secondary review by the Finance Department or a vendor approved by the Finance Director will be required for all Airport requests for reimbursements. The City is in the process of identifying a vendor to contract with Airport to assist with federal compliance and provide training to Airport staff on relevant Uniform Guidance requirements. The vendor’s scope of work will include performing secondary review of requests for reimbursement and helping with developing and documenting policies and standard opera􀆟ng procedures for requests for reimbursement. In CY24 the City will provide Uniform Guidance training to staff which will include internal controls related to activities allowed and allowable costs over payroll. Due Date of Completion: December 31, 2024 Responsible Official: Emily Oster - Finance Director, James Harries - Airport Manager, Matthew Bonifer - Accounting Officer, Grants Manager (in recruitment).

Federal Agency Name: Department of Health and Human Services, Assistance Listing No. 93.829 and 93.696 Program Names: Section 223 Demonstration Programs to Improve Community Mental Health Services, Certified Community Behavioral Health Clinics Expansion Grants Finding Summary: Appropriate documentation to support the allocations of compensation applicable to the referenced programs, or to support allowable costs or that the level of effort requirements, as outlined in the grant contracts were not readily available. Corrective Action Plan: Controls have been put in place to ensure that expenditures of program funds allocated through payroll expense are reviewed and approved by program management and are properly allocated based on time and activities worked consistent with grant requirements. Level of effort requirements as made known in grant contracts will be substantiated by payroll allocations. Responsible Individual: Trica Walters, Chief Human Resources Officer Completion Date: May 2024

Views of Responsible Officials: Agreed that the differences were insignificant, however, ASCB understands how important it is to ensure the timesheet hours match the general ledger. So we have already created a new salary allocation worksheet that uses less complex formulas and calculations to streamline the process. The new worksheet also uses less manual input which reduces room for error.

Finding 2023-001 a. Name of Contact Person Responsible for Corrective Action: Rhonda D. Locke b. Corrective Action Planned: • Special Education Director and Assistant Special Education Director will attend the Annual Fiscal Conference presented by OSEP through MDE. • Special Education Director and Assistant Special Education Director will train all certified staff in the proper method to complete monthly personnel activity reports [to include but not limited to: how to calculate percentages of effort by cost objective, expected timelines, and proper documentation]. • Special Education Director and Assistant Special Education Director will train all non-certified staff in the proper method to complete semi-annual certification reports [to include but not limited to: how to complete semi­ annual certification reports, expected timelines, and proper documentation/signatures]. • Special Education Director and Assistant Special Education Director will train the bookkeeper in the proper procedures for collecting and maintaining monthly personnel activity reports and semi-annual certification reports. • Special Education Director and/or Assistant Special Education Director will provide new PARs spread sheets to ensure all formulas for calculation of hours are correct and without corruption. • Special Education Director will review and sign each of the PARs monthly to ensure percentages of effort by cost objective are in line with expected activity compensation, signatures are provided by each employee, and each completion date is prior to the 5th of the month. • Assistant Special Education Director and/or Bookkeeper will contact each of the assistant teachers to provide an advanced reminder regarding the completion of the semi-annual certification reports no later than end of business on the last working day of December and May. c. Anticipated Completion Date: July 3, 2025

COVID-19 Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024

CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. . Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024

2023-003 – Allowable Costs/Cost Principles Corrective action plan: Management implemented a process to evaluate time spent each month. That allocation is used to classify actual salary paid to particular federal awards on a pay period basis. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer; Peg Clark, Grant Accountant; Reyann James, Senior Accountant. Estimated corrective action completion date: May 2024

Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.

Corrective Action: DRW will review and revise it cost allocation and program income documentation. Steps: Review current policies, procedures, and internal control documentation. Review will include agency cost allocation method and implementation as well as program income documentation. 1. DRW will update internal controls based on the suggestions for process, procedural and internal control improvement made by outside consultants. Suggestions will include the use of project codes in payroll documentation. 2. Review supporting records, level of effort and timekeeping systems to ensure proper level of documentation. 3. DRW supervisors will be trained on expectations of oversight and participate in quarterly review of financial status to ensure proper implementation. 4. The process will be implemented by the Fiscal Manager, the Comptroller and the Fiscal and Operations Specialist and overseen by the Executive Director. Anticipated Completion: September 30, 2024

Management acknowledges that there were deficiencies in the process at the beginning of the fiscal year, which is why the organization changed payroll systems. The issue in question is from the time that the organization was transitioning to the new system. This matter was addressed. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards and added checks and balance to ensure award expenses are allowable and allocable.

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish and maintain written policies, procedures, and standards of conduct including internal controls over the Federal awards that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award. Specific requirements relate to the following: § 200.302 Financial management  § 200.305 Payment  § 200.319 Competition  § 200.320 Methods of procurement to be followed  § 200.430 Compensation—personal services  § 200.431 Compensation—fringe benefits We recommend that the City implement the required written policies and procedures. Action Taken: Management, namely Jan Boutwell, City Clerk, agrees with the finding and will implement the necessary written policies to comply with the UG. Management anticipates completion by September 30, 2024.