Corrective Action Plans

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the employee worked the hours noted, but lacks the employees’ signature. This is not a typical occurrence Time and Effort is used and submitted. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Procedure has changed a reminder will be communicated by March 30th.

Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19 Provider Relief Fund – Assistance Listing 93.498 were allocated to the Provider Relief Funding and including in reporting of expenditures based on management review of guidance provided by HRSA in determination of the portion of the payroll costs allocated as qualifying and allowable expenditures under the program. The guidance on allowable costs was determined by HRSA subsequent to disbursement of the funds by HRSA and after incurrence of the expenditures given the immediacy of the COVID-19 pandemic providing of funds and incurrence of costs. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management’s controls over approval of time sheets operated effectively 97% of the time prior to processing payroll. The payroll expenditures related to the 1 time sheet not approved prior to payment of payroll are for an employee assigned to work specifically on the program funded by Assistance Listing #93.778. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management expects the corrective actions described above to be complete no later than June 30, 2024.

REFERENCE: 2023-003 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: St. Mary Medical Center – Long Beach Bailey-Boushay House Finding: At St. Mary Medical Center – Long Beach and Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At St. Mary Medical Center – Long Beach, the leadership team implemented a timecard review process to ensure timecards are properly signed off and approved each pay period, with exceptions confirmed via email from the appropriate manager. At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders will be sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator will send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The executive director will ensure supervisory follow-up with each name that shows up in the audit report each pay period by Kronos Reports. Person Responsible: Vo Phay Sin, Controller – St. Mary Medical Center, Long Beach Rob Hays, Executive Director – Bailey Boushay House Expected Completion: April 2024

REFERENCE: 2023-002 – Allowable Costs/Cost Principles Medical Assistance Program (Medicaid Cluster) (Assistance Listing No. 93.778) Federal Grantor: U.S. Department of Health and Human Services Facility: Mercy San Juan Medical Center Finding: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing. Corrective Action Plan: In addition to timecard approval by supervisors, Mercy San Juan Medical Center Finance will review a sign-off report and obtain written approval via email for unapproved timecards. Person Responsible: Lianna Petrosyan, Director of Finance Expected Completion: April 2024

Finding Reference Number: SA2023-002 Documenting Payroll Costs Charged to Grant Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Betsy ZoBell, Housing and Community Development Manager • Corrective Action Plan: ECD staff will perform periodic review of estimates to confirm that payroll allocations are supported by timesheet documentation of actual hours worked. • Anticipated Completion Date: 06/30/24

Finding Number: 2023‐001 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425U, 84.425W Contact Person: Andrea Leon Foster, Director of Federal Programs Anticipated Completion Date: June 30, 2024 Planned Corrective Action: Although the Federal Programs Department has a process for periodic certification, compression was not included in the percentage breakdown for each classified staff salary. Reporting adjustments have been made to include ESSER funded positions with additional oversight  on  percentage  breakdowns  for  positions  funded  with  multiple  cost  objectives.  These  breakdowns are reflected in the electronic version of FORMS B and D in addition to the hard copies. The  Federal  Programs  Director  will  work  with  district  leadership  to  ensure  all  employees  in  each  department (Curriculum and Instruction, Professional Development, etc.) on the process of maintaining Time and Effort logs and signing the bi‐annual FORM B and FORM D.

The district Information Technology Services unit is currently working with Ellucian to configure and implement the Time and Effort reporting module within the BANNER timekeeping system. This will allow departments to monitor time and effort activity and ensure that allowable costs are tracked and charged to the appropriate programs and services. This should be completed by June 30, 2024.

Finding #2023-001: Reconciliation of Allocated Costs CLIENT PLANNED ACTION: Hospital Sisters Health System agrees with the finding and will reevaluate the procedures in place to reconcile all costs allocated to grants. We will implement processes to ensure that all costs are substantiated with appropriate supporting detail and are reconciled and reviewed in a timely manner. CLIENT RESPONSIBLE PARTY: Steve Canny, System Director-Financial Reporting, Compliance & Internal Control COMPLETION DATE: We anticipate having these procedures in place by June 30, 2024.

NOTE: While discrepancies in payroll entries were observed during the period of emergency declaration, which provided full flexibility in fund usage, it's important to note that this doesn't justify inconsistencies between timesheets and the general ledger. The CFO will immediately evaluate the procedures involved in recording employee time on timesheets and transferring this data to the financial management system. The CFO will immediately evaluate the need for additional controls to ensure accurate recording of time charged to programs as reflected on the employee's timesheet. The CFO will immediately implement new processes that establish checks and balances to verify that the programs charged in the general ledger align with the time recorded by the employees and is verified by their supervisor. The CFO and HR director will provide training sessions to all staff and new hires on the importance of accurately capturing and recording payroll costs by April 30, 2024. The CEO will immediately provide training to the CFO and staff accountant on the significance of aligning time charged with the programs designated in the general ledger for proper grant award billing. The CFO will conduct periodic reviews of payroll transactions to identify any discrepancies or irregularities promptly and take action immediately upon identification of such. These reviews will continue through FY 2025.

Finding 2023-003: Inadequate Documentation of Employee Time and Effort Allocation for Federal Program Identification of the Federal Program: Assistance Listing Number 17.259 - WIOA Youth Activities Program - U.S. Department of Labor. Pass-through Entity: New York City Department of Youth and Community Development. Award Number: 90535A / 90536A / 90537A / 90538A. Compliance Requirement: Allowable Costs/Cost Principles. Criteria: Requirements per section 2 CFR Part 200.430 of the Uniform Guidance state that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During our testing for the year ended June 30, 2023, we noted a lack of detail for employee's actual hours spent on different programs. Time and effort are allocated based on budgeted amounts. Cause: Allocation to funding sources was entered into the payroll system based on budgeted estimates rather than actual time records. Effect or Potential Effect: The lack of contemporaneous documentation of employee hours worked by grant or federal program could allow the Organization to improperly allocate employee pay to federal grants. Questioned Costs: $65,379 Context: As most employees work specifically on a single program, there was only one employee that worked on multiple programs for which time spent on the program could not be substantiated. The total questioned cost allocated to the program for this person totaled $65,379. Plan: 1. Mandatory Time and Program Effort Records: OBT has implemented allocations by program in our payroll software. Hourly employees allocated to multiple programs will clock in and out for each program and all timecards are approved by management. Reports are reviewed every payroll for accuracy. 2. Training: OBT has provided training to all employees on the importance of accurate time and effort reporting for federal programs, ensuring that employees understand the requirements and their responsibilities in maintaining these records. 3. Internal Controls: OBT has implemented internal controls to review and verify the accuracy of time and effort records, ensuring that charges to federal awards comply with regulations. 4. Monitoring and Auditing: OBT conducts regular monitoring and internal audits to validate the accuracy and completeness of time and effort records. Name of Contact Person: Carla Licavoli, Chief Operating & Compliance Officer Target Date: OBT implemented all four steps within this plan by December 31, 2023, with ongoing monitoring and improvement.

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance

Charter School Program - Assistance Listing No. 84.282 Recommendation: We recommend the School ensure policies and procedures for payroll expenditures for grant programs be charged to the federal grant based on approved hours worked in the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Options Schools, Inc. will implement policies and procedures for payroll expenditures charged to federal grant programs that track approved time worked. Name(s) of the contact person(s) responsible for corrective action: Jack Colwell Planned completion date for corrective action plan: July 1, 2023

This was noted in last year's audit but was identified late in the fiscal year. The time required to do the due diligence and implementation was part of our timesheet review system was not fixed until after June 2023. As noted in last year's goal, Sewall administration completed a review of payroll companies and committed on a new system that began in October 2023. Along with that, we have organized a new internal system of tracking staff's time given the complexities of the many blended funding sources. We have also implemented a regular review and supervision of time sheet allocations.

The payroll allocation process was adjusted during the fiscal year following the transition that created both the fiscal year 2022 and 2023 findings. This process has also been reviewed by NSF. A system of checks and balances are also in place to make sure wages are accurate between files and the payroll system. Person(s) Responsible: Gina Grange Timing for Implementation: Complete

ection IV – Corrective Action Plan Finding 2023-001 Programs: LIFF Grant Significant Deficiency over Financial Reporting Repeat Finding: No Auditee’s Corrective Action Plan: In the future, when payroll data is imported from ADP, we will include LiFF grant code to track costs on the accounting system. This is implemented for non-payroll related costs. Contact Person: Berhane Ayichew

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Sarah Haven, Director of Finance & Operations Corrective Action: The Winooski School District will implement the following to address finding 2023-001 Implement control processes and procedures to ensure that time certifications are accurate and complete. Anticipated Completion Date: 6/30/2024

A/B. Allowable Costs and Cost Principles/Activities Allowed or Unallowed Administrative Cost Grants for Indian Schools FFAL #15.046 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified four expenditures where payroll was not paid in accordance with employment letter. Corrective Action Plan: Anticipated Completion Date: The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. June 30, 2024

A/B. Allowable Costs and Cost Principles/ Activities Allowed or Unallowed Indian School Equalization FFAL #15.042 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified five expenditures Corrective Action Plan: Anticipated Completion Date: where payroll was not paid in accordance with employment letter. The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. June 30, 2024

2023-004 FINDING: INADEQUATE CONTROLS OVER PAYROLL EXPENDITURES AND NONCOMPLIANCE WITH ALLOWABLE COST & COST PRINCIPLES REQUIREMENTS APPLICABLE TO THE HEAD START CLUSTER Corrective Action Plan: The University has updated its process to collect time and effort information on a semi-annual basis rather than quarterly, which relieves some burden from staff, but still complies with federal regulations. By collecting time and effort information on a semi-annual basis, staff will have more time to reconcile time and effort against actual payroll expenditures. The University has also redesigned the time and effort collection form to show the 100% distribution of work. Further, the University now has a full-time financial research administrator who will help ensure that payroll related adjustments are done timely. The financial research administrator will work with the Early Head Start program management to ensure that the related payroll reports are reviewed and reconciled timely, in accordance with existing University procedures. Responsible University Personnel: Erin Soto, Executive Director of Family Development Center; FeMia Norwood, Director of Office of Sponsored Programs and Research; Jessica Braddy, Financial Research Administrator. Anticipated completion date: Already implemented.

Department: Administrative and Financial Services Title: Internal control over monitoring of employee classification and compensation needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The department will allocate resources to adhere to the statutory review of the classification specifications--a timeframe which as of 2024 is every 10 years. The department will continue to document reviews of classifications specifications, including those which do not result in changes. The department will create and maintain a spreadsheet to record all reviews of classification specifications. Completion Date: June 30, 2024 Agency Contact: Breena Bissell, Director, Bureau of Human Resources, DAFS, 207-624-7368

Planned Corrective Action: Meals on Wheels of the Monterey Peninsula (MOWMP) will address the finding by taking the steps outlined below: 1. Expenditure Allocation: Controller and/or bookkeeper will allocate expenditures based on the number of meals prepared each month and the percentage of meals prepared for each program and funding. Yearly reviews of the allocation process will be conducted to ensure accuracy and relevance. Adjustments may be made based on changes in meal demand, program requirements, funding sources, or other factors affecting meal preparation costs. 2. Payroll Reporting: On a yearly basis, Managers and/or Directors will allocate the amount of time each employe works based on tasks performed and the amount of time worked on federal award activities. This allocation will be expressed as a percentage of total work hours performed. Periodic adjustments to time allocations may be necessary to reflect changes in project priorities, staffing levels, or other factors affecting workload distribution. Person Responsible for Corrective Action Plan: Leadership Oversight – Christine Winge, Executive Director Operational Oversight – Kay Smith, Controller Anticipated Date of Completion: MOWMP will complete the Corrective Action Plan by June 1, 2024. We will implement the Corrective Action Plan beginning July 1, 2024.

2023-002 Special Education Cluster – Assistance Listing Numbers 84.027, 84.173 Recommendation: We recommend procedures be strengthened to document and maintain on file the management review of time and effort. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The School Department has reviewed the finding and is in the planning process with corrective actions. Name(s) of the contact person(s) responsible for corrective action: Amy Mistrot, NPS Director of Business Operations. Planned completion date for corrective action plan: NPS has completed the first of two required Time and Effort Certifications for FY24. We will add managerial review of the completed certifications as an additional level of oversight for both the first and second certifications this year and continue this practice henceforth.

Management will update time and effort documentation process with additional steps to ensure compliance and review requirements with applicable employees.

The University implemented a new grant management software that will provide greater functionality to complete the effort certification process within the time requirements as identified in the University's Time and Effort Reporting policy.

Action taken in response to finding: A comprehensive spreadsheet including all wages allocated to Federal Grants was created during the course of the Federal Awards program Audits. This spreadsheet allows SBCHC staff to track and verify all wages allocated to Federal Awards on a contemporary basis with internal checks and balances included. These verification processes now happen with every payroll cycle and are documented as such. Any revisions that are required now occur on a regular basis and correspond with the bi-weekly payroll cycle. Name(s) of the contact person(s) responsible for corrective action: Matt Gehri, CFO Planned completion date for corrective action plan: Currently deployed as of February 2024, and has been reviewed back to the beginning of the H80 Federal Grant year of May 1, 2023.