Corrective Action Plans

Corrective Action: The District has communicated with all departments that pre-filled forms should not be utilized when documenting salaries and wages charged to federal awards. Additionally, the District has reviewed all employees with recurring federal time and effort requirements to ensure the proper forms are completed. Monitoring will occur at the beginning of each semester to ensure all required time and effort documentation has been completed and collected. Responsible Officials: Kevin Caskey, CPA - Chef Financial Officer - (843) 680-6013 Anticipated Completion: Immediately

The Hingham Public Schools’ general weekly payroll is approved on a weekly basis by Management. In the case of our summer programs a similar control has been put in place by Management to ensure all payroll records are approved before processing.

Hingham Public Schools has circulated training guides and templates to grant writers on the requirement to have time and effort reporting completed in a timely manner for staff assigned to specific grants. Grant accounting associates have also been provided with the training material to ensure that there is an additional review of time and effort reports as part of the grant accounting, review and finalization process.

Time & Reporting - Corrective Action Plan In order to strengthen the internal controls surrounding time and effort reporting, the Organization has modified its policies and procedures relating to time and effort reporting to align with any changes in payroll processes and any changes in personnel at the Organization to ensure that appropriate support is maintained at all times at the Organization. Further, the Organization plans to implement regular internal inspections of records to ensure completeness and adherence to the policies in place.

Finding #2023-001 – Allowable Costs relating to Time and Effort and Internal Controls Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – First Quarter of 2024 Information on the Major Federal Program: U.S. Department of Health and Human Services Name of Program: Substance Abuse and Mental Health Services Assistance Listing Number: 93.243 Grant Award Number: 1H79TI085239-01/6H79SM080760-03M001/1H79TI084237-01/ 1H79SM080760-01 Grant Award Period: September 30, 2022 to September 29, 2027, November 30, 2018 to November 29, 2023, September 30, 2021 to September 29, 2026/November 30, 2018 to November 29, 2023 U.S. Department of Veterans Affairs Name of Program: Veterans Supportive Housing Per Diem Program Assistance Listing Number: 64.024 Grant Award Number: VOAQ754-1291-558-PD-21, VOAQ754-2080-558-CM-22, VOAQ754-2286-565-CM-22 Grant Award Period: October 1, 2022 to September 30, 2023 Corrective Action Plan: Effective immediately, the Organization will strictly enforce its policy for employees to properly complete their timesheets and for supervisors to properly review and approve employees’ timesheets. To do this, the Organization will conduct a training for all employees and supervisors about how to properly complete and review timesheets. To ensure compliance with the policy, the Organization will conduct random checks of timesheets every pay period to verify that supervisory approval is performed. Appropriate disciplinary action will be implemented for non-compliance.

The Institute has implemented procedures to ensure all documents to support the salaries and wages charged to federal programs are prepared in accordance with the SCDE requirements.

The Institute has implemented procedures to ensure all budget estimates used for salaries and wages are reviewed quarterly and adjustments will be made to reflect actual cost for the activity performed in accordance with the SCDE requirements.

The School District recognizes the issue identified during the audit and has made all necessary adjustments to ensure compliance with spending down the remaining ESSER III funding.

The Assistant Superintendent of Curriculum & Instruction will work with the Business office and the Human Resources department to ensure that the Certification of Federal Awards forms accurately reflect the employee's time charged to the grant. The forms will be reviewed to ensure the costs are allowable and properly documented.

The District will implement a system of internal controls to ensure that all certifications are completed timley. Additionally, the District will ensure that time being charged to the grant agrees to actual time spent working in the grant for each employee.

Ashley Community Schools will immediately implement procedures to ensure documentation of distribution of salaries and wages is regularly completed, reviewed, authorized and maintained. The direct supervisor of all staff providing services under federal awards will ensure documentation is compiled, reviewed and authorized no less than quarterly. Original documentation will be maintained by the direct supervisor and copies of fully executed documentation will be shared with the superintendent’s office for storage for a minimum of five years.

Item 2022.003 - Activities Allowed or Unallowed Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and Payrate Review and Approval: • Standardize timesheet submission and approval process • Utilize an electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, reviews, and approvals by supervisors • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors NonPayroll Expenditures: • Evaluate and improve upon existing processes to ensure internal controls over nonpayroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors

During this period, Hope the Mission experienced rapid organizational growth in which our internal infrastructure had not yet caught up to support the significant growth in programs and funding. Since then, management changed our 3rd party payroll provider in order to better support our payroll and reporting needs. As part of this transition, we worked closely with our new payroll provider to implement job-costing functionality that will accurately track time across grants funded programs. In addition, we have established a process requiring department leads to review and approve all timesheets prior to submission. We also partnered with our new 3rd party payroll provider to set up time allocation for salaried employees.

Re: Corrective Action Plan - Audit Finding 2022-02 - Improve Controls and Documentation over Payroll Planned Corrective Action: The District will enhance payroll documentation controls by standardizing processes for verifying pay rates, retaining payroll support documents, and documenting/approving transfers and allocations. Cross-department procedures between Payroll, HR, and Business Office will be formalized. Staff involved in payroll and federal grants will receive training. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature Ms. Emilys Peña Assistant Superintendent Dr. Deanne Galdston Superintendent of Schools Ms. Lisa Gibbons Director of Finance and Operations Dr. Ceronne Daly Director of Diversity, Equity, Inclusion, and Belonging Dr. Kathleen Desmarais Director of Student Services Ms. Amanda Owens Director of Human Resources

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

Corrective Action Plan The documentation deficiencies identified were largely due to the absence of a dedicated internal Human Resources (HR) department and the absence of formalized HR procedures. During the audit period, HR services were outsourced to a third-party provider; however, the services provided were not comprehensive nor su􀆯iciently tailored to the agency’s operational and compliance needs. Additionally, the scope and deliverables under that contract were not clearly defined, resulting in incomplete documentation practices and potential risk exposure.

The Government concurs with the auditor's findings and recommendations. The Division of Human Resources is now adjusting the Notice of Personnel Actions to reflect the requisite Project code at the beginning of each Fiscal year.

The Government concurs with the auditor's findings and recommendations. DOH fully acknowledge and accept the auditor’s finding regarding DOH’s inability to reconcile the payroll expenses listed in the SEFA with those documented in the payroll register. This discrepancy arose because payroll adjustments were not completed in time to reflect accurately in the FY2022 SEFA. To address this, DOH team has received thorough training, and staff members now have the necessary access to make payroll adjustments in the Government Financial Management System as of FY2024. Moving forward, DOH will strengthen our SOPs by conducting monthly reconciliation meetings with all relevant program teams to ensure timely adjustments and continuous monitoring. Additionally, DOH will update procedures to guarantee that all new fiscal staff are granted complete financial system access and are trained on reconciliation and adjustment processes within two weeks of starting.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit finding related to payroll activities and recognizes the need for stronger internal controls to ensure full compliance with federal regulations. To address the identified discrepancies and prevent future occurrences, VIDE will enhance timesheet management and strengthen rate verification processes. To improve timesheet management, VIDE will implement a system to ensure all timesheets are submitted and readily available. This will include electronic timesheet submission, mandatory supervisor review and approval before payroll processing, and secure electronic storage and archiving of timesheets. VIDE will also strengthen its rate verification process by implementing a standardized procedure that includes a checklist for comparing NOPA rates with payroll system rates. Payroll staff will be required to complete this checklist at the start of each pay cycle and maintain a tracker to flag any discrepancies. To ensure all employees and supervisors understand the new policies and procedures, VIDE will conduct mandatory training sessions. These sessions will cover proper timesheet completion and submission, rate verification requirements, and the importance of adhering to the new guidelines.

The Government concurs with the auditor's findings and recommendations. DHS transitioned from a manual payroll process to the Government electronic Timeforce (STATS) system. All time and attendance are now vetted and approved through the various levels of applicable management, ultimately being approved by the Agency Head or designee. Payroll is generated based on the cost centers listed on the Notice of Personnel Action. Payroll is now reconciled by the Financial Analyst once it is posted by the Department of Finance to ensure that cost is applied appropriately. Additionally, a workflow is now established in the NOPA approval process to ensure the current org, objects and projects are listed on the Notice of Personnel Actions (NOPA) which is utilized for payroll purposes.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit findings regarding Child Nutrition Cluster payroll and is committed to strengthening internal controls for federal compliance. VIDE will enhance timesheet management by developing clear policies for completion, submission, approval, and secure retention, ensuring accurate effort documentation. Federal Grants and Payroll staff will collaboratively verify employee authorization, accurate project coding, and consistent pay rates (NOPA vs. payroll register); this reconciliation will occur periodically and before key reporting deadlines. We will also improve payroll register completeness by adjusting reporting configurations to consistently include all mandatory employer-paid benefits (e.g., retirement, health insurance) and resolve individual instances where hours worked were inaccurate. Finally, mandatory training will be conducted for relevant staff and supervisors on new timesheet procedures, federal time and effort requirements, NOPA reconciliation, and accurate payroll documentation. This comprehensive approach, supported by ongoing monitoring from the Office of Fiscal and Administrative Services, will ensure sustained compliance and robust financial management for the Child Nutrition Cluster.

2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. The Organization hired a Human Resource Manager June of 2024, moved to ADP for payroll in January 2025 and updated policies and process for review in May 2025. Procedures are in place for review and approval of each payroll.

Since the hiring of the Executive Director in March of 2022, we have implemented the following: Created A Human Resources Department, which did not exist at CRA before 2022. Hired a Human Resources Director to oversee department. Initiated a comprehensive HR information system where staff can review their pay, track their time, and review benefits. Initiated the process of uploading personnel information to our new system, while keeping backups secured in our Google workspace. This includes hiring documentation and change of status forms for employees.

View of Responsible Officials and Corrective Action Plan We acknowledge that the purchase of gift cards was not an allowable expense under federal grant guidelines. During the COVID-19 pandemic, our staff were tasked with responding to urgent and overwhelming public health demands, particularly as the New Mexico Department of Health became overextended. To recognize staff who went above and beyond to ensure timely case reporting and investigations for tribal communities, gift cards were used as a form of appreciation. Corrective Action Plan Timeline Moving forward, we will ensure full compliance with federal grant requirements. Specifically: 1. We will adhere strictly to the cost principles and allowability guidance outlined in federal regulations and the terms of each Notice of Award. 2. In instances where the allowability of an expense is unclear, we will proactively seek guidance and written approval from our Federal Grant Management Officer before incurring the cost. 3. We will provide refresher training to program and fiscal staff on allowable costs under federal awards to prevent recurrence of similar findings. These corrective actions will ensure future expenditures are fully compliant with federal guidelines and that staff recognition practices remain appropriate, allowable, and consistent with award terms. Corrective Action Plan Timeline • Immediate (Already in Effect): Ceased use of gift cards and other unallowable incentives. • Within 30 Days: Finance and program leadership will review current grant guidance and distribute a written summary of allowable/unallowable costs to all program managers. • Within 60 Days: Refresher training on federal cost principles (2 CFR 200) and Notice of Award guidance will be provided to all program and fiscal staff. • Ongoing: When ambiguity exists regarding allowable costs, staff will consult with the Federal Grant Management Officer prior to obligating or expending funds. Designation of Employee Position Responsible for Meeting Deadline Program Managers/Directors, Finance Officer, and Accounting Manager.

The HS program has established an internal process of requester/approver in place to review the transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025