Corrective Action Plans

Community Partners acknowledges that payroll costs did not consistently have sufficient documentation to support the hours charged to the program. Prior leadership did not establish clear guidelines for staff and program personnel to emphasize the time and effort requirements of federal awards. Current management has implemented guidelines and review procedures to ensure that compliance staff verify that hours charged to programs are appropriately supported. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

FA 2022-001 Improve Controls over Employee Compensation Compliance Requirements: Activities Allowed or Unallowed Allowable Costs/Cost Principles Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education AL Numbers and Titles: 10.553 – School Breakfast Program 10.555 – National School Lunch Program Federal Award Number: 225GA324N1199 (Year: 2022) Questioned Costs: $41,309.92 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the employee compensation process as it relates to the Child Nutrition Cluster. Corrective Action Plans: The Hancock County School District has updated the internal controls over the employee compensation process as it relates to the Child Nutrition Cluster and has corrected the employee codes for the director and former director to ensure that the correct employees are paid from CNC. Estimated Completion Date: June 30, 2024 Contact Person: Matthias Jones, Finance Director Telephone: (706) 444-5775 Ext. 125 Email: mjones@hancock.k12.ga.us

Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 93.243 Federal Award Identification Number and Year: H79TI081935 – 2022, H79TI080298 – 2022, H79TI085517 – 2022 Pass-Through Agency: Pierce County Pass-Through Number(s): SC-107323, SC-105454, SC-110121 Award Period: May 31, 2019 through May 30, 2024, September 30, 2017 through September 29, 2022, September 30, 2022 through September 30, 2027 Criteria or specific requirement: 2 CFR 200.430(i)(1)(viii) states that “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: (A) The system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) Significant changes in the corresponding work activity (as defined by the non-Federal entity's written policies) are identified and entered into the records in a timely manner. Short term (such as one or two months) fluctuation between workload categories need not be considered as long as the distribution of salaries and wages is reasonable over the longer term; and (C) The non-Federal entity's system of internal controls includes processes to review after-the-fact interim changes 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.” Condition: Grant hours are not consistently tracked on the employee monthly timesheet. Wages charged to the program are based on budgeted estimates. Per 2 CFR 200.430(i)(1)(viii), this is not allowed without additional steps to ensure accuracy, allowability and proper allocation. Insufficient evidence was presented to support a reasonable reflection of employee federal and non-federal activity. The alliance does not have a written policy nor system of internal controls to review and true-up grant wages to actual. Questioned costs: $447,634 Context: A sample of 40 was made from a population of 504 transactions charged to the major program for salaries and benefit expenses. Of the 40 sampled costs, all were found to be out of compliance with the provisions for 2 CFR 200.430 Compensation - personal services of Uniform Guidance. Sampled wages totaled $137,021.54. Total salaries and wages totaled $971,744 of the $1,599,883 tracked to the major program. Extrapolating the error to the actual costs reported on the SEFA results in a likely questioned cost amount of $447,634. Cause: Management was aware that estimated budgeted costs alone are not sufficient to support personnel costs charged to Federal awards. Effect: Charging grant wages based on estimates rather than actual hours worked on the program may raise compliance concerns. Estimating grant wages without adequate support for time and effort documentation may result in noncompliance with grant regulations. This can also lead to overcharging or undercharging the federal grant, which may result in penalties or repayment obligations. Repeat Finding: No. Recommendation: We recommend that the Alliance incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by adjusting the format of the monthly timesheet to include a column that specifies how many hours per day were spent on which federal and nonfederal activities. PCA can further enhance clarity, accountability, and transparency by moving from a "day" format to an "hour" format on their timesheets. View of Responsible Official: Pierce County Alliance has enjoyed the decades long relationship with our prior audit firm. We had been advised to record staff time on an hourly basis. We were then redirected to record time on a daily basis. However, with this recommendation, we are being redirected to record on an hourly basis. At no time has a finding been previously issued on how staff time is recorded, on timesheets or on the back end of our third-party payroll software. Corrective Action: Pierce County Alliance will reinstitute an hourly timesheet format in order to account for positions with multiple funding sources.

Finding 2022-002: Allowable Costs/Cost Principles U.S. Department of Health and Human Services- Passed through DHS- Tit le IV-E Foster Care (ALN 93.658) Condition: During our audit, it was noted that there was no process in place to ensure that payroll costs were alloca ted among grant funded programs in accordance with the Uniform Guidance. During our testing, we noted that payroll was allocated based on a semi-annual time study. The time study wa s used to allocate the payroll costs for the year, without determining if the semiOannual periods were representative of the time worked by employees for the remainder of the year. Criteria: The Code of Federal Regulations (2 CFR 200.430) requires that payroll costs be allocated in an equitable manner. Cause: The County Children's Services department does not have adequate procedures in place to verify that payroll costs are allocated in an equitable manner in accordance with the Uniform Guidance. Effect: The County Children's Services department may not be allocating payroll costs equitably. Questioned Costs: The amount of questioned cost, if any, is not able to be determined. Recommendation: We recommend that the County Children's Services department establish procedures that provide a system and related documentation to support an equitable allocation of payroll costs. Management Response: The Department reviews the staff time study categories every six months (Staff time studies are conducted in May and November). The Department will now review the staff time study categories every three months to determine if the staff percentages are accurate. This three-month review will be added to the time study policy and will include discussions with each supervisor to confirm the staff categories. This confirmation will be documented on the staff category listing. Anticipated Completion Date: Immediate

Finding No. 2022-003 Area: Allowable Costs/Cost Principles Views of Auditee and Planned Corrective Action Condition 1. Disagree with the finding. The Education Stabilization Fund (ESF) of the Public System was awarded to and was designed to provide additional funding (supplement) support to the local school system (PSS) as a result of the impact of the COVID-19 pandemic. Background: On March 16, 2020 PSS suspended classroom instruction, ease central office operation to a certain level, implemented furloughs, and effectuated cost-containment initiatives, among drastic measures to mitigate the crisis brought about by the pandemic. Of the public elementary, middle, and high schools on Saipan, Tinian, and Rota, only one school - Kagman Elementary School - was provided limited instruction (during summer of 2020). Kagman Elementary School was the first to reconfigure its facilities to maintain a safe (social distancing) facility for in-person student learning. The $480,743 as cited (Condition 1) was an ESF-approved and sanctioned funding allocation. However, the change in funding source was initiated after the payroll processing. And in order to reflect the correct funding source, the JE adjustment was initiated. Due to JE limitation these entries are not reflected to “subsidiary” ledgers. Condition 2. Disagree with the finding. Cited in this finding were three (3) 190-day employees. The 190-day employees worked for ten months, however, their pay is stretched out over a period of twelve months. Further, these pay periods are inclusive of the days that they are not supposed to report to work including summer months. Hence, no timesheet(s) is/are required. Anticipated Completion Date: N/A Name of Contact Person and Title Contact Person – Arlene Lizama, Director of Finance Contact – arlene.lizama@cnmipss.org

FINDING 2022-006 Finding Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 3 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 3 employees. We provided sufficient alternate documents that would allow the State to validate the contract amount being paid, and whether the proper employees were paid from or should have been paid from the Education Stabilization Funds. The documents provided sufficient data to support the questioned cost of $26,207 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024

FINDING 2022-003 Finding Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 10 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 10 employees. We provided sufficient alternate documents that would allow the State to validate the contract's amount being paid, and whether the proper employees were paid from or should have been paid from the Title I funds. The documents provided sufficient data to support the questioned cost of $203,488 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024

We will be performing a reconciliation between HR and Payroll to ensure that individuals being paid by a grant are documented correctly and paid according to that documentation.

We agree with this finding regarding the allocation of payroll costs for one-time bonus payments. We have taken steps to correct the issues identified and during June 2023 we modified our procedures for allocation of payroll costs to federal programs. In June 2023, we changed our payroll processing vendor. This will allow us to have better controls over our payroll processing. We will make sure all staff certify their time and effort expended for each payroll.

Recommendation: We recommend that the University increase the time and effort certification process to be more timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: Sponsored Projects Administration (SPA) will decrease the amount of the time between the end of the semi-annual reporting periods and distribution of the Personnel Activity Reports (PARs). Deadlines for either certifying that the charges to sponsored awards reported on the PARs reasonably reflects the work activities for those projects or notifying SPA that salary adjustments are required. SPA will send reminder notices periodically prior to the deadline. After the deadline for the reporting period, past due notices will be sent repeatedly after the deadline until certification or notification of adjustments is received. SPA will establish a system for accepting change notifications and closely monitor the status of retroactive labor adjustments so that updated PARs can be issued, reviewed, and certified in a timely manner. Name of the contact person responsible for corrective action: Dawn Boatman, Assistant Vice President for Research Administration Planned completion date for corrective action plan: July 1, 2023

Recommendation: We recommend that the University increase the time and effort certification process to be more timely Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: Sponsored Projects Administration (SPA) will decrease the amount of the time between the end of the semi-annual reporting periods and distribution of the Personnel Activity Reports (PARs). Deadlines for either certifying that the charges to sponsored awards reported on the PARs reasonably reflects the work activities for those projects or notifying SPA that salary adjustments are required. SPA will send reminder notices periodically prior to the deadline. After the deadline for the reporting period, past due notices will be sent repeatedly after the deadline until certification or notification of adjustments is received. SPA will establish a system for accepting change notifications and closely monitor the status of retroactive labor adjustments so that updated PARs can be issued, reviewed, and certified in a timely manner. Name of the contact person responsible for corrective action: Dawn Boatman, Assistant Vice President for Research Administration Planned completion date for corrective action plan: July 1, 2023

FINDINGS - FEDERAL AWARD PROGRAMS AUDIT SIGNFICANT DEFICIENCY/COMPLIANCE 2022-01 Procurement Policies and Procedures Recommendation: Quotes should be obtained whenever possible when purchases are expected to be between $10,000 and $250,000. If purchases are to equal or exceed $250,000, the proper bidding procedures should be followed. Bidding procedures, quotes, and efforts to give preference to minority or women-owned businesses should be documented, including documenting if bids or quotes could not be obtained. A procurement policy should be established as soon as possible and an individual should be assigned to monitor the implementation of the policy. Action Taken: The Organization has begun the process of establishing a procurement policy and have it completed by March 16, 2023. The Organization will also go back to purchases starting July 1, 2022, that exceeded the micro purchase threshold of $10,000 and prepare the required documentation as listed in the recommendation. This will be completed by April 30, 2023. Any purchases exceeding the micro purchase threshold of $10,000 going forward will be supported by the required documentation.

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has transitioned to an allocation-based payroll in the summer of FY 2022. This change was determined the best practice for the organization to help set standards for forth coming periods. The payroll process is timely and consistent with the allocation base. Staff will maintain clocking hours for time worked, after each quarter a review of actual time spent on grants is compared to the allocated time for each grant. These times studies will the determine the reconciling JE, if any, will be processed to show the actual amounts due for the grants. The time studies will effectively assist in the allocation for the next quarter to determine how each staff member is allocated for payroll. Each WPHW staff member will receive a certification letter for them to review and sign to verify the hours in which they have worked. These certification letters will be built by the Senior Accountant that oversees the payroll entry process. The Director of Finance will have a review process to verify that all staff members have had a full-time study review and that certification letter are correct before staff receive them and the Financial Quality and Compliance Manager will review entire process for each of the first two quarters. Through the multi-step review the overall payroll allocation and expenditure process will be more defined and follows the internal control processes. After receiving the FY22 audit we will be switching back to time-based payroll processing based on actual hours posted by staff. Beginning effective 3rd quarter FY23 our payroll process will remain with Director of HR and the Financial Quality & Compliance Manger reviewing and submitting payroll through TRAXpayroll. The accounting team will then use the Project hours report from Bamboo HR, directly tied to staff time sheets, to input the data for actual hours worked into the payroll workbook to build the JE for each remaining payroll for FY23. The JE will be entered into the financial software prior to the federal draw. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

Condition: Time records provided to support salaries and wages charged to the school lunch revolving fund were not approved by supervisory personnel. Corrective Action Planned: The District has implemented procedures utilizing time clock systems. The Administrative Assistant assigned to the Food Service Program reviews the system report to verify hours worked and absences. The report is then printed, reviewed and signed-off by the Food Service Manager prior to submitting the wage/hourly report to payroll. Anticipated Completion Date: January 2023 Contact: Ronald D. Tarro, Director of Business & Finance

Program: AL 20.509 ? Formula Grants for Rural Areas ? Allowability & Subrecipient Monitoring Corrective Action Plan: The Controller Division, Audit Section, will provide support through continued engagement and work collaboratively as an additional resource to the NDOT Transit staff and transit recipients. NDOT Transit staff in collaboration with the Controller Division will be improving the standard operating Procedures which will be utilized for the in-depth review of monthly invoices moving forward. Contact: Khalil Jaber Anticipated Completion Date: Ongoing

Program: AL 84.010 ? Title I Grants to Local Educational Agencies ? Allowability and Subrecipient Monitoring Corrective Action Plan: The Department will contact the two subrecipients noted to provide one-on-one technical assistance and will also provide additional technical assistance regarding proper time and effort documentation to all subrecipients. Additionally, time and effort guidance is available to all subrecipients on the Department?s website, will be discussed at upcoming subrecipient training opportunities and supported by a dedicated Grants Management Training Specialist. The Department will ensure the identified written deficiencies noted in the subrecipient fiscal monitoring exit letter clearly identifies a finding vs. technical assistance needed; whereas a finding is supported by follow-up in accordance with federal UGG regulations and technical assistance provides knowledge of the Department?s training and resources available. Contact: Jen Utemark, Budget and Grants Management Anticipated Completion Date: December 31, 2023

FINDING 2022-001 Contact Person Responsible for Corrective Action: Adam C. Minth, Assistant Superintendent Contact Phone Number: 219-374-3504 Views of Responsible Official: The school corporation concurs with the finding and will be implementing corrective procedures by the end of this fiscal year. Description of Corrective Action Plan: The Corporation Treasurer and the Assistant Superintendent of Business and Operations are going to perform an analysis on the identified employee who is currently splitting her duties between the Child Nutrition Cluster and other non-federal duties. The analysis will be used to determine what percentage of her workload is directly related to the Child Nutrition Cluster, and what percentage is directly related to non-federal duties. Once the analysis has been completed, the Assistant Superintendent of Business and Operations will direct the Payroll Specialist in regard to what percentage of her pay should go to the Child Nutrition Cluster, and what percentage should go to the Operations Fund. Anticipated Completion Date: 4/30/2023

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: Our internal control process is properly designed to approve and calculate the payroll expenses and allocation of time to the program, but we did not maintain support for a true up for actual time spent on the program compared to the budget. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: The program manager will review and approve the level of effort contributed to the program by the employees. Formal documentation providing the support for a true up of actual time spent on the program compared to the budget will be maintained. Anticipated Completion Date: December 2023

Views of Responsible Officials: As of March 2023, we have implemented timesheet and work tracking for all employees and contractors receiving compensation from the Foundation. The timesheets have been enhanced to show the task completed. Each timesheet is reviewed, signed and dated by the Executive Director.

Nemours will create a standard operating procedure (SOP) that outlines a centralized process for effort allocation review and editing. The SOP will incorporate procedures to ensure accuracy and validation of all correcting entries. Meetings with each Nemours principal investigator (PI) will occur at least quarterly to review study financial information. An effort certification report will be reviewed by the PI for accuracy and sign off. Nemours policy 11.1.4, Cost Transfers for Funded Activities, will be reviewed and updated. Corrective action will be complete by October 31, 2023.

Views of Responsible Officials: We have streamlined and consolidated the payroll allocation file so that such manual errors will not occur in the future. We will also institute a monthly review process of employee timesheets, and the Executive Director will review and approve timesheets on a quarterly basis.

Audit Finding Reference: 2022-001 Improve Time and Effort Documentation Planned Corrective Action: We understand the importance and requirement regarding this finding. Semi-Annual certification of all staff funded fully out of grants will be completed. Monthly Time and Effort certifications will be completed for all staff funded out of multiple accounts, grant or local. Stipend and Payment for additional work forms will be completed for all staff supporting grant funded activities outside of contractual time. These forms will be re- viewed and maintained by Grant administrators. The district will use forms created and recommended for use by Massachusetts Department of Elementary and Secondary Education. Sample forms are attached. Name of Contact Person and Completion Date: Laureen Cipolla, Accountability and Student Achievement, laureen.cipolla@leominsterschools.org 978-537-7700 x l345 Anticipated date of completion - 6/30/23

In order to ensure City personnel time is allocated accurately and for allowable time charged to the CDBG program the City will continue to utilize employee-completed timesheets which match City pay periods. Each timesheet will be reviewed by the employee?s supervisor within about a week of the completion of any pay period. Since there are already policies and procedures established for time keeping for the CDBG program, the Department of Finance and Management will issue a memo for City personnel supervising CDBG funded staff outlining the time keeping procedures to be followed.

FINDING 2022-001 Contact Person Responsible for Corrective Action: Patricia L. Clark, Superintendent Corrective Action: The Milford School Department will prepare and disseminate to all employees wage agreements with documented pay rates. Anticipated Completion Date: October 15, 2023

FINDING 2022-005 Contact Person Responsible for Corrective Action: Mary K. Kaczka, Assistant Director, Community Development Contact Phone Number: 574-322-4472 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Program Income ? Use Management has taken or will take the following steps related to the weaknesses identified in payroll and vendor payments: Payroll: Employee time and effort logs were implemented as part of our corrective action plan for finding 2021-003. Due to the timing of the previous finding Management was unable to fully implement the action plan for the 2022 audit year. Time and effort logs are required to be completed by staff whose salaries and wages are paid from more than one Federal award as defined by 2 CFR 200.430(i)(1)(vii). Time and effort logs include allocation of time by program activity and general ledger account number. The time and effort log is acknowledged by the employee and the supervisor as part of the bi-weekly payroll process. Vendor: Late fees and taxes: Management will review existing claims process with staff and strengthen as necessary. Management will communicate with staff involved with the payment of claims that the payment of late fees or taxes the unit is exempt from are ineligible uses of federal funds. Program Income: Determining or Assessing and Recording: Management will address the program income weaknesses as follows: CDBG staff meets with city controller staff monthly and will expand its existing reconciliation to include program income receipted by the city and recorded in IDIS. Anticipated Completion Date: August 31, 2023