Corrective Action Plans

CORRECTIVE ACTION PLAN Year Ended June 30, 2024 Finding Number: 2024-001 Planned Corrective Action: Cleveland Play House has had difficulties with finding a long-term replacement for the Director of Finance roll and thus the position has experienced much turnover since June of 2023. During this time period, practices have been put in place for the reviewing of grant draws and the approval of time and effort logs. However, the turnover has led to inconsistency with the application of these practices. While the Director of Finance position remains temporarily staffed, there has been improvement in the following of industry best practice for the monitoring of time and effort and grant expenditures. Based on the reduction in questioned costs down from prior year findings and with the continued adherence to best practices for grant costs, Cleveland Play House continues to work towards a clean audit for the fiscal 2025 year ending June 30th, 2025. Anticipated Completion Date: June 30, 2025

Finding & Recommendation 2024-005: As per 2 CFR, part 430(i)(l) of the Office of Management and Budget's Uniform Grant Guidance, charges to Federal Awards for salaries and wages must be based on records that accurately reflect the work performed. The district did not complete Federal payroll certification until May 2024 and did not have sufficient internal controls in place to ensure the certification process was being performed. It is recommended the district's written procedures addressing internal controls with respect to the program requirements be followed to ensure the district tis in compliance at all times. Corrective Action: The district concurs and understands the importance of maintaining internal controls in accordance with 0MB Uniform Grant Guidance. By June 30, 2025, Assistant Superintendent Christopher Carballo will review the existing procedure for Federal payroll certification with Business Office staff to ensure compliance in the future.

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-013 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should update its procedures and controls and perform additional training over time and effort reporting to ensure that payroll costs charged to the program are based on actual time and effort and a combination code that is allowable under the program. The Department should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Action taken in response to finding: EOLWD Finance continues to address time and effort reporting compliance through targeted training and system enhancements. Ongoing training is provided for new staff to ensure they correctly enter combo codes that align with the activities performed. To strengthen oversight, a custom report has been developed to identify employees missing combo codes each week, allowing Finance staff to proactively follow up and ensure proper time charging weekly. Looking ahead, Finance will collaborate with departments in the upcoming fiscal year to update labor distribution profiles, ensuring that employees are defaulted to the correct combo codes for accurate and efficient time reporting. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Anna Yong, Vina Yung Planned completion date for corrective action plan: 12/31/2025

Views of Responsible Officials: Our Federal funds from January 1 to July 31, 2024, were subcontracts with two partners, NACCHO and ASTHO. Each was a flat fee agreement where we were not required to maintain timesheets for contracted work. Where more work was needed than covered by a contract, BCHC used other funds to cover salary. As of August 1, 2024, when we were in receipt of a direct Federal award, we did implement timesheets for effort tracking. While we do track hours work in accordance with what has been budgeted, we continue to supplement all projects (Federal and nonFederal) with additional funds. That said, we have revisited time tracking with our staff and anticipate enhanced accuracy of time capture. Further, from August to December we used a standardized 160 hours for monthly allocations as the denominator to determine payroll percentage per project. We have now started using actual hours per period for those pay periods that have more than 80 hours or months that have more than 160 hours. The implementation of a new allocation format is now in effect, and along with increased diligence on effort tracking across our team, we believe we will enhance accuracy.

Auditor’s Recommendation: Time and effort documentation be documented per Uniform Guidance requirements and used to review and adjust budgeted compensation and benefit costs charged to the award to be accurate, allowable, and properly allocated. Written policies and procedures should be designed and implemented for documentation of time and effort. Corrective Action: TEACH.org will write a policy regarding documenting required procedures to track employee time & effort charged to Federal grants. Each employee who charges time to a Federal grant will receive a copy of this policy annually. The policy will indicate that employees must provide signed time & effort tracking statements at least quarterly while they are charging time to Federal grants. Each statement will be signed by the employee, their supervisor, and the program director. These statements will be used to properly document time & effort charged to Federal grants and prepare invoices or claims for all Federal grants. Each invoice or claim will be compared to time & effort tracking and tied out to the amounts charged to the Federal grant. Responsible for Corrective Action: TEACH.org internal and external accounting staff will write the time & effort procedures with oversight from a TEACH Co-Executive Director. Once the procedures are approved, TEACH internal and external accounting staff will be responsible for identifying employees working on Federal grants and must supply them with a copy of the policy at least annually. Quarterly time & effort documentation forms will be prepared by internal and external accounting staff, and sent to employees, supervisors and program directors. TEACH internal and external accounting staff will be responsible for collecting and retaining all required time & effort documentation. TEACH program directors will be responsible for reviewing all completed time & effort documentation and reconciling time tracked to invoices or claims prepared for all Federal grants. Anticipated Completion Date: TEACH.org will write the time & effort tracking procedures, supply to all employees working on Federal grants, complete all time & effort tracking documents, and tie out to all invoices and claims retroactively to July 1, 2024. This work will be concluded by June 30, 2025, and starting July 1, 2025 the new procedures will be implemented for all Federal grants.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will review time certifications in comparison to salaries and wages recorded to federal programs. See 2024-005 for management's detailed action plan surrounding the time certification findings.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the maintenance, review, and approval of time certifications. See 2024-005 for management's detailed action plan surrounding the time certification findings.

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the review and approval of time certifications. Action Plan:  Review current staffing for employees paid with federal funds: o To ensure accurate financial reporting, the Finance Team must establish a structured filing system within Google Drive/Team Sheets under Payroll with the following structure: [FY25 / Time Certifications].  Subfolder Structure:  Semi-Annual Time Certs  Monthly Time Certs  Time Certs Internal Audit o Time Certs Internal Audit  Download the Detail Distribution Report for the current year to date.  Add a column identify the Source of Funds based on budget unit coding.  Create a Pivot Table using the Source of Funds column, employee names, and amounts.  Time Certification Requirements: Employees paid with federal funds must complete time certifications.  Less than 100% federal funded: Monthly time certification required.  100% federally funded: Semi-annual time certification required.  One-time stipend from federal funds: No time certification required, but the offer letter documenting the stipend must be saved.  Anticipated completion date of May 15, 2025, with an updated monthly review.  Create, review, and secure signatures for time certs: o All time certifications must be created, reviewed, and signed by both the employee and supervisor as soon as possible.  If a time certification is not received, a payroll redistribution will be required to move the salary out of the federal fund – this is not ideal and should be avoided. o Timely completion ensures compliance and prevents unnecessary adjustments.o Anticipated completion date of May 15,2025, with an updated monthly review.  Conduct a quarterly audit of time certifications and federally funded payroll records: o As stated above, if a time certification is not received, a payroll redistribution will be required to move the salary out of the federal fund, which is not ideal and should be avoided. o The anticipated completion date is May 20, 2025, with an updated monthly review.

Recommendation We recommend that NIYC strengthen its payroll controls by: Implementing a secondary review of WEX timesheets prior to payroll processing, - Requiring all pay rate changes to be documented using standardized personnel action forms, and -Conducting periodic payroll audits to verify compliance with documentation and approval requirements. Management Response Corrective Action: NIYC will strengthen internal controls over payroll by implementing additional monitoring and review processes. Going forward, the HR Accounting Coordinator will be responsible for an annual review of all staff employment files to ensure that all required documentation is present and up to date. Furthermore, no changes will be made to any employee pay rate without prior written approval and documentation using the standardized personnel action form. Once the change has been made in the payroll system, all approvals and documentation for the change in pay rate will be given to the HR Accounting Coordinator to include in the employee's file. We have also implemented a secondary review of WEX timesheets by the Accounting Manager during the payroll process. This should find and correct any errors in the spreadsheet used to summarize the timesheets and process WEX payroll. Due Date of Completion: Implementing new internal controls starting June 1, 2025 Responsible Person(s): Accounting Manager, HR Accounting Coordinator

Recommendation Implement a centralized, access-controlled digital system for participant file storage. Additionally, management should require the use of a standardized eligibility checklist and conduct periodic file audits to ensure documentation completeness and compliance with WIOA requirements. Management Response Corrective Action: In response to this incident, we have reinstated the Eligibility Determination and Intake (EDIR) Form. This form clearly states the participant identification information, the characteristics tracked by our program data management tool (GPMS), and states what has been provided by the participant to determine their eligibility for the program. Provided in a check list format, the form clearly demonstrates what makes the participant eligible for our program services. The form also lists the documentation included in the application that has been provided by the participant. This form added to the program application and maintained in the participant's official record will ensure that all WIOA eligibility documentation has been received, reviewed, and approved at the time of intake. Due Date of Completion: Completed as of May 31, 2025 Responsible Person(s):Director of Programs and Development is responsible for re-instating the use of the form and the Field Office Managers and Job Developers are responsible for filling out the form and including it in the participant's official record.

FA 2024-001 Improve Control over Employee Compensation Compliance Requirement: Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program COVID-19-10.555 - National School Lunch Program Federal Award Number: 245GA324N1199 (Year: 2024), 225GA324N1099 (Year: 2024) Questioned Costs: $102,234 Prior Year Finding: 2023-004 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 District is developing correction action to strengthen controls, policies, and procedures and ensure adherence through improved monitoring. Estimated Completion Date: June 30, 2026 Contact Person: Connie Walker, School Nutrition Executive Director Telephone: 678-676-1780 Email: Connie_R_Walker@dekalbschoolsga.org

Corrective action planned: In alignment with 2 CFR 200.430, Housing Connector will develop and implement a formal time tracking policy and procedure to ensure that personnel expenses charged to federal grants are supported by records reflecting the actual time worked on each award.

Finding Reference Number: 2024-007 Description of Finding: Lack of Semi-Annual Certifications for Special Education Personnel (Controls over Compliance - Special Education Cluster) Corrective Action Planned:The district has implemented new procedures for fiscal year 2025 to ensure that semiannual certifications are prepared, signed, and retained for all employees working solely on federal programs, including the Special Education Cluster (IDEA). A tracking system has been established, and staff training has been completed to reinforce documentation requirements. The district will continue to monitor compliance to ensure procedures are consistently applied. Responsible Contact Person: Patrick M. Faour, Interim Superintendent Anticipated Completion Date: August 30, 2025

To address this issure and ensure timely approval of time sheets, the following corrective actions have been implemented and will be maintained: 1. Recurring Communications on Payroll Deadlines: A structured communication schedule has been developed, through which both HR and the CEO will issue regular notices to staff and payroll supervisors. These communications will serve as timely reminders of payroll approval deadlines and emphasize the importance of compliance. 2. Ongoing Training and Support: Staff and supervisors will continue to receive training to address common barriers to timely approvals. On April 28, 2025, a leadership team training was conducted, which included all payroll supervisors. During this session, the importance of timely time sheet approvals was strongly emphasized. This training is part of our ongoing effors to ensure that all personnel involved in payroll processing understand their responsibilities and are equipped to meet them. 3. Escalation and Accountability: A clear escalation procedure has been established for instances where approvals are not completed by the deadline. Repeated non-compliance will result in disciplinary action, as part of a commitment to maintaining accountability. 4. Internal Processing Buffer: An internal buffer has been integrated into the payroll schedule. This allows additional time for finalizing approvals and ensures payroll can be processed accurately and on time. 5. Mandatory Immediate Action: In cases where time sheet approvals are not completed by the specified deadline, both staff and supervisors will be required to take immediate corrective action. This ensures delays are minimized and payroll operations are not disrupted.

Finding Summary: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. These transfers between grants were completed after the end of the fiscal year. Responsible Individuals: Andre Stringfellow, Chief Financial Officer Corrective Action Plan: Management agrees with this finding. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained.. Anticipated Completion Date: August 2025

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its 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 that are calculated in a consistent manner that ensure costs are applied uniformly to respective benefited activities, and that are reflective on employees’ time and effort records Explanation of Disagreement With Audit Finding: Management partially agrees with this finding. First, 45 CFR Part 1635 codifies the timekeeping requirement. CLS keeps track of every case and time dedicated by staff in strict compliance with this requirement. Additionally, the distribution of expenses in the general fund, which includes LSC and two other funding sources, represents a fair method and allocation. Regarding the questioned costs, CLS disagrees with the finding of material weakness given the extremely low total dollar value. 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 2026

BVCASA agrees with the audit finding and is working to complete the final assessment of the unallowable payroll costs and reallocate the expenses to the appropriate programs. Management will self-report on the total impact of the finding to HHSC within 60 days of the date of the audit report. Additionally, management will ensure internal controls are strengthened over payroll processing and adequate reconciliations are performed each pay period to verify that payroll costs are allocated appropriately.

As a corrective measure, BGCPR will take the following actions and will anticipate completing on June 30, 2025: a. Establish clear guidelines for the creation, storage, access, updating, and disposal of records. b. Define retention periods in accordance with legal requirements. c. Develop periodic monitoring procedures to verify record completeness and compliance. d. Implement scheduled internal reviews and standardized checklists. e. Assign specific responsibilities to Human Resources personnel for policy enforcement.

Views of Responsible Officials: Timesheets are now being submitted with every payroll to the proper supervisor for review and signatures.

Finding Number – 2024-001 Procurement Finding & 2024-002 Payroll Finding Planned Corrective Action 1. Policy Development: Draft a comprehensive procurement policy that aligns with federal standards and addresses all required elements, including conflict of interest provisions and procurement methods. 2. Approval Process: Present the drafted policy to leadership or the governing body for review and approval. 3. Implementation: Roll out the approved procurement policy to all relevant departments and stakeholders. 4. Training: Conduct training sessions to ensure staff understand and comply with the new procurement procedures. 5. Monitoring: Establish a system to regularly review procurement activities for compliance with the policy and federal regulations. 6. Implement a system of internal controls to ensure payroll charges are supported by accurate records reflecting actual work performed. This system should include regular reconciliation of estimated payroll allocations with actual time worked and documented certifications by employees or supervisors. Anticipate Completion Date – May 31, 2025 Responsible Contact Person – Monique Langston, Grant Director

The district has reviewed the time and effort issues with the new food service director, and going forward the Treasurer will see that all time and effort sheets are signed by both the employee and supervisor.

Finding 2024-005 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing No.: 97.036 Federal Grantor: U.S. Department of Homeland Security Passed-through: County of El Dorado, California Award No.: FEMA 5302-FM-CA, LEMA Year: 2024 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material Weakness in Internal Control Over Compliance and Material Noncompliance Department’s Management Response: Ventura County Sheriff’s Office’s (VCSO) management agrees with the recommendation to implement internal controls to ensure all costs charged to the programs are calculated correctly in accordance with the program requirement, and that there is proper review and approval. View of Responsible Officials and Corrective Action: To ensure compliance with program policies and requirements, VCSO management has developed a Reimbursement or Invoice Review form to document the internal review of cost allowability and cost calculation accuracy for reimbursements. The use of the Reimbursement or Invoice Review form will ensure that claims and invoices are properly reviewed and approved by a supervisor or fiscal grant manager. VCSO management understands the complexity of the manual calculations of claims and reimbursements for salaries and benefits. Additional training will be provided for all VCSO fiscal grant managers and accounting staff on the calculation of salaries and benefits. Name of Responsible Persons: Amber Butler, VCSO Director of Finance Implementation Date: April 1, 2025, Implemented the usage of the Reimbursement or Invoice Review Form April 30, 2025, Salaries & Benefits Training

Finding 2024-003 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Year: 2024 Compliance Requirement: Activities Allowable or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: VCPH Management agrees with the recommendation to strengthen the established policies and procedures to ensure that all timecards consistently document evidence of supervisor approval. View of Responsible Officials and Corrective Action: To ensure compliance with timecard approval policies, VCPH Management will take steps to strengthen oversight and accountability. Health Care Agency’s payroll personnel currently sends email reminders to supervisors, managers, and VCPH Management before and after the close of each pay period to identify any outstanding unapproved timecards. Management will reinforce the importance of timely approvals by providing additional training for supervisors and managers. In cases where a supervisor is unavailable, an existing alternate approver process is in place and will be utilized to ensure timely approval. VCPH Management will monitor adherence to these procedures and ensure all timecards are approved promptly. Name of Responsible Persons: Laura Flores, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: May 1, 2025, instructions to be provided to all supervisors at a WIC Supervisor Team Meeting.

MVRTD is in the process of procuring and implementing software that will be managed regularly to ensure that the general ledger reflects the allocation and disbursements that will assist in reconciling the payroll costs with the grant budget. MVRTD will assign different individuals to handle payroll preparation, approval, and reconciliation.

RIDOH agrees with the finding and recommendation. Corrective action plan: • In gathering time sheets for the requested audit samples, RIDOH found that some Master Time Sheet Coordinators (staff responsible for receiving signed time sheets, populating the Master Time Sheet spreadsheets sent weekly from/to HR/Payroll, and saving time sheets to the Time Sheet Repository in Teams) were saving documents locally instead of in the central Teams site. RIDOH is providing training and increased oversight of the non-compliant Time Sheet Coordinators and is conducting ongoing checks of the time sheets uploaded to Teams weekly to assure the time sheets are saved properly. • Instructions have been provided and will be reiterated Department-wide that all time sheets must be signed and dated by both the employee and supervisors, and signatures without dates are not acceptable. • RIDOH will adjust the questioned costs for ELC and DWSRF to appropriate non-federal funds. • RIDOH has been working to move staff that use the general category codes (i.e., EH Management & Leadership) to non-federal funding sources as much as possible and will begin requiring staff on federal funds to record their hours for each federal grant separately. This is a complicated process and will be fully implemented once Time and Effort reporting is transferred to Workday (the ERP). Anticipated Completion Date: The first three bullets above will be completed by June 30, 2025. Transition of Time and Effort reporting to Workday has been delayed, and the new target implementation date has not been announced. Contact Persons: Alisha Colella, Chief Financial Officer, Department of Health alisha.colella@health.ri.gov Carla Lundquist, Deputy CFO / Federal Grants Manager, Department of Health carla.lundquist@health.ri.gov