Corrective Action Plans

Finding 2022-004 - Strengthen controls surrounding program-related record keeping including increasing the frequency of reconciliation's and program wage allocation procedures to match the payroll cycle. Program Affected Under the U.S. Department of Health and Human Services - Award Year October 1, 2021 - September 30, 2022: Assistance Listing 93.262 Occupational Safety and Health Program Corrective Action The Organization agrees with the finding. The Organization has implemented both time and effort reporting by pay period and wage reconciliations as part of a monthly close process. Responsible individual - JJ Bartlett Completion 9/30/2023

Finding: The Organization allowed payroll related costs to be submitted for reimbursement under the grant for time that did not match approved timesheets. This is not in compliance with program allowable cost requirements. The amount of payroll and related costs discovered to be incorrect was a net amount of $25, which when projected onto the remaining payroll and related costs that were not tested, amounted to $1,038. Corrective Action Taken or Planned: The Organization will review audit findings and ensure accurate future reimbursements, develop a comprehensive process for verifying time sheets against service delivery, and implement a paper timesheet system in which supervisors must enter time based on timesheets, ensuring 1:1 reimbursement. Name of Contact Person: Jacob Ducey, Grants Manager Phone Number of Contact Person: (540) 907-4555 Projected Completion Date: October 31, 2023

Item: 2022-003 Assistance Listing Number: 84.425U Programs: American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) Federal Agency: U.S. Department of Education Pass-Through Agencies: Arizona Department of Education Pass-Through Grantor Identifying Number: Unknown Award Year: April 19, 2022 to September 30, 2024 Criteria: In accordance with 2 CFR § 200.430 – Compensation – the entity’s system of internal controls should include a process to review after-the-fact interim charges made to federal awards based upon budget or allocation estimates. Condition: The entity’s system of internal controls did not include a process to review after-thefact interim payroll charges made to federal awards based upon budget or allocation estimates. Name of Contact Person: Doug Taylor, CFO Phone Number: (602) 230-1116 Anticipated Completion Date: December 31, 2023 Views of Responsible Officials and Corrective Actions: Special Olympics Arizona, Inc. will revise its policies and procedures to require that actual time be recorded on timesheets for the actual efforts spent on Federal awards. Management will utilize actual time and effort when charging expenditures to Federal awards going forward.

Item: 2022-002 Assistance Listing Number: 21.027 Programs: Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Arizona State Office of the Governor; Maricopa County Pass-Through Grantor Identifying Number: Unknown Award Year: January 1, 2022 to December 31, 2024; January 28, 2022 to June 30, 2023 Criteria: In accordance with 2 CFR § 200.430 – Compensation – the entity’s system of internal controls should include a process to review after-the-fact interim charges made to federal awards based upon budget or allocation estimates. Condition: The entity’s system of internal controls did not include a process to review after-thefact interim payroll charges made to federal awards based upon budget or allocation estimates. Name of Contact Person: Doug Taylor, CFO Phone Number: (602) 230-1116 Anticipated Completion Date: December 31, 2023 Views of Responsible Officials and Corrective Actions: Special Olympics Arizona, Inc. will revise its policies and procedures to require that actual time be recorded on timesheets for the actual efforts spent on Federal awards. Management will utilize actual time and effort when charging expenditures to Federal awards going forward.

Assistance listing number and program name: 12.401 National Guard Military Operations and Maintenance (O&M) Projects Agency: Department of Emergency and Military Affairs (DEMA) Name of contact person and title: Jensen Forde, CFO Anticipated completion date: April 30, 2024 Agency’s Response: Concur DEMA HR anticipates having this completed by April 2024 at the latest. All employee records will be audited, corrected and maintained per the finding. HR staff has received a copy of the Department’s Record Retention Schedule and effective immediately will adhere to the policy.

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager

Views of Responsible Officials: When SAMU commenced operations at the end of June 2022, the Welcome Respite Project (funded by FEMA) was SAMU's only active project. The HR platform/timekeeping software, Gusto, was implemented prior to the project start date (i.e. employees offer letters and onboarding materials were sent via the platform). Incoming staff were provided with an overview of how to use Gusto during onboarding, one-on-one meetings with supervisors, and staff meetings. Employee time was remunerated according to the rates authorized. During 2022, staff entered their hours in Gusto and were not engaged in outside, non-project-related activities. In 2022 we had only one project and therefore, some salaried staff were instructed that the completion of a timecard was not needed. However, that changed in 2023 as the new Managing Director requested that all staff, including salaried staff, complete timecards appropriately. Additional project codes were implemented in January 2023 and October 2023. SAMU provided updated guidance on timekeeping and use of project codes during the course of several staff meetings and one-on-one meetings. In 2023, SAMU developed a Gusto training and continues to reinforce timekeeping policies and expectations during meetings. Rate and position changes were and continue to be communicated to staff via official HR letters and stored in program files.

Management understands that according to CFR 200.430(i), charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. The records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Hood River County is currently working toward stronger internal controls, education of staff, and a more intense review process. It is expected that these changes will take time. The new Grants Committee is meeting monthly to keep grant management in the forefront of all those concerned.

Management understands that valid data must substantiate Payroll expenses charged to any grant. Therefore, Hood River County has formed a Grant Review Committee to implement processes and procedures to include reviewing after-the-fact time and effort documentation compared to budgeted amounts charged to federal grants to ensure that amounts charged are appropriately supported. This committee has started monthly meetings. New payroll tracking procedures are in the testing phase to see if they are the solution to this problem. This should not be a future problem in fiscal year end 2024.

Management understands that valid data must substantiate Payroll expenses charged to any grant. Therefore, Hood River County has formed a Grant Review Committee to implement processes and procedures to include reviewing after-the-fact time and effort documentation compared to budgeted amounts charged to federal grants to ensure that amounts charged are appropriately supported. This committee has started monthly meetings. New payroll tracking procedures are in the testing phase to see if they are the solution to this problem. This should not be a future problem in fiscal year end 2024.

Criteria - 2 CFR 200.430(i) requires the auditee to establish and maintain effective internal control over the allocation of personnel expenses whereby charges to Federal awards for personnel-related expenditures are supported by official records of the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities which are allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: The non-federal entity's system of internal controls includes processes to review after-the-fact interim charges 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. Condition – Personnel costs allocated to the award did not agree to time and effort reports maintained for those employees charged to the award. Cause – PPHS does not have a process whereby time and effort reports are reconciled to payroll allocated to federal awards. Effect – Time and effort reports documented that 100% of employee time should have been allocated to the award. However, some employees wages were only partially allocated to the award. Corrective Action Plan – PPHS had significant turnover in finance personnel during the 22-23 school year. For FY23, we contracted with accounting consultants to assist with financial management and reporting and with improving processes and procedures, including reconciling personnel costs with grant claims. We will continue to improve our process for reconciling personnel costs allocated to federal awards with time and effort reports. Contact Person(s) Responsible for CAP – Todd Burleson, Financial Controller. Anticipated completion date – Processes were improved in FY23 through assistance from accounting consultants. Policies and procedures updates will be implemented in FY24.

Significant Deficiency in Internal Control over and Compliance over Programs Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No.21 .027 Recommendation: CLA recommends that the program manager and a member of the finance committee knowledgeable about 2 CFR § 200.430(i)(1) review the executive director costs charged to the Coronavirus State and Local Recovery Funds program. Action planned in response to finding: Executive Director's time and effort reports will be reviewed by a member of the Finance Committee, who also serves as an Officer of the Board, on a quarterly basis to insure correct assignment of hours. Names of the contact persons responsible for corrective action: Michael Cade, Michael McGauly, and Matt Stacey Planned completion date for corrective action plan: November 14, 2023

Significant Deficiency in Internal Control over and Compliance over Programs Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027 Recommendation : CLA recommends increased payroll training and reconciliation procedures. Action planned in response to finding : Classification of payroll hours assigned to Coronavirus State and Local Fiscal Recovery Funds, and all others, are to be reviewed and signed off on by accounting or administrative staff before submission of payroll. Names of the contact persons responsible for corrective action: Maria Hemmen, Brooke Johnson or Matt Stacey. Planned completion date for corrective action plan: October 27, 2023

Finding 2022-002 - Significant Deficiency in Internal Control over Compliance: While allocations and allocation methodologies were reviewed by executive and senior management of Rising Communities, these reviews were not adequately documented. Rising Communities has / will take steps to address this f inding. First, Rising Communities’ new f inancial system requires that all journal entries, including journal entries for the recording and allocation of payroll, be approved by a manager. This control has been in place since the beginning of the third quarter of 2022. Second, Rising Communities will implement a process where the appropriate member of the executive management team reviews allocation methodologies and specif ic allocation percentages for staf f . When a change to either the methodology or percentages needs to be made, the appropriate executive management team member will approve before implementation. Third, Rising Communities will utilize systems to back test allocation methodologies and allocation percentages. Rising Communities has implemented a time tracking as of January 2023, and will contract with a new payroll provider, Paylocity, in January 2024 to further ref ine their allocation practices. Rising Communities also utilizes a project management system which executive management reviews on a continual basis, providing them with qualitative information on where Rising Communities resources are being allocated. Finally, Rising Communities with its new financial system, is continually implementing new and more efficient ways of supporting program managers allowing them to have signif icantly greater insight into the spending on their respective programs. Contact Person Responsible for Corrective Action: Michelle Burton, CEO Anticipated Completion Date: November 2023

Organization's Response: MCJ agrees that the salary expense for the one employee noted in the Finding was not correctly allocated. Prior to this Finding, MCJ had already implemented a process that allows review of payroll allocations each per pay period. Since April 2023, a payroll allocation spreadsheet is generated and regularly reviewed for correct grant allocation. Furthermore, since that time, the finance team meets throughout the fiscal year to ensure salaries are being allocated according to grant budgets with the appropriate allocation percentages.

Finding: 2022-003 – Payroll Documentation Auditor Description of Condition and Effect: Salaries and wages were allocated using percentages to distribute payroll costs allocated to grants. Costs were not consistently allocated to reflect the activity actually performed in five out of the six payroll cycles that we tested. The Organization did have a system of controls in place for the fiscal year ending September 30, 2022 requiring employees report time spent in specific areas on their timesheets. However, the control was overridden by management and was not applied on a consistent basis. There were payrolls tested where timesheet was not compared to payroll journals provided by the payroll service, the accounting records, or the reimbursement requests for grants. Payroll costs reflected in the books and records of the Organization did not agree to the payroll journals, timesheets, and reimbursement requests. This required the Organization to use spreadsheets and calculation to support grant funding requests. Some timesheets were found to be inaccurate, resulting in employee personnel costs being reimbursed without proper documentation. Auditor Recommendation: We recommend that the Organization improve its financial management policies and procedures to ensure that multiple staff members are involved in the process of reviewing and allocating personnel expenses to grants. Policies and procedures over payroll should include employees entering time accurately across areas where they spent time, supervisory review, recalculation and approval of timesheets, review of timesheets and compiled time reporting before it is sent to the payroll provider and review of the reporting provided after the payroll run. Payroll postings input into the accounting system should accurately reflect time spent in each grant area (class) and grant reporting and reimbursement requests should be prepared using those numbers. Corrective Action: SIREN will improve its internal controls and policies to ensure that multiple staff members are involved in the process of reviewing and allocating personnel expenses to grants. Multiple staff members will review and ensure that grant reporting and reimbursement requests are based on the actual payroll postings input into the accounting system. Responsible Person Martha Richard Anticipated Completion Date: September 30, 2023

Management's Action Plan: Kevin Holland, Vice-President-Stone County and Operations will oversee the supervisory review and approval of timesheets for the next few pay cycles to ensure management is reviewing 100% of the records. He will also work to ensure none of them are being missed through special circumstances as has happended in the past in order to achieve and sustain 100% compliance. Name of Person Responsible for the Plan: Kevin Holland, Vice-President Stone County & Operations. Anticipated Completion Date of the Plan: 3 payroll cycles spanning six weeks. Approximately mid-December 2023 for completion.

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

BA has worked with Accountant to ensure all employees complete Time and Effort sheets. These requirements have been reviewed with Building Administrators and all federally paid employees will sign the certifications. BA will review to ensure all employees have completed and will report any missing signatures with employee’s supervisors.

2022-004- Internal Control Over Compliance and Compliance – Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: Done. Management’s Corrective Action Plan: Since August 2022, in response to technical issues with an import file that caused some timesheet allocations to not be correctly coded, the CFO has added a layer of review for payroll entries to match import file values to approved timesheets. NGA accounting team members began to train and reach out to employees to reinforce the importance of completing timesheets accurately and promptly following NGA employee policies. NGA accounting since February 2023, has completed the indirect cost, compensated absences, and fringe calculations as a part of the same process for uploading payroll entries. This ensures that the calculations are accurately calculated based on the payroll file. This has ensured that these entries are produced each payroll period and correspond to supervisor-approved timesheets under 2 CFR 200.430 Compensation – Personal Services.

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 will provide 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 will conduct regular monitoring and internal audits quarterly to validate the accuracy and completeness of time and effort records. Name of Contact Person: Carla Licavoli, Chief Operating & Compliance Officer Target Date: Management has already begun implementing mandatory time and program effort records during the year ending June 30, 2024. OBT will continue to monitor and improve these processes, ensuring full compliance with federal regulations and reducing the risk of questioned costs.

Finding 2021-008 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Management will strengthen internal controls over payroll and review personnel files for adequate pay rate documentation. Proposed Completion Date: October 31, 2026

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

In a previous period and by previous auditors, PAX was told that because we were using a percentage of effort calculation in budgeting that time sheets were no longer needed for this purpose. At that time, we abandoned the time sheet process (which was arduous). Based upon current auditor’s advice, PAX will, going forward, establish an effort verification reporting system. This system will accurately capture the effort spent by each employee on specific grants, ensuring proper allocation of wages and salaries to the respective federal awards. Dije Kucana, Comptroller, effective immediately

Item 2021.003 – 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 and electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, review, and approval 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 control 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.