Corrective Action Plans

2024-006 Program: Equitable Sharing Program Federal Financial Assistance Listing Number: 16.922 Federal Grantor: U.S. Department of Justice Award No. and Year: 2024 Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable and properly allocated. Condition: During our testing of the Sheriff Department’s compliance with allowable costs/cost principles requirements, we noted that thirty-three (33) of forty (40) overtime cost calculations were miscalculated. Cause: Equitable sharing funds may not be used for salaries, except under certain provisions outlined in Section V.B.3 of the Equitable Sharing Guide including overtime. The Sheriff’s Department calculates the allowable portion of personnel salaries using a separate template that contained a formula error which inaccurately calculated the total salaries costs allocated to the program. The Sheriff’s department did not have internal controls in place to ensure that the allowed salaries were being calculated correctly. However, the error was detected after the 5th out of 6 months in which these types of costs were allocated to the program. Effect: Salary costs were allocated to the program in an incorrect amount. Questioned Costs: Our testing resulted in questioned costs in the amount of $3,550. However, the total questioned costs for the total population was $23,409. Context/Sampling: A sample of forty (40) individuals were selected from a population consisting of (840) payroll transactions. Repeat Finding from Prior Years: No. Recommendation: We recommend the Sheriff’s Department establish and maintain internal controls to ensure the overtime calculations are being accurately allocated to the program. Management Response and Corrective Action: 1. Person Responsible: Tiffany Mui, Fiscal Administrator 2. Corrective Action Plan: a. Staff corrected the formula error in the Overtime (OT) calculation workpapers. Detailed workpapers, including formulas, will be reviewed by Fiscal Administrator. b. Updated desk procedures for Sheriff’s Narcotics task will include updated OT calculation change. Procedures will be reviewed and initialed by Fiscal Administrator and Sr. Fiscal Manager. 3. Anticipated Implementation date: March 2025

Condition: The documentation to support reasonable assurance for salaries and wages consisted of documentation of when employees completed a therapy session but no clear documentation of how much time when employees were on-call or completed case notes for this grant. Recommendations: We recommend The Center remind its employees complete a personnel activity report that show all of the hours employees spend on the grant not rely just hours documented in the Center system used to track therapy sessions. Management response: Management agrees with the finding and has already put a process in place for documenting time spent on grant-funded activities. Management is working with our Chief Compliance Officer to ensure that the process encompasses all necessary steps to ensure complete and accurate records of the grant-related activities by those who have the time covered by the grant funds.

Contact person(s) responsible for corrective action – Lisa Lawson, Sr. Accountant Corrective action planned – KMHS will move forward with billing benefit expenses as actual as of January 2025 contract billing. All employee and employer benefit costs will be billed out per the actual benefits enrolled and received. Anticipated completion date – 1/31/2025

2024-002 - LACK OF WRITTEN FISCAL POLICIES AND PROCEDURES As of March 27, 2025, scaleLIT has updated its fiscal policies and procedures to reflect all the federal guidelines required by the Uniform Guidance. The scaleLIT Board Treasurer has reviewed and approved the updates.

2024-001 – MATERIAL WEAKNESS IN INTERNAL CONTROLS OVER FINANCIAL REPORTING In July 2024, scaleLIT switched accounting firms. This engagement has led to a more robust monthly close-out process to ensure accurate and complete class allocations. The Director of Operations meets with the firm weekly to review accounts receivable, expense and income coding and allocations, and other activities related to billing and invoicing. The Director of Operations and Executive Director meet monthly with another accounting team member to review monthly financial reports. PART III - FEDERAL PROGRAM AUDIT FINDINGS 2024-001 – MATERIAL WEAKNESS IN INTERNAL CONTROLS OVER FINANCIAL REPORTING As stated above, scaleLIT is now working with a new accounting firm, Jitasa. Jitasa tracks all grants on separate ledgers. scaleLIT meets with Jitasa weekly to ensure that all income and expenses are correctly allocated. scaleLIT is implementing time studies for staff beginning on April 1, 2025, to become more detailed with the staff time spent on federal contracts.

2024-001. Allowable Costs/Cost Principles United States Department of Education, Passed Through New York State, Department of Education: Special Education Cluster Special Education Grants to States: IDEA Part B ALN: 84.027 Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Education Preschool Grants: IDEA Preschool ALN: 84.173 Special Education Preschool Grants: IDEA 619 ARP Allocations ALN: 84.173X Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee’s compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PAR) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District prepared periodic certification equivalents, but it did not comply with Subpart E, 2 CFR §200.430. Planned Corrective Action: The District will adopt procedures that ensure that time performed will be used to support costs charged to the federal award, and comply with Subpart E, 2 CFR §200.430. Responsible Contact Person: Michael I. DeVito, Esq. Assistant Superintendent for Finance and Operations Long Beach City School District 235 Lido Boulevard Lido Beach, New York 11561 Anticipated Completion Date: June 30, 2025.

FINDING 2024-004 Finding Subject: A sample of 14 payroll population from the School's ESSER disbursement population was selected for testing to verify if the transactions were for allowable costs. An employee was paid 50% of the ESSER grant and no documentation was provided. Contact Person Responsible for Corrective Action: Greg Elkins, CFO Contact Phone Number and Email Address: (317) 485-3100, greg.elkins@mvcsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The school is assuming that time & effort documentation was required for the one individual paid 50% with ESSER funds. That is occurring now, and always has with the only current federal fund that partially pays for staffing (Title 1.) It is unknown why this individual did not archive this information as they served as the Title 1 director as well during this time. No corrective plan is needed. The grant is closed, no funds are available, no further transactions will occur from this grant. Anticipated Completion Date: 3/11/2025 (the grant is closed)

Action taken in response to finding: Program staff will continue to ensure that all timesheets are signed by the division head Name(s) of the contact person(s) responsible for corrective action: Janet Antonellis, CDBG Administrative Assistant, Svetlana Taksa, Fiscal Manager, and Lara Kritzer, Director of Housing and Community Development. Planned completion date for corrective action plan: This has been and will continue to be implemented with all future timesheets.

2024-002 Allowable Costs Recommendation: We recommend the School ensure policies and procedures for payroll expenditures for grant programs be charged to the federal grant based on approved hours worked in the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For federally funded employees, CFO will complete semiannual certifications to validate federal grant based payroll expenses. Time and Distribution logs will be used for any part time federally funded employees. Name(s) of the contact person(s) responsible for corrective action: Deborah S. Czmiel Planned completion date for corrective action plan: 05/31/2025

Management has historically maintained robust timekeeping procedures to ensure time is allocated as accurately as possible based on projected activities. However, we recognize the need for a more timely process for making adjustments from estimated to actual time worked. To address this, the new program director scheduled quarerly meetings with our external accountant, beginning in April 2025, to review and update time allocations based on actual activity> We have also requested that fringe benefits be allocated in a manner consistent with how salalries are charged to the federal grant and will review to verify. These steps will ensure that both time and fringe benefit allocations more closely reflect actual effort and remain in alignment with federal grant requirements.

The Department will conduct a formal review of its processes and policies to identify potential weaknesses in the payroll timekeeping and approval process, and will update its policies and procedures to align with the roles and responsibilities of those involved in rostering and timekeeping. The department has already taken corrective action to ensure that duty chiefs are finalizing the rosters before the end of their shift and making it the responsibility of the timekeeper to initiate action when finalization by the Duty Chiefs has not occurred so the timekeepers review process can be completed.

a. Name of Contact Person Responsible for Corrective Action: Jarrad Robinson Director of Federal Programs b.Corrective Action Planned: All employees whose salary is specifically funded with federal monies including federal grants, will be required to complete either a personal activity report (PAR) and/or a semi annual report. c.Anticipated Completion Date: Currently ongoing

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (1 instance). b) Calculation errors for expenses allocated to the grant (3 instances). c) Employee tracked 2.7 hours under the federal program and a nonfederal program line in ClickTime (1 instance) causing it to be double counted. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. An employee entered 8 hours of PTO into ClickTime for two days each; however, the employee was only paid for 4 hours of PTO for each day. The calculation errors were due to the use of a wrong employee’s allocation percentage and a keying error for payroll expenses for an employee. The secondary review of the employee ClickTime timecards did not identify the incorrectly tracked hours and double tracked time. Also, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Project Directors (Rebecca McCrackin, Missy Martini), Project Accounts Manager (Marsha Bomgaars) and CEO (Dan Ries) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Twenty-First Century Community Learning Centers ALN: 84.287 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee's compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District had not prepared periodic certification equivalents for all employees. Planned Corrective Action: The District will monitor procedures to ensure that documentation to support salaries and wages charged to federal awards is in a format that complies with the requirements of the Uniform Guidance Subpart E, 2 CFR §200.430. Responsible Contact Person: Peter Daly Interim School Business Administrator Bridgehampton Union Free School District 2685 Montauk Highway Bridgehampton, New York 11932 Anticipated Completion Date: June 30, 2025.

Dear Mr. Waguespack, Please find below the University's management response to the audit finding titled "Control Weakness and Noncompliance with Personnel Expenses Charged to Federal Awards." Management Response: The University partially concurs with the finding. The audit finding states that UL Lafayette did not perform time and effort certifications for the period January 1, 2024, through June 30, 2024. However, we clarify that these certifications were not intentionally omitted. As outlined in our prior response, the University has been transitioning from a manual to an electronic effort certification system. In the transition, we had opted shifting from a fiscal year-based reporting framework to a calendar-year-based framework. The effort certifications for the period in question are scheduled for completion by April 15, 2025, at which point they will fully support that salaries and wages charged to federal awards are based on records accurately reflecting work performed. Corrective Actions: • The University has developed a structured plan to complete the January 1, 2024 — June 30, 2024 effort certifications, ensuring compliance with 2 CFR §200.430(i), which requires after-the-fact confirmation of personnel costs. • The Standard Operating Procedure (SOP) will be updated to require biannual effort reporting, enhancing monitoring of personnel effort. • The University will retain the full calendar-year effort reports (January 1, 2024 — December 31, 2024), including the January 1, 2024 — June 30, 2024 period, electronically on file for audit and compliance purposes. Planned Actions: • Completion of Effort Certifications: The University will finalize and retain the calendar-year effort reports for January 1, 2024 — December 31, 2024, by April 15, 2025, ensuring compliance with federal regulations and addressing audit concerns. • Transition to Biannual Effort Reporting: Effective FY 2025, UL Lafayette will implement biannual effort reporting to enhance compliance and personnel effort monitoring. The updated SOP will reflect this change. • The University will make every effort to secure effort certification for Key personnel leaving the university prior to their departure. The University remains committed to making continuous improvements and appreciates your understanding and support as we address these challenges.

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office’s findings related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address the findings and provides the following response and corrective action plan. Recommendation: Management should ensure they have adequate controls over time and effort certifications, purchases, and reimbursement requests. In addition, management should ensure adequate segregation of duties covering approvals of all transaction types. Response and Corrective Action Plan: Effective FY25, LSUHSC-S has implemented an electronic Time & Effort certification system through PeopleSoft in conjunction with New Orleans. Training in the new system was provided by the New Orleans IT Department to all departmental Business Managers. Technical support questions are addressed by OSP Post Award and New Orleans IT Department. LSUHSC-S Administrative Directive 4.4 will be revised to include the new electronic process. The Office of Research Administration will hold Post-Award Monitoring meetings with all principal investigators and designated departmental staff on a quarterly basis. These meetings will begin in March 2025. During these meetings, Grant Managers from OSP Post Award will review grant ledgers to ensure that all grant accounts are reconciled monthly. Departmental Business Managers will sign off on the completed monthly reconciliations. Personnel expenditures will be included in this monthly review. Discrepancies will be reviewed with the PI and business manager for accuracy and possible corrective action plan. Prior to submission, OSP Pre-Award will provide the RPPR to the PI and Business Manager for review and certification, to ensure time and effort allocations match the current budget and PER report. OSP Pre-Award will aid Business Managers as needed. A new PER electronic system was implemented and the AD for Cost Transfer is being revised and approved. The revised AD will require greater detail in the justification for changes in source funding for salaries. Justification must meet the requirements in the revised AD. A new Standard Administrative Procedure will be implemented in March 2025 that requires all salary changes on grant accounts to be made no later than 90-days after the effective date. All requests that are greater than 90 days will be evaluated through a rigorous review process and may or may not be approved. LSUHSC-S Research Administration will ensure accurate information is available and provided to auditors upon request in a timely manner. LSUHSC-S will explore the implementation of additional PS module vendor transaction utility, such as adding more approvers, to ensure adequate segregation of duties for approval. The removal of the ability for self-approval of requisitions within the PeopleSoft requisition workflow will prevent a requestor and an approver from being the same person. A monthly report will be auto-generated and emailed (ad-hoc ability as well) to the Director of Purchasing and the Executive Director of Financial Operations. The report will list detailed requisition information to include the requestor names and approver names of requisitions created for that period for review to ensure the approval process is properly working. Name of Contact(s) Responsible for Action Plan Ramey Benfield, Chief Financial Officer, Vice Chancellor for Research Administration Jen Katzman, Vice Chancellor, Administration and Budget (with Departmental Business Managers) Tracy Calvert, Associate Director, Office for Sponsored Programs Post Award William Haacker, Assistant Director, Office for Sponsored Programs Post Award Steven McAlister, Associate Director of General Accounting Anticipated Completion Date: Continuous

Allowable Activities and Costs Health Centers Cluster – Assistance Listing No. 93.224 and 93.527 Recommendation: We recommend the Organization implement a comprehensive and thorough process to review all wages charged to federal and state grant prior to initiating a drawdown request or submitting a reimbursement request to the grantor. As part of this, the Organization should implement a process to review changes to salary and wage information as changes are made or identified.. Action taken in response to finding: The process has been changed as of July 1, 2024 and will continue forward. Name(s) of the contact person(s) responsible for corrective action: Daria Sztaba, CFO Planned completion date for corrective action plan: July 1, 2024

Views of Responsible Officials: We acknowledge the audit finding regarding the documentation of personnel time. To address this issue, we have implemented the following corrective actions and will continue to enhance our process: 1. Enhanced Training: We are providing comprehensive training to all relevant staff on the importance of accurate timesheet entry/review and the proper procedures for documenting and allocating personnel expenses. 2. Improved Internal Controls: We have strengthened our internal control procedures to ensure that timesheets are completed accurately, reviewed thoroughly, and retained properly. Allocations are additionally entered into the payroll system for further accuracy. These are reviewed and approved then entered into the accounting system. This is then reconciled to the payroll system for further accuracy. 3. Regular Audits: We are conducting regular internal audits of timesheet and payroll records to ensure ongoing compliance with documentation standards and to identify any areas needing improvement. 4. Accessible Records: We have established a system for the retention of allocation documentation in a readily accessible format to facilitate future audits and ensure transparency. 5. Addressing Turnover: We recognize that high turnover rates within the finance and program departments have contributed to these issues. To mitigate this, we will continue to focus on improving staff retention through enhanced support, training, and development opportunities, ensuring continuity and consistency in our documentation processes.

TASC of Southeast Ohio is currently reviewing all personnel files to ensure that all approved rates are included in the files. Internal controls surrounding the documentation of approvals of timesheets and pay raises are currently being implemented.

Immunization Cooperative Agreements – Assistance Listing No. 93.268 During our testing, we noted the Chapter charges benefits to the programs based on an estimated allocation calculated based on the percentage of salaries as determined in the contract budget. However, we noted the Chapter does not have internal controls in place to provide a review of the actual fringe benefits incurred. Recommendation: We recommend Pennsylvania Chapter, American Academy of Pediatrics establish a process for periodic after-the-fact reviews of interim charges made to federal awards based on budget estimates. Based on the review, management should make any necessary adjustments to the interim charges based on the results of the periodic reviews. This would ensure that the final amount charged to the federal award is accurate, allowable, and properly allocated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Chapter will implement a process for the review of interim charges made to federal awards and make any necessary adjustments that ensure the final amount charged to the federal award is accurate, allowable and properly allocated. Name(s) of the contact person(s) responsible for corrective action: Annette Myarick, Executive Director Planned completion date for corrective action plan: The planned corrective action will be completed by June 2025.

The Treasurer will ensure that the appropriate documentation supporting the time spent on a federal grant, in accordance with the Service Center’s Policy 6116 for Time and Effort, for all employees having wages and/or benefits charged to federal grants.

Finding 2024-003 – Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: For 5 selections, in a sample of 5 payroll transactions, the School Corporation did not have time and effort logs to support the portion of the employee’s time charged to the grant. The employees’ time was split with a non-federal fund; however, the School Corporation did not have support for the allocation of the time charged to the School Lunch fund. Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: 765-747-5222 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all payroll amounts recorded to food service are reviewed to ensure they represent food service payroll activity only. Anticipated Completion Date: March 2025

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Allowable Costs/Cost Principles compliance requirements. Context: During testing of the Allowable Costs/Cost Principles compliance requirements, there were two vendor vouchers in a sample of 60, where the School Corporation was unable to locate any supporting documentation. These two selections totaled $1,530 charged to the grant. It was further noted that during our testing of payroll costs charged to the COVID-19 – Education Stabilization Fund, for 2 selections in a sample of 40, the School Corporation was unable to provide any support to validate the amount of payroll charged to the grant. These two selections totaled $414 charged to the COVID-19 – Education Stabilization Fund. Corrective Action Plan: The School Corporation will establish a system of internal controls to ensure that documentation is maintained and that expenditures charged to the grant comply with the grant agreement and are allowable. Person responsible for implementation and projected implementation date: The Business Manager will be responsible for overseeing the implementation of the corrective action plan, which will go into effect immediately.

iv. Management Response and Corrective Action Plan: Program staff allocate their time spent at work each day based on their client load and recurring weekly activities, e.g., case conferencing meetings. Staff must allocate their daily time and activity hours on their timesheets corresponding to the project/s each client is enrolled in. Leave allocations should reflect each payroll period’s project time and activity actual percentages. Staff must manually record this information on complicated timesheets and consequently errors are made as not all staff are equally administratively adept. While there are multiple levels of review over timesheets, as the company has grown, it has become apparent that NBCC must integrate a more reliable method of always ensuring accurate allocation calculation of regular and leave hours. The expectation was that our new payroll solution provider, Paychex, was going to custom tailor a system that prevented such calculation errors, but this has not been the case thus far. Therefore, NBCC is actively once again researching payroll companies in an effort to find a solution better aligned with our timesheet needs. In the interim, management will work to edit our existing timesheet template to create a more user-friendly timesheet tool that auto-calculates where necessary and as appropriate so as to avoid misallocation. Management will also conduct additional timesheet trainings with staff as necessary. The end goal will be to secure a new payroll solution provider with system functionality that eliminates this kind of human error. v. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Victoria Garfield, Grants Administration Director, vgarfield@sbnbcc.org Michael Dzierski, Finance Director, mdzierski@sbnbcc.org vi. Anticipated Completion Date: The anticipated completion date of the first step of editing our existing timesheet and retraining all staff as necessary is June 30, 2025. The anticipated completion date of the second step of having an integrated new payroll system with a new payroll solution provider will be dictated by the identification of a new vendor, and the subsequent development and implementation process of the new system, with an estimated completion date of December 31, 2025.

2024-001. Allowable Costs/Cost Principles: Compensation – Personal Services United States Department of Education, Passed Through New York State, Department of Education: Special Education Cluster Special Education Grants to States: IDEA Part B ALN: 84.027 Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Education Preschool Grants: IDEA Preschool ALN: 84.173 Special Education Preschool Grants: IDEA 619 ARP Allocations ALN: 84.173X Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee's compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District prepared periodic certification equivalents, but it did not comply with Subpart E, 2 CFR §200.430. Planned Corrective Action: The District will monitor procedures that ensure that time performed as reported to comply with Subpart E, 2 CFR §200.430, be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. The District will also see that sufficient details exist regarding the duties performed by the employees whose compensation is reimbursed by federal awards. Responsible Contact Person: Reza Kolahifar Assistant Superintendent for Human Resources and Personnel Connetquot Central School District 700 Ocean Avenue Bohemia, New York 11716 Anticipated Completion Date: June 30, 2025.