Corrective Action Plans

Corrective action planned – The Organization will reinforce and expand its policy of reviewing contracts for federal awards to include development properties and other forms of non-standard expenditures including non-cash assistance and loans. These policies and procedures will be added to the year-end financial statement reporting checklist which is reviewed and monitored by the Controller. During this process, the staff member assigned to completing the schedule of federal expenditures (currently the senior fiscal program analyst), will communicate with risk management to review incoming contracts during the year, as well as at year end to ensure that federal monies are accounted for, and that significant unusual transactions will be accounted for. The staff member assigned to completing this report will also communicate it to the Controller for review. Name(s) of contact person(s) responsible for corrective action – Richard Sroka, Senior Fiscal Program Analyst in charge of grant reporting Anticipated completion date – Implemented.

Finding 2023-004- Lack of Effective Controls Over Preparation of Schedule of Expenditures of Federal Awards Grantor: U.S. Department of the Treasury Assisstance Listing#: 21.027 Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Award Year: Fiscal year 2023 9/1/22-8/31/23 Award Number: Not Listed Management understands the importance of effective internal controls over the preparation of the Schedule of Expenditures of Federal Awards (SEFA). At the time of preparing the 2023 SEFA, $2 Million was improperly excluded causing the reported to be restated. Corrective Action Plan and Anticipated Completion Date: The total expenditures reported in error for the 2023 SEFA will be restated and the consolidated Financial and Compliance Report in Accordance with the Uniform Guidance will be re-sibmitted to the appropriate federal and state agencies. On a go forward basis, management's review will include a reconciliation of all grant expenses reported on the current SEFA to the grant awards listed on the State of Illinois Department of Public Health (IDPH) grant portal (EGrMS) to ensure all federal awards are reported.

Action Taken: Management is in the process of instituting additional procedures to ensure all awards are assessed not only to identify whether sources of funds are Federal, requiring inclusion on the SEFA, but also to identify continuing compliance period when applicable. Management has also conducted internal training relative to applicable 2 CFR 200 regulations and requirements and will continue to provide periodic staff training to ensure continued compliance. Anticipated Completion Date: Management estimates that additional processes will be in place by December 31, 2024.

Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with CFR Section 200.502(a) and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Planned Corrective Action: County management will develop a closing process to ensure all federal expenditures are identified, recorded, and reconciled on the SEFA. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

The Alliance team will establish a review process to verify the accuracy and completeness of the SEFA before submission. BGCA will utilize a checklist or other tools to ensure all required information is included in the SEFA.

Material Weakness over Schedule of Expenditures of Federal Awards (SEFA) Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is “live” as of August 2022, the City is currently working to refine the software and fully utilize functionality. The Workday grants modules requires the grant funding source be defined prior to grant approval and fields are available for the AL titles and numbers and sub-recipients’ information. The implementation of the Workday grants modules centralizes much of the grant management function by requiring the agencies to upload the grant documents into Workday. The City has: • Held weekly meetings for two years with agency grant representatives to design and configure the Workday grant module. • Uploaded the grant award, sponsor information and grant budget data into a Workday. • Implemented a “new grant” request which uses a Workday business process. • In the process of reviewing and correcting recoverable costs per grant award so it is properly recorded. • Within Workday we are able to track grant performance period, CFDA, manage and capture grant related expenditures and calculate automated billing to sponsors on recoverable costs Business processes have been developed and implemented in Workday’s grant management module to include: Definition of the grant funding source by creating a system-generated grant work tag (identifier) upon receipt of the Sponsor’s Notice of Award; populated fields in Workday with passthrough award data with Prime Sponsor and Bill to sponsor Billing data, and modification of the create award process to add the Grants Management Office to final approval. In FY 24 the City implemented a citywide Grants Management Committee coordinated by the Mayor's Office of Performance and Innovation. Through feedback from this workgroup we identified an expanded scope of responsibility for the Grants Management Office; including oversight and compliance, technology, training and budget monitoring. In the short term a new Grants Director position was created and onboarding is to occur in the first quarter of FY25. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City. Completion Date: June 2024

Condition: The Authority did not identify that they were subject to an audit under the Uniform Guidance (U.G.) and a schedule of expenditures of federal awards (SEFA) was not prepared by management. Recommendation: The Authority should review federal, state, and local grants to determine if they are federally funded and, if federally funded, utilize the account number outlined in the State of Michigan chart of accounts to track federal funding. Planned Corrective Action: A schedule of federal awards will be created to track total costs covered by federal awards beginning in FY24. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

The Treasurer will review the Schedule of Expenditures of Federal Awards to ensure all federal awards are being reported and the expenditures are properly reported.

Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Finding: 2023-011 Contact Person: Sarah Castillo Grants Accounting Officer Emergency Operations Center (EOC) Finance Division Phone: (562) 570-5479 Email: Sarah.Castillo@longbeach.gov Planned Actions: The Emergency Operations Center (EOC) Finance division acknowledges there has been deficiencies in the manner we report expenditures related to a declared disaster on the SEFA, which will be addressed by issuing a Financial Management Disaster Procedure Manual that will include a narrative on this specific matter. The manual will be published on our City Intranet and utilized for all City Staff as a resource for all future disasters that occur. Revisions to the Procedure Manual will be made as needed to ensure we are up to date with the latest compliance changes. Expected Completion Date: 12/31/2024

2023-004 Preparation of and Internal controls over Schedule of Expenditures of Federal Awards Preparation (Material Weakness) Federal Agency: U.S Department of Education Program Name: Education Stabilization Fund Assistance Listing Number: 84.425 Award Period: June 30, 2023 Recommendation: The Board of Education and management should review the financial reporting process. Once this review is complete, the District should then perform a risk assessment to determine the best way to implement appropriate internal controls over financial reporting to ensure that the District prepares the schedule conformity with Uniform Guidance. Action Taken (Unaudited): Management plans to work with a third-party consulting firm to address issues and improve protocols. Contact Name – Dr. Jessica Dain Expected Completion Date - 12/31/2024

Individuals Responsible for Corrective Action Plan: BGCA Fiscal Team-Shelby Mahoney; Alliance Director Corrective Action: Review all federal grant contracts to determine if any separate funding sources should be listed for total funds received. Anticipated Completion Date: December 31, 2024

2023-008 - Significant Deficiency in Internal Control and Non-material Noncompliance - Schedule of Expenditures of Federal Award Awareness and Preparation WPHW understands this finding and has already taken steps to ensure this issue does not come back up for FY24. The follow process has been put in place to ensure compliance: 1) Director of Accounting and Grants Director will ensure they have appropriate training and work collaboratively to develop documentation process a. The Grant Director will update all grants as they are received, to ensure an accurate list of grants b. The Director of Accounting will update all of the financial data for each grant 2) The Director of Accounting will be responsible for the review and submitting document to the auditing firm For FY24, the Director of Accounting and Grant Director will jointly build the document and review to ensure completeness and accuracy. In FY25, the schedule of expenditures of federal award will be prepared as the year progresses.

Finding 2023-002 Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 21.027 / 93.778 / 93.914 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reporting

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

2023-001 – Preparation of the Schedule of Expenditures of Federal Awards Individual Responsible for Corrective Action Plan Jennifer Maher, CFO Londilia McCoy-Scott, Director of Contract and Grant Accounting Anticipated Completion Date: December 31, 2024 Corrective Action Plan: In reconciling the 2023 grant expenditure activity, management identified that some grant expenditures from 2022 were not included in the 2022 Schedule and self-disclosed this anomaly to the auditor. These expenditures were then incorporated in the 2023 Schedule to ensure that they were reported as timely as possible. Grants management staff from Finance and Program departments are meeting monthly to ensure that the expenditures are recorded in the appropriate year.

Individuals Responsible for Corrective Action Plan: BGCA Fiscal Team – Shelby Mahoney, Senior Accounting Manager Corrective Action: Alliance team will enhance procedures and internal controls with respect to preparation and review of the SEFA by reviewing detail of expenses included in prior year with current year expenses, to prevent duplicate entries being reported. Anticipated Completion Date: December 31, 2024

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-004 Significant Deficiency in Internal Control—Schedule of Expenditures of Federal Awards (SEFA) Program(s): National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: • $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. • $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. • $626,894 of expenditures related to ALN 93.563 was missing from the schedule. • $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Hennepin County’s Corrective Action Planned in Response to Finding: The County will continue to strengthen controls over the preparation of the SEFA. Hennepin County Employee Responsible for the CAP: Elena Doran Planned Completion Date for CAP: September 30, 2024

During our review of the December 31, 2023 Schedule of Expenditures of Federal Awards (SEFA) prepared by management, we noted that controls over the preparation of the SEFA were not properly designed resulting in adjustments to the SEFA for amounts passed through to subrecipients that were identified during the audit. Recommendation: We recommend management review current internal controls over preparation and tracking of federal expenditures to ensure that all federal awards are captured and reported in the correct period and that internal controls are properly designed to detect and correct errors to the SEFA. Views of Responsible Officials and Planned Corrective Action: ACT accepts the auditors' recommendation. In preparing the SEFA for future Single Audit periods, ACT will update its processes to include a more rigorous review of the SEFA schedule prior to submission to the auditors. The process will include preparation of the SEFA by ACT’s accounting team, followed by a review and signoff by ACT’s Program Officer and the CEO. An internal schedule prepared by the accounting team that totals amounts separately for beneficiary payments and for subrecipient pass-through payments will be included as part of the review process for the SEFA and presented for signoff by the Program Officer and CEO. For further discussion, please contact Heather Peeler, President and CEO at healther.peeler@actforalexandria.org. 703-739-7778.

Condition: The total amount of expenditures originally reported on the SEFA excluded $1,024,472 of expenditures related to the Congressional Directives program. Planned Corrective Action: Livingston County will implement a review process going forward to ensure all expenses are included on the SEFA. Contact person responsible for corrective action: Cynthia Arbanas, Deputy County Administrator Anticipated Completion Date: 12/31/2024

Management will strengthen its processes and internal control to ensure that report of expenditures is reviewed by Finance prior to submission and only includes expenditures incurred in the period. In addition, Management will amend its procurement policy to ensure the policy includes the required regulations as outlined in the Code of Federal Regulations in relation to Federal Awards and that all relevant documentation will be retained. Christopher Caulfield, Executive Director of Financial Operations, will effectuate the corrective action plan, which is anticipated to be completed by December 31, 2024. caulfieldc@sjhmc.org 973-754-2016

Management recognizes the importance of maintaining proper documentation for grant expenditures and has implemented the following corrective measures to address the deficiency: 1. Development of Comprehensive Documentation Guidelines: We have developed detailed guidelines outlining the specific documentation requirements for all grant-related expenditures. This includes mandatory documentation such as receipts, invoices, contracts, and timekeeping records, as well as detailed descriptions of each expense. 2. Centralized Repository for Grant Documentation: A centralized, secure digital repository has been established to store all grant-related documentation. All departments are now required to upload supporting documents immediately after incurring expenses, ensuring they are readily accessible for review and audit purposes. 3. Staff Training on Documentation Requirements: We have initiated a mandatory training program for all fiscal staff involved in grant management. This training covers the specific documentation and reporting requirements for federal, state, and private grants, emphasizing the importance of complete and accurate records. 4. Strengthened Review and Approval Process: We have enhanced the internal review process for grant expenditures. All grant-related transactions will be subject to a secondary review by the controller and Chief Financial Officer to ensure that the necessary supporting documents are included and expenditures are properly classified and documented. Management will closely monitor adherence to the new documentation policies and conduct quarterly audits to assess the completeness and accuracy of the records. Any discrepancies or missing documentation will be addressed promptly, and corrective actions will be taken to prevent recurrence. Management is fully committed to maintaining detailed and accurate records for all grant expenditures. The actions outlined above are designed to strengthen internal controls, ensure compliance with grant requirements, and support future audits with comprehensive documentation.

To address the identified weaknesses and strengthen internal controls over the preparation of the SEFA, management has initiated the following actions: 1. Establishment of Formal Policies and Procedures: We have developed and implemented a formal, written policy for the preparation and review of the SEFA. This policy outlines clear roles, responsibilities, and timelines for all departments involved in the process. 2. Centralization of Data Collection: We are centralizing the process of collecting expenditure data, which will be overseen by a designated team within the fiscal department. This will ensure consistency and accuracy in reporting across all departments. 3. Staff Training and Development: Key personnel involved in SEFA preparation are undergoing specialized training on federal, state, and city compliance requirements. This includes training on the proper classification of awards and expenditures. 4. Internal Review and Monitoring: A second layer of review has been introduced to verify the accuracy and completeness of the SEFA before it is submitted. A senior financial officer will perform this review, ensuring that any discrepancies are identified and corrected before submission. Management will implement ongoing monitoring to ensure adherence to the new policies and procedures. Quarterly reviews will be conducted to assess the accuracy of the data and the efficiency of the control measures. Management is committed to maintaining robust internal controls over the preparation of the SEFA to ensure the timely and accurate reporting of federal, state, and city awards. The actions outlined above are designed to prevent the recurrence of this deficiency and ensure full compliance with regulatory requirements.

Management Response Expenditure amounts in the Schedule of Expenditures of Federal Awards (SEFA) included reimbursable costs allocable to the contract only. Revisions were made during the audit process for costs in excess of the contract award amount and post award costs. Identification of subrecipients vs contractors is addressed in the response to finding 2023-005. The new monitoring policy includes the difference between the two and provides for education in identifying the services appropriately. Corrective Action Plan This was the first time the organization had to prepare the SEFA and was inexperienced in the requirements. The Garden has hired a new Director of Finance who will attend training specific to federal grants reporting in order to ensure that the 2024 SEFA is prepared correctly. The Garden has now documented its Federal Subrecipient Monitoring Policy. Education on and reverification of proper processes regarding federal subrecipient monitoring transactions will be taken by all principal investigators. Contact person(s) responsible for the corrective action: Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org. Anticipated Completion Date: The Director of Finance is registered for a September 2024 training on federal grants. The subrecipient policy is in writing. Education on that policy will be complete by August 31, 2024.

Corrective action plan: The Department will work with their accounting consultant to properly prepare the SEFA. The Department will verify all Assistance Listing Numbers and make all necessary adjustments prior to submitting the SEFA to the auditors. Personnel responsible for corrective action: Lisa Donham (Finance Manager) and contracted CPA consultant Estimated corrective action completion date: February 28, 2025

Description of Finding: The Schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Statement of Concurrence or Nonconcurrence: The audit was not submitted on time. Corrective Action: Staff turnover contributed to the need for multiple adjustments after the fact. Of the five positions within the department five were vacated within a 12 month period. During and leading up to the closing of the FY 22/23 year, a complete turnover of staff occurred including all senior staff within the Finance Department. There were a number of journal entries that required a depth of historical knowledge to perform properly as many of the capital projects associated with the SEFA are multi year. Budgeted large transfers and project transfers complicated the process of closing projects and funds. To reduce the need for as many audit adjustments, a new process was implemented during the FY 23/24. Payroll and invoices are being direct billed to the funds and projects to reduce the need for unnecessary transfers. This step will simplify the structure of funds. This standard accounting practice will enable staff to reconcile, evaluate, and accrue much more timely and accurately. Name of Contact Person: Aimee Beleu, Finance Director, (530) 872-6291, abeleu@townofparadise.com Projected Completion Date: 4/1/24