Corrective Action Plans

Recommendation: Procedures should be implemented to create a materially accurate Schedule of Expenditures of Federal and State award financial statement, which should include ascertaining between loan and grant expenditures, and understanding the process for reporting loan balances on the SEFSA. Views of Responsible Officials and Planned Corrective Actions: In order to create a materially accurate Schedule of Expenditures of Federal and State award financial statement, the Authority will establish procedures to ascertain loan and grant expenditures, as well as taking into account the Uniform Guidance requirement for presenting loan balances on the SEFSA.

Research Administration will implement a new standard operating procedure to review and update labor distribution allocations on a quarterly basis to timely identify any changes required to prevent any manual adjustments in future periods. The process for effort certification has also been created to generate statements that will be verified each quarter to confirm effort allocations are correct. The Accounting department will update the review procedures for the preparation of the draft Schedule of Federal Awards (SEFA) to include an additional level of review by the Assistant Vice President, Accounting. Her review process will include a focus on manual adjustments if required to reconcile the draft SEFA to the underlying general ledger accounting details to ensure the completeness and accuracy. Corrective action to ensure timely effort reporting changes will be complete by November 30, 2024. Corrective action to ensure a complete and accurate SEFA will occur during the preparation of December 31, 2024, draft SEFA.

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-003 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the City prepare financial statements that reflect its financial position, results of operations or changes in net position, and, where appropriate, cash flows for the fiscal year audited, including the Schedule of Expenditures of Federal Awards (SEFA) for the year ended December 31, 2023, which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. Management is responsible for establishing and maintaining effective internal controls over compliance with requirements applicable to federal programs, including separately tracking federal expenditures within the finance system to provide for accurate preparation of the SEFA. Corrective Action Plan Actions Planned – The City plans to review its internal control procedures over reporting and verify completeness of expenditures reported on the SEFA in the future. Official Responsible – Sally Vogel, Finance Director. Planned Completion Date – December 31, 2024. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – Sally Vogel, Finance Director, will continue to work with staff to review its internal control procedures over reporting and verify completeness of expenditures reported on the SEFA in the future.

2023-003 Reporting Compliance Requirement Finding Summary The School did not have sufficient controls in place to ensure completeness of the Schedule of Expenditures of Federal Awards (SEFA) and compliance with this requirement. The School’s SEFA was understated by $507,980 in federal expenditures related to the Comprehensive Literacy Development federal program. Corrective Action Plan Actions Planned – The School has implemented new processes and procedures in 2024 which address this internal control finding to comply with the Uniform Guidance in the future. Official Responsible – Matthew Cisewski, Executive Director. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The School agrees with this finding. Plan to Monitor – The School’s Executive Director, Matthew Cisewski, will ensure the new process and procedures implemented address internal controls and procedures in this area to ensure future federal grant compliance.

2023-001: Congressional Directives SEFA Reporting Federal Agency: Department of Health and Human Services (“HHS”), Health Resources and Services Administration (“HRSA”) Assistance Listing Program Title: Congressional Directives Federal Award Project Title: Community Project Funding/ Congressionally Directed Spending ‐ Construction Assistance Listing Number: 93.493 Federal Award Identification Numbers: CE146569, CE152406, CE152466 Management acknowledges that during the fiscal year ending December 31, 2023, Jamaica Hospital Medical Center (“Jamaica”) did not properly apply the accrual basis of accounting for the Congressional Directives Grant, which affected the accuracy of reporting on the Schedule of Expenditures of Federal Awards (SEFA). To prevent future errors in SEFA reporting related to the accrual basis of accounting, Jamaica will implement the following controls and procedures: 1. Appointment of Grant Coordinator In 2024, James Farrell was hired as the Assistant Director of Development and Contract Management. Mr. Farrell will serve as the primary coordinator for all grant-related requirements, ensuring expenses are reported on the accrual basis of accounting on the SEFA. 2. Implementation Timeline These controls and procedures will be fully implemented by the end of the third quarter of 2024. Management responsible for corrective action plan: James Farrel, Assistant Director of Development and Contract Management (jfarrel1@jhmc.org) Manzar Sassani, Vice President of Finance (msassani@jhmc.org) Mark Abboud (maboud@jhmc.org) Yesenia Torres (ytorres@jhmc.org)

Condition: The schedule of expenditures of federal awards (SEFA) was not complete and accurate. Planned Corrective Action: The Albion College Business Office has established revised procedures for SEFA funds, in tandem with the Financial Aid Office, in which all Federal Awards and Grants will be reconciled on a quarterly basis, to be completed no later than the end of the first proceeding month of the quarter. The procedures create a dual-control process for the drawdown, recordation, and reporting of SEFA funds. Additionally, in FY24, the Perkins portfolio was divested. The Perkins Close-out will be part of the FY24 Single Audit. Contact person responsible for corrective action: W. Scott Roberts Anticipated Completion Date: 06/30/2024

Appendix A - Management’s Corrective Action Plan Year Ended December 31, 2023 2023-001 Significant Deficiency in Compliance and Internal Control over Compliance with Reporting (Preparation of the Schedule of Expenditures of Federal Awards) Corrective Actions: 1. Utilize attribute/field in accounting system: • Leverage the existing attribute/field in the accounting system to capture R&D/cluster classification information for each federal award. • Completed 2. Provide training and awareness: • Educate relevant staff on the importance of accurate award classification, including the criteria for R&D/cluster classification and procedures for tracking and SEFA reporting. • Initial training completed; ongoing regular sessions planned 3. Reinforce award classification during award setup: • Ensure award classification is consistently considered and accurately captured during the award setup process. • Provide clear instructions and reminders to encourage staff to complete this critical step. • Ongoing 4. Regularly review and verify award classifications: • Perform regular internal audits, reviews, and verifications to ensure award classifications are accurate, consistent, and compliant with established procedures. • Ongoing, with initial review completed within 90 days Individual(s) Responsible for Corrective Action Plan Name: Robert M. Buchanan Position: Vice President, Controller, and Treasurer Contact number: (202) 261-5322

No response was provided.

2023-004 – SEFA REPORTING Recommendation: We recommend that the Council implement controls over financial reporting, including the SEFA, to ensure the accuracy of financial data. Action Taken: As part of the agreement with Matheny and Company, the Senior Manager will review all period-end documents and financial reports to ensure that transactions, including SEFA documentation, are recorded and reported in the correct fiscal year.

Community Development Block Grants – Assistance Listing No. 14.228 Recommendation: We recommend that the Council record federal expenditures on the SEFA under the program in the year upon which the loan disbursement occurs using the proper report from NLF’s loan management software. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal Office will work with the Program Director to ensure the proper report is used to identify actual loan disbursements, rather than agreed upon loan amounts, if different, for future SEFA preparation. Name(s) of the contact person(s) responsible for corrective action: Anita Cameron, NLF Director and Becky Walter, Finance Director Planned completion date for corrective action plan: December 31, 2024

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-005 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the Academy prepare appropriate financial statements, including the Schedule of Expenditures of Federal Awards (SEFA) for the year ended June 30, 2023, which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. Management is responsible for establishing and maintaining effective internal controls over compliance with requirements applicable to federal programs, including separately tracking federal expenditures within the finance system to provide for accurate preparation of the SEFA. During our audit, we noted the Academy did not have sufficient controls in place to ensure completeness of the SEFA and compliance with this requirement. The Academy’s SEFA was understated by $158,815 in federal expenditures related to the Emergency Connectivity Fund federal program. Corrective Action Plan Actions Planned – The Academy will implement new processes and procedures which address this internal control finding to comply with the Uniform Guidance in the future. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will assure appropriate internal controls and procedures are in place to ensure compliance with reporting compliance requirements in the future.

The Township will establish controls to determine federal revenues and if an audit under the Uniform Guidance is required. The anticipated completion date is June 30, 2024.

Responsible Party: JCCS PC & Sara Hudson Anticipated Completion Date: February 29, 2024 Corrective Action Plan: For the fiscal year ending June 30, 2023, the organization prepared a draft of the SEFA with the intent of finalizing it with the assistance of the auditor. We were unaware this would result in a finding in the audit. The organization will work with JCCS PC going forward to independently prepare the annual SEFA.

FINDING 2023-001 Individual Responsible for Corrective Action Plan: Shelby Mahoney/Alliance Fiscal Agent Team in conjunction with the Alliance Director/grant management team Corrective Action: Management will review SEFA for proper inclusion of all federal grant expenditures, and Alliance Director will ensure all invoices are properly coded to grants as applicable. Anticipated Completion Date: December 31, 2024

Management Response: The Tulare County Regional Transit Agency (TCRTA) is working to ensure creation of a ledger that establishes internal control by specifying multiple departments and units. The creation of this ledger will ensure that incoming revenue is properly recorded whereas on the expenditure end TCRTA will work to book expenses in a correct fashion whereby tagging back to the restricted unit thus facilitating the flow of restricted revenues appropriately with matching expenditure. Views of Responsible Officials and Corrective Action: The Tulare County Regional Transit Agency (TCRTA) will ensure multiple levels of review before submitting Federal and State expenditures to the auditor-controller/treasurer-tax collector’s (ACTTC) Office for reporting purposes. This will include detailed reviews of the expenditures to ensure they are categorized appropriately and recorded accurately. TCRTA will coordinate ACTTC Office to provide additional training to staff regarding reporting requirements, and TCRTA will implement additional review procedures when compiling the Financial Closing and Reporting Process and either directly or indirectly compiling the Schedule of Expenditures of Federal Awards (SEFA).

Condition: The FEMA expenditures on the schedule of expenditures of federal awards (SEFA) initially presented for audit were not complete and accurate. Planned Corrective Action: Seek training from our auditors on the proper recording of obligated expenditures. Contact person responsible for corrective action: Laura Randall Anticipated Completion Date: 06/14/2024

We agree that, due to data entry errors, the SEFA provided at the start of the single audit did not include the appropriate and applicable federal expenditures. We will be more diligent in the preparation of the SEFA to help prevent the potential for inadvertently misrepresenting the total federal expenditures and avoid the necessity for adjustments to the SEFA in future audits. At the issuance of the reports, we have enhanced our internal controls and processes related to the preparation of the SEFA to prevent this situation in future years. Our goal is to eliminate any errors to ensure that all applicable federal expenditures are complete and accurate.

2023-002 [2022‐002]—PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presented in Schedule of Expenditures of Federal Awards. Award Number and Program Award Year: All presented in Schedule of Expenditures of Federal Awards. Compliance Requirement: Other – Schedule of Expenditures of Federal Awards preparation Statement of Condition During our audit, we reviewed the Coalition’s federal grants report for the fiscal year and identified the federal grants, Assistance Listing #s (AL#s) and the amounts of the federal expenditures and all of the other items required to properly present the Schedule of Expenditures of Federal Awards (SEFA). We then had the finance staff of the Coalition confirm the correctness of the SEFA. Despite the confirmation of accuracy, additional federal expenditures and grouping of grant expenditures were identified after several reviews of the SEFA.Criteria 2 CFR 200.510 indicates that the auditee must 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 2 CFR 200.502, Basis for Determining Federal Awards Expended. Per 2 CFR 200.502, the determination of when a federal award is expended should be based on when the activity related to the federal award occurs. Generally, the activity pertains to events that require the non-federal entity to comply with federal statutes, regulations, and the terms and conditions of federal awards, such as expenditure/expense transactions associated with awards. In addition, 2 CFR Part 200.303 requires the program to establish and maintain effective internal controls over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of federal awards. Effect Without an established process governed by effective internal controls, the Coalition may not prevent or detect material misstatements on its SEFA in a timely manner. In addition, the errors could result in improper selections of major program(s) for the single audit and a substandard single audit. Cause Historically, the Coalition has requested the auditor assist in identifying accruals related to federal grant expenditures as the organization has maintained these records on a cash basis. As the organization has taken more responsibility on maintaining its federal grant expenditures on an accrual basis, an incomplete SEFA has been provided. Recommendation We recommend the Coalition prepare the Schedule of Expenditures of Federal Awards and submit this to the auditor for testing. The SEFA should include the name of the grant, name of grantor, the AL #, the pass-through number if applicable and a reconciliation of the federal revenues and expenditures to the Coalition’s general ledger. The Coalition staff should perform more detailed reviews of the reports to ensure they properly reflect grant receipts and expenditures. This review should be performed by someone other than the preparer and should include documented evidence of agreeing the reported data to the accounting records. We further recommend training for those individuals involved in the preparation and review of the reports to ensure they are fully aware of the requirements. View of Responsible Officials and Corrective Action Plan: The corrective Action Plan will be carried out in the 2024 Fiscal Year and information will be given to the auditors when requested for the next audit. The Coalition will ensure that all information needed for the SEFA is kept and entered accurately (this process has already begun). When the fiscal year closes out, the Coalition will provide the auditors with a test SEFA to confirm that the information we are collecting throughout the year and are asserting are the correct numbers for our federal grants, is indeed the correct information. Corrective Action Plan Timeline: Completed by December 13, 2024 (Final copy of the SEFA will not be given to the auditors until requested for the 2024 Audit) Designation Of Employee Position Responsible For Meeting Deadline: Executive Director will oversee this project and work directly with NMCEH finance staff work closely with the auditors to make sure that the information saved and shared is correct. Type of Finding: (F) Significant Deficiency in Internal Control over Compliance of Federal Awards. Questioned Costs: None

We take the findings and recommendations of the disinterested third party auditor very seriously. Going forward, all federal awards will be reconciled quarterly to ensure they comply with the Schedule of Financial Assistance and individual grant funding requirements. We will work with our auditors early to determine acceptable documentation requirements and do random sampling internally, throughout the year, to determine appropriateness of all cash receipts, general expenditures, payroll expenditures, and allocated costs.

Actions Planned – The City will continue efforts to appropriately identify whether funding is federal, state or locally sourced and properly account for the funds. Official Responsible – Amy Sevig, Deputy Finance Manager Planned Completion Date – December 31, 2024 Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – Amy Sevig, Deputy Finance Officer, will oversee the process to ensure the City is in compliance with reporting requirements.

MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN Finding 2023-001 – Federal Award Omitted from Schedule of Expenditures of Federal Awards Award: Medical Assistance Program Federal Agency: Department of Health and Human Services Assistance Listing Number: 93.778 University of Alabama Health Services Foundation, P.C. Management acknowledges and agrees with the finding as presented. Dating back to FY 2020, a single grant was improperly omitted from the Schedule of Expenditures of Federal Awards (the “Schedule”). Upon identification of this omission, Management reached out to the respective pass-through entity. In June 2024, Management corresponded with the Office of Contracts and Grants at the Alabama Department of Mental Health to discuss the finding and reached an agreement that prior year reports would remain unchanged and the Schedule for the year ended September 30, 2023, would only present the current year expenditures of the grant. In June 2024, we incorporated a comprehensive review and reconciliation of all amounts recorded in a fiscal year. This captured federally sourced revenue and expenditures recorded throughout the institution and were to be reported on the Schedule. Further, funded sources identified through this reconciliation were reviewed in depth to confirm federal financial compliance requirements are being met or were corrected immediately. Education to key stakeholders also took place to spread awareness of the compliance requirements regarding federally funded sources that are to be reported on the Schedule. At the completion of each fiscal period, grants accounting, in collaboration with general accounting, will prepare a comprehensive reconciliation of grant revenue recorded throughout the organization. Grant accounting and general accounting personnel will jointly review any and all changes to grant contracts to identify payment changes. Funding sources will be reviewed in depth to confirm federal financial compliance requirements are being met.

The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation from PMS will provide a history of the approval flow. Accountants will not have the authority to certify the reports in PMS. The HSSC Comptroller, the Accounting Manager, the AFO and the Budget Staff will perform a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and appropriately identify expenditures for subrecipients, if applicable. Additionally, DBH is working with OCP (Office of Contracting and Procurement), to attach to DC Health’s contract to implement a grants management system that is on the Salesforce platform. The system will automate workflow and enable “alerts” to notify users when reports are due. If the notification is not acted on, the system will automatically escalate the alert to senior management. In the interim, DBH is working through the Districts Grants Management Advisory Board to identify DIFS reports (e.g., DIFS report for FFATA, Subrecipient Grant Report R071). To note, all programmatic data that was used for the PPR was available to the auditors. The supporting documentation for the chart that included spending for administrative and data costs had not been saved, which was the source of the finding. Contact - FAPIIS and FFATA: Renee Evans Jackman, Director of Grants Management, FFR (SF-425) and SEFA: Barbara Roberson, HSSC Accounting Officer, PPR: Sharon Hunt, State Opioid Treatment Authority Estimated Completion Date - Grants Management System is due to be implemented on January 1, 2025. See Corrective Action Plan for chart/table

The Department of Employment Services (DOES) concurs to this finding. Management is committed to closely monitoring the PNG clearing account and implementing timely adjustments at the source as necessary. We will also evaluate and enhance internal controls pertaining to subledgers and the General Ledger (GL). Regular reconciliations, reviews, and adjustments will be conducted to ensure alignment between subledger and General Ledger amounts, and to maintain consistency between SEFA amounts and Federal reports. The fiscal year 2023 SEFA has been revised to accurately reflect federal expenditures, and management will ensure ongoing compliance with established controls to ensure the fair presentation of SEFA data moving forward. Contact - Shilonda Wiggins, Agency Fiscal Officer Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

2023-005 - Internal Control Over Compliance and Compliance – Reporting (Preparation of the Schedule of Expenditures of Federal Awards) Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: December 2024 Management’s Corrective Action Plan NGA has begun to produce quarterly versions of the Statement of Federal Awards (SEFA). This routine process has enabled staff to proactively identify new awards and lapsed agreements to keep the SEFA current. Given the importance of this schedule to NGA’s continued management of federal funds, we have emphasized and trained staff to follow all applicable federal requirements when managing funds on this schedule. We expect our action plan to continue until December 2024 as we have encountered several issues this fiscal year that required reconciliation of prior years.

Finding Number 2023-001: Allowable Cost/Cost Principles: Grant Award Period Year Ended December 31, 2023. Condition: In testing performed under Air Forces Defense Research Sciences Program, the Auditors indentified a deficiency that was the result of subrecipients expenses being recorded in accordance with GAAP rather than CFR compliance for the purposes of the single audit. (SEFA). View of Responsible Officials and Planned Corrective Actions: Management concurs with the finding. The Organization revised its review procedures and controls so that subrecipient expenditures are recorded in the proper accounting fiscal year according to 2 CFR Part 200 Subpart F section 200.502, whereby amounts will be reported as expended when the disbursement is made to the subrecipient for single audit purposes. These steps should correct the deficiency. Contact Person: Stephanie Peluso, Senior Staff Accountant Finance (760-802-7554) and/or Diane Peluso, Senior Contract Advisor (760-522-5300) Propsed Completion Date: This action plan was completed on 5/17/2024.