Corrective Action Plans

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

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).