Corrective Action Plans

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.

2023-002 – Internal Control over Compliance and Compliance with Period of Performance Contact Name – Jeff Kaufman Position – Global Controller Contact – jkaufman@corusinternational.org Estimated date of completion: September 30, 2024 Corrective Action Plan – Corus management concurs with this finding and reaffirms its commitment to responsible stewardship of funding awarded to Corus by the United States Government and other donors. There are occasions when Corus may anticipate successfully negotiating a program extension with the USG or other donors. In the event there are immediate needs of the program’s potential beneficiaries, Corus may decide to utilize its own unrestricted funds in expectation that if the extension is obtained, these funds will be reimbursable under the terms of the extension. Corus recognizes that there is no guarantee that the program will be extended; thus, it understands that it incurs the expenses at its own risk. As a point of emphasis, while the expenses referenced in this finding were incorrectly coded such that this spending was erroneously included on the SEFA, Corus did not draw on USG funding to recover these expenses, the expenses were funded by Corus’ own unrestricted resources. Action steps to be implemented during the Corus 2024 fiscal year include: • The steps outlined in response to 2023-01 should also ensure proper account coding of expenses and timely monitoring of program spending against available obligated funds as well as program expiration dates.

2023-002 - Internal Controls Over Compliance and Compliance with Reporting - Preparation of the Schedule of Expenditures of Federal Awards Contact Name: Charlie Feeney Position: Chief Financial Officer Telephone Number: (202) 796 2496 Corrective Action Plan – Management is establishing additional review procedures to ensure that SEFA schedule is accurate and fairly stated when submitted. Estimated Completion – September 30, 2024

In response to the reported deficiency of internal controls over compliance with the preparation of the Schedule of Expenditures of Federal Awards (SEFA), ANSER will implement the following Corrective Action Plan:

1.      During the Kick-Off meeting of new awards or modifications, the contracts staff will provide the proper Federal Assistance Listing Number (FALN) to be associated with the new activity from the Catalog of Federal Domestic Assistance produced in SAM.gov by the GSA.

2.      Accounting staff will include the FALN in the Project Setup in the Project Accounting system.

3.      ANSER will also perform a more rigorous review of all elements of the SEFA in advance of submitting the document to external auditors. This will include participation by contracts and accounting staff.

Individual(s) Responsible for the Corrective Action Plan: Rick Clark, Corporate Controller, Kate Edwards, Director of Contracts & Pricing.

Anticipated Completion Date: May 2024

Ryan White HIV/AIDS Program Part A SEFA reporting Management’s Views and Corrective Action Plan Management’s Views and Opinion Sunset Park agrees that the draft SEFA amount for this program was not reflective of the total reimbursement received under this award. Sunset Park also agrees with the recommendation to ensure that grants reimbursed by methods other than cost reimbursement are reported and aligned with deliverable or allowable activities for SEFA purposes. Corrective Action Plan Sunset Park will conduct semi-annual reviews in January and May for awards that are not based on cost reimbursement. The purpose of these reviews is to ensure that the amounts reported on the SEFA align with the allowable activities that are not based on cost reimbursement. This process will ensure proper reporting that is in line with the reimbursement policies of the granting agency. Furthermore, the Director of Grants and the Grants Fiscal Team will review all award terms to ensure an accurate reporting structure for accounting and SEFA reporting purposes. Timeline for Action Plan Date of Completion: 08/31/2024 Responsible Individual Leonardo Arias Email: Leonardo.Arias@nyulangone.org

Tapestry 360 Health will improve the timely submission of the Single Audit Reporting Package by ensuring that grant programs are tracked and reported in detail monthly, resulting in fewer errors for the SEFA. Tapestry will also perform a hard close semi-annually that will allow us to perform a mid-year analysis and reconciliation. Furthermore, contracts will be stored in a central, organized manner to facilitate the consistent use of the documents as reference. Finance and the Grants Development team will meet monthly regarding grant programs to review dates, terms, budget, for each program. The anticipated completion date to correct the Finding 2023-002 is August 15th, 2024.

Tapestry management will review the SEFA and its corresponding contracts to aide in the attestation of compliance. To further enhance timely submission, Tapestry will use technology and automation to aid the tracking and organization of grant programs. Technological upgrades include using the general ledger to uniquely identify Federal grants and enhance fiscal reporting, using software to store and organize contracts. The anticipated completion date to correct the Finding 2023-004 is August 15th, 2024.

Prior to submitting the SEFA each year, a Staff Accountant in ATCC’s Finance & Accounting team will prepare the SEFA, it will be reviewed and approved by ATCC’s Federal Solutions Finance team and the CFO/Controller for completeness, accuracy, and compliance with CFR Section 200.510(b), confirm consistency with the trial balance, and correct any inconsistencies prior to submitting the SEFA report.

Finding Reference Number: 2023-001 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: Operation Care agrees with the finding as stated above. Corrective Action: Beginning immediately, Operation Care will keep a running, updated SEFA. As soon as Operation Care receives a grant agreement, the Fiscal Director and Executive Director will review it to see if there are federal funds. If so, the Fiscal Director will enter the grant, along with the CFDA number and all other pertinent information into the SEFA. At the end of the grant year, the SEFA will then be updated to reflect Federal Expenses. The updated SEFA will then be provided to the Executive Director. Name of Contact Person: Ashley Carnicello, Executive Director, (209) 223-2897 ashley@operationcare.org Bruce Platt, Fiscal Director (209) 223-2897 bruce@operationcare.org Projected Completion Date: SEFA will be updated by June 15, 2024 and will continue to be updated as needed.

Finding Number: 2023-004 Condition: The schedule of expenditures of federal awards (SEFA) was inaccurate. Planned Corrective Action: Management would like to point out that this finding is related to finding 2023-001. The accrual of additional grant invoices resulted in parallel updates to our SEFA schedule. Therefore, this finding is a direct result of finding 2023-001. As an aside, our current process for reporting SEFA is manual. We are investing in a new accounting system, in which the SEFA information will not require manual intervention and thus reduce any potential entry errors in the future. Contact person responsible for corrective action: Colette Champine, CFO Anticipated Completion Date: Already completed

The migration to a new general ledger financial reporting system is an isolated incident and given the improved reporting capabilities the change in product provided a positive impact. UWGC experienced turnover for the program manager position that created a learning curve that was addressed but resulted in audit completion delay. UWGC has an experienced manager currently overseeing the program who will follow policies and procedures as prescribed and on a timely basis to allow for prompt reporting submission.