Corrective Action Plans

UWGC experienced a staffing turnover during the 2024 fiscal year of the manager responsible for the reporting on the SEFA. The manager tracked financial reports on a cash basis causing a timing difference with not recognizing accounts payable. The finance team accounted for expenses in the appropriate period, therefore the Finance team will crosscheck reports for timing difference prior to submission to governing agency.

Finding Number: 2023-003 Condition: The schedule of expenditures of federal awards (SEFA) was not complete. Planned Corrective Action: The College will ensure that the schedule of federal awards (SEFA is reviewed for completeness. Going forward, the SEFA will be compared with the prior year SEFA and a separate schedule of new awards for the current fiscal period. The results of this comparison will be reviewed by the grants office, the controller’s office and the Vice President’s office. This will increase the level of reviews to a three-tiered process which should address issues of completeness of the SEFA. Contact person responsible for corrective action: Ms. Jackie Brown, Ms. Deborah McKenzie, and Dr. Sharron T. Burnett Anticipated Completion Date: 06/30/2024

The YWCA will implement the following changes in its accounting procedures: The Schedule of Expenditures of Federal Awards (SEFA) will be reviewed for accuracy by either the CFO or CEO after it is produced, to ensure that all federal awards are included, and that the amounts on the schedule are accurate.

Views of Responsible Officials: IW has developed and implemented enhanced procedures for the preparation of the SEFA. These procedures include detailed steps for ensuring that all costs related to Federal awards are fully allocated in the general ledger at the time of transaction and prior to SEFA preparation. This process is designed to prevent any future discrepancies between the SEFA and the general ledger. To further strengthen our internal controls over Federal award management, IW has instituted regular monthly reviews of expenditures charged to Federal awards. This review process includes verifying that expenditures are correctly allocated and supported in the general ledger, thereby ensuring the accuracy and completeness of the SEFA.

MNCASA and MACC will implement a review process for accruals and reversals; this review process will occur at the end of each month and the end of the fiscal year. This process will ensure that the ledger matches the SEFA reporting, accruals, and reversals and is done in a timely manner. MNCASA and MACC staff will also attend a training session on SEFA prepartation to increase our knowledge and ensure proper reporting.

Management response to finding 2023-001: Accuracy of expenditures on the Schedule of Expenditures of Federal Awards and submission of special reports for the Head Start Program Cluster Name: Head Start Federal Awarding Agency: Department of Health and Human Services Award Name: Head Start and Early Head Start, COVID (P.L. 116-260) Award Number: 09CH010228-05-05, 09CH011831-02-03, 09HE000328-01-00 Award Years: 2019-2021, 2021-2022, 2021-2023 Assistance Listing Title: Head Start Assistance Listing Number: 93.600 Pass-through entities: Not applicable As described in finding 2023-001, the University inadvertently charged and drew down budgeted capital expenditures from Head Start awards before actual expenditures were incurred by the University. Additionally, the University charged expenditures to a Head Start award after liquidation extensions had expired. The adjustments required to correct these errors were identified in the subsequent fiscal year, resulting in expenditures on the fiscal year 2023 Schedule of Expenditures of Federal Awards (SEFA) being overstated. The University will take the necessary corrective actions as described below to ensure the accuracy of expenditures reported on the SEFA. Finally, as described in finding 2023-001, the University did not identify and track reports required to be submitted for Head Start awards. The corrective actions described below will ensure all award specific reporting requirements are met. Although the University has limited federal awards that are utilized to fund capital expenditures, the Office of Sponsored Projects Accounting and Facility Planning and Management will perform a full review of the current Head Start capital construction accounting policies and practices to ensure they comply with the Uniform Guidance and the terms and conditions of federal awards before June 30, 2024. Reinforcement of the University’s policies and practices will ensure proper grant accounting, and thus, will prevent SEFA reporting adjustments from having to be made. Faculty leadership responsible for overseeing the Head Start program at the University will fill current vacant financial management positions within the Head Start program as soon as possible (with a three month target), undergo a full review of program requirements with all staff, and modify and develop new internal controls related to this finding. Specifically, before July 2024, Head Start fiscal personnel along with faculty leadership will develop a reporting schedule specific to Head Start awards, provide training and resources to staff involved with reporting, implement internal controls related to the reconciliation and validation of reported data prior to report submission, and strengthen internal controls related to the allocability of expenditures to awards (particularly in situations where liquidation extensions or expenditure carry forwards have been granted). Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu

--Management Response to Finding 2023-001-- I, Heather Ficht, on behalf of EC Works' leadership acknowledge and take responsibility for the deficiencies in the use of internal procedures to accuracy of information reported on the SEFA. To immediately address this deficiency, effective March 1, 2024, all operations staff will be cross trained on the proper completion and submission of the SEFA; additional procedures will also be put in place to ensure grants and other financial awards are identified as federal or nonfederal at the time of receipt. Upon receipt of any grant agreement, the Chief Operations Officer shall be responsible for identifying and communicating the source of each grant/award with the leadership team. The Finance Director shall ensure accuracy of this information and is then responsible for the timely documenting of the information on the "Grant Schedule". The Finance Director shall also be responsible for working with the Senior Accounting Technician to ensure that the proper accounting codes are assigned to each award, indicating if the award is federal or non-federal. Accounting codes and the information contained on the "Grant Schedule" shall be reviewed by the Chief Operations Officer on an ongoing, and no less than quarterly basis. Lastly, the SEFA and all financial reports prepared by the Finance Director and/or the Senior Accounting Technician shall be reviewed and approved by the Chief Operations Officer for accuracy prior to submission.

Finding Number 2023-208: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller (Office) included multiple errors. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP) 21.027 - Coronavirus State and Local Fiscal Recovery Funds 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises 93.558 - Temporary Assistance for Needy Families (TANF) 93.568 - Low-Income Home Energy Assistance 93.569 – Adoption Assistance 93.575 - Child Care and Development Block Grant (CCDF 93.658 - Foster Care Title IV-E 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Medical Assistance Program Related to Prior Finding: 2022-211; 2021-206 Agency’s view: The Department agrees with this finding. Corrective Action: Since the implementation of LUMA, the department has been cognizant of the systematic challenges and risks and is acutely attentive to monitoring and review efforts. For example, due to LUMA, finance now has a new chart of accounts structure, meaning previously used reports for compilation of the SEFA are no longer a concern. The department held a required training on March 12-13, 2024, for all employees involved with grant administration where the determination of contractor vs. subrecipient, as well as proper account coding, were reiterated. Finance has efforts underway to strengthen compliance through report building and monthly monitoring of proper coding. The department will be moving forward with the implementation of Grant Management Software in SFY25, which finance believes will provide further assurances of data accuracy. Finance will confirm all expenditures and adjustments are completed before running reports when preparing the SFY24 and future SEFA’s. This confirmation will be documented via an email to the Financial Manager of the Budget section. The email response will be retained with the SEFA preparation file for audit purposes. Anticipated Corrective Action Date: Partial efforts already completed; full completion by June 30, 2025. Responsible for Corrective Action: Staci Phelan, Division Administrator Staci.Phelan@dhw.idaho.gov 208-334-0632 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-204: The Schedule of Expenditures of Federal Awards (SEFA) closing package understated the Education Stabilization Fund - Governor’s Emergency Education Relief (GEER II) by $1,039,753 and overstated the Education Stabilization Fund – Emergency Assistance to Non-Public Schools (EANS) program by the same amount. Federal Programs: 84.425C – Governor's Emergency Education Relief; 84.425R - Emergency Assistance for Non-Public Schools Related to Prior Finding: 2021-202 Agency’s view: The Board agrees with this finding. Corrective Action: The corrective action is to reclass any GEER II Project transactions in FY 2024 to EANS/GEER II Project. That will ensure there are no GEER II transactions in FY 2024 that would need to be adjusted. This was done on March 21, 2024. Anticipated Corrective Action Date: March 21, 2024 Responsible for Corrective Action: Patrick Coulson, Chief Financial Officer Patrick.coulson@OSBE.idaho.gov 208-332-1563

Finding Number 2023-202: Closing package submissions and revisions completed prior to the draft of the Schedule of Expenditures of Federal Awards (SEFA) being submitted for audit were not included in the schedule resulting in misstatements. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund; 93.778 – Medical Assistance Program; 93.767 – Children’s Health Insurance Program Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: An agency submitted a revised SEFA template in November 2023. We inadvertently excluded those revisions from the draft of the SEFA provided for audit. To prevent this error from happening again, we will document each agency that submits a revised SEFA template(s) on our SEFA review checklist. This will require the preparer and reviewer(s) to verify and sign off on changes made to the SEFA master file. Anticipated Corrective Action Date: Errors identified were corrected before issuance of the Single Audit report. Corrective actions will be implemented for fiscal year 2024 reporting. Responsible for Corrective Action: Tiffini LeJeune, Reporting and Review Bureau Chief TLeJeune@sco.idaho.gov 208-334-3100

2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director will reevaluate the controls and set in place policies and procedures for SEFA completion. Name(s) of the contact person(s) responsible for corrective action: Director of Restricted Funds Accounting, Symone Merritt Planned completion date for corrective action plan: October 2024

REFERENCE: 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation SFA Cluster (Assistance Listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted in an overstatement of the SEFA expenditures reported in the SEFA. Corrective Action Plan: This finding has been corrected. Good Samaritan College of Nursing & Health Science has revised how data will be obtained for the schedule of expenditures of federal awards. Additionally, the G5 report will be provided to National Grant Accounting with the SEFA. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Completion: February 2024

The Business Service Department will work with CSRS to ensure the FEMA funded projectes are reported correctly on the SEFA. Timeline: Immediately Responsible Person: Naquisha Larks, Grants Accountant

Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and implement internal controls around the Schedule reconciliation process back to the consolidated financial statements. The corrective action will be implemented no later than June 30, 2024. The primary designated official is Chief Financial Officer.

Ballad Health will utilize technology efficiencies within upgraded accounting system to supplement reporting. Additionally, a resource will be added directly responsible for grant accounting. The SEFA will also be reviewed frequently to ensure accuracy.

2023-002 FEMA COVID-19, Disaster Grants - Public Assistance – Federal Assistance Listing Number 97.036 Recommendation: The University reevaluate policies and controls related to the preparation of the SEFA to ensure it is complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In addition to its review of federal expenditures, Widener University will revise its procedures when preparing the SEFA to additionally review dates of all obligated funding to ensure all amounts are included in the proper reporting year. William Lockard, Associate Vice President of Fiscal Operations & Risk Management is the person responsible for corrective action. Planned completion date for corrective action plan: June 30, 2024

Cheyney University: The discrepancy in the SEFA is primarily due to a timing issue with the approval of the HCM2 Claims. However, the Federal Title IV grant and loan funds should be properly reflected in the upcoming SEFA because the University will be current in its processing of 2023-2024 Federal Student Aid and request for reimbursement. Hence, the University should not have this issue in the FY24 fiscal year. In addition to timely processing, relevant staff in the Financial Aid, Bursar, and Business Office have participated in Federal Student Aid (FSA) Cash Management Training. Furthermore, effective July 2023, reconciliation has been outsourced to FAS. Therefore, monthly reconciliations will inform the SEFA development process. Meaning, adjustments that required for the SEFA will be made more timely than in the recent past.

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with this finding and recommendation. DPH will ensure to report Federal expenditures in the SEFA under the correct ALN based on Time Studies received. 3. Anticipated implementation date: March 7, 2024

1. Person responsible: Director, Department of Public Health 2. Corrective action plan: DPH Finance agrees with finding and recommendation. Finance will take the following corrective action: • Initiate direct, written communication with the Auditor-Controller to seek precise instructions and guidance on the inclusion of accruals in our reporting. • Proactively review and document accrual procedures, ensuring alignment with regulatory requirements. • Prospectively include and implement accrual reporting in the Single Audit. • Establish a communication protocol with the Auditor-Controller to address any future uncertainties promptly. Through these measures, DPH aims to address the audit finding, establish clear guidelines for accrual reporting, and ensure compliance with reporting requirements while maintaining transparency and accuracy in our financial reporting practices. 3. Anticipated implementation date: April 1, 2024

Department: Education Title: Internal control over the submission of CNC Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will work with auditors to find the SEFA numbers. The Department director will create a procedure to report the SEFA numbers to DOE Finance. The Department will review with DOE Finance for approval of the procedure. Completion Date: March 1, 2024, May 1, 2024 and June 1, 2024 respectively Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

Carroll County, Maryland respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 Audit firm: CliftonLarsonAllen LLP The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings - Federal Award Program Audits: U.S. Department of Transportation U.S. Department of Treasury U.S. Department of Health and Human Services U.S. Department of Homeland Security Reference Number: 2023-001 Federal Program – Assistance Listing Numbers: Airport Improvement Fund – Assistance Listing No. 20.106 Highway Planning and Construction – Assistance Listing No. 20.205 Federal Transit Cluster – Assistance Listing No. 20.507 COVID 19: Coronavirus State & Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Medicaid Cluster – Assistance Listing No. 93.778 Assistance to Firefighters – Assistance Listing No. 97.044 Recommendation: We recommend that the County improve its SEFA compilation process to ensure that program expenditures reported on the County’s SEFA are complete and accurate based on when the expenditure was incurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Accounting office with assistance from the Grants Management Office will take the lead in documenting and training appropriate staff so they become knowledgeable and experienced with the requirements for the County’s SEFA compilation process to ensure that program expenditures reported on the County’s SEFA are complete and accurate based on when the expenditure incurred per Uniform Guidance requirements. Accounting will work with the Grant Management Office as well as various Grant Administrators to review and update our formal documentation: Carroll County Guide to Grants to include detail for Grant Administrators to manage and maintain records for their federal reimbursable expenses to provide appropriate data to the Accounting department for the SEFA preparation. Once updated in FY24, we will train staff with fiscal responsibilities of managing and maintaining records of expenses incurred for these federally funded grants for the SEFA compilation. This topic will also be added to our current quarterly / monthly grant meetings with various departments. Accounting will review the internal controls for its SEFA compilation process for FY24 and future fiscal years. In future years our new ERP system, Tyler Technologies, will improve this process. Name(s) of the contact person(s) responsible for corrective action: Jennifer D. Hobbs, Comptroller Bobbi-Jo Fout, Bureau Chief, Accounting Deborah Standiford, Grants Manager Planned completion date for corrective action plan: FY24 for Audit period: July 1, 2023 – June 30, 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Jennifer D. Hobbs or Bobbi-Jo Fout at 410-386-2085.

Program: CDBG - Entitlement Grants Cluster/ Highway Planning and Construction/ Nationally Significant Freight and Highway Project Funds Federal Financial Assistance Listing No.: 14.218 / 20.205 / 20.934 Federal Agency: U.S. Department of Housing and Urban Development/ U.S. Department of Transportation Direct Award: U.S. Department of Housing and Urban Development Pass-through: California Department of Transportation in relation to the Highway Planning and Construction Award Year: Multiple Grant Award Number: All Compliance Requirements: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.SlO(b) - Schedule of expenditures of Federal awards Views of Responsible Officials and Corrective Action: We concur with the finding. The City will provide training for new and unfamiliar programs and continuing training for existing programs to employees involved with the grant program. The City will implement internal controls to ensure all federal expenditures are accurately tracked and reported on the SEFA. Personnel knowledgeable of federal expenditures will review amounts coded to federal programs for completeness and accuracy. The SEFA will be prepared and reviewed in a timely manner and reconciled to underlying records as well as the basic financial statements. Name of Responsible Person: Jennifer Hennessey, Director of Finance Projected Implementation Date: June 30, 2024

Management has instituted measures to ensure that future reporting is accurate and complete. This includes review of all grant expenditure activity as transacted in the financial general ledger, as well as a full review of all funding received identified as either a grant or award. All supporting documentation shall be obtained and reviewed for proper designation of funding source, with determination as to whether funding is federal in nature. This information will be used to populate the SEFA template to ensure accurate reporting before submission into the Corporation’s consolidated SEFA. Support obtained from funding sources will also be used to correctly identify the federal ALN that in turn will be reported on the SEFA. Final review of the SEFA with supporting documentation and sign off will be performed by the Regional Controller.

Contact Person: Kristen Nagle, Assistant VP Finance/Controller Corrective Action: The University Finance department has updated their policies and procedures to ensure that the SEFA is being prepared in accordance with required guidelines. We will work closely with our grants department to ensure all required elements are properly identified and disclosed. Anticipated Completion Date: July 1, 2024

Department of Health and Human Services 2023-003 SEFA Reporting – Recording Expenses in the Correct Period – Assistance Listing No. 93.211 Condition: Schedule of Expenditures of Federal Awards (SEFA) contained expenses that were not allowable. Auditors’ Recommendation: We recommend the institutions review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified, recorded, and classified in the accurate year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During a reconciliation of the project, Post-Award Accounting identified $1,175 in salary that should not have been recorded to the grant. These expenses were not reported to the sponsor, nor were they invoiced. However, expenditures were not removed from the grant fund promptly. To address this finding, campus grant administrators will be provided with a deadline to remove unallowable expenditures. If the expenditures are not removed according to this deadline, the responsible departmental chair or dean will be notified of the non-compliance until the expenditure is removed. Name(s) of the contact person(s) responsible for corrective action: Julie Schwindt, Director, Post-Award Accounting Planned completion date for corrective action plan: June 30, 2024. If the Department of Health and Human Services has questions regarding this plan, please call Julie Schwindt at 601-984-1058.