Corrective Action Plans

Views of Responsible Officials and Planned Corrective Actions: In 2024 during the SEFA analysis and in discussion with auditors it was determined that a USG-funded contract, attached to a grant, was incorrectly left off the SEFA. This was amended as soon as the mistake was noted. AL is required to submit financial statements to a non-US Government donor by June of each calendar year. To comply with this grant stipulation AL starts pre-audit document checks in early January and full fieldwork in mid-February following our financial year close on December 31. While the majority of our annual financial statement is complete by mid-January we have one outstanding USG grant which only reports at the end of February for an end-of-January quarter close. As a result, we are only able to provide a preliminary SEFA when the auditors request the first document checks in January. For FY 2025 we will request that the auditors start with a basic audit of Financial Statements and then submit the SEFA once all the quarterly reports have been submitted to USG. Anticipated Completion Date: Already decided for FY 2024 audit. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.

Finding 2023-002 Significant Deficiency: Schedule of Expenditures of Federal Awards (SEFA) – Control Finding; Personnel Responsible for Corrective Action: Pete Vujcich, Public Works Division Manager; Anticipated Completion Date: June 30, 2024; Corrective Action Plan: In 2021, El Paso County recognized and appropriated $4 million from a CDOT grant (Fed) and $831,501 of local match that was provided by PPRTA (reimbursement) for construction on the South Academy widening project. The overall South Academy project is funded by PPRTA but managed by El Paso County. In May of 2023, PPRTA issued a Purchase Order for $59,965,997.99 to SEMA Construction and the construction contract with SEMA was executed. In December of 2023, SEMA performed work on the project resulting in billings of $4,456,362.07. A payment application was sent to the construction management firm (Wilson & Company) on January 17, 2024 from SEMA. This payment request was rejected due to insufficient certified payrolls. On February 27, 2024, Public Works received an invoice package with all required documentation. During February 2024, Public Works realized that PPRTA would not be able to submit for reimbursement because the IGA was directed to the County and not PPRTA. At that point, the project manager requested a 2024 Purchase Order to pay this invoice. On March 6, 2024, Public Works submitted the 2024 invoice along with a 2024 Purchase Order to Accounts Payable requesting payment was made to SEMA. At that point, the payment was issued and booked to 2024 without recognition of the actual work performance period. Since the invoice was booked in 2024, the expenditure was also not reflected on the 2023 SEFA. As soon as this expenditure was brought to our attention, we immediately requested Accounting record the $4.5 million on the 2023 SEFA. Standard operating procedures include a request of all project managers to identify any anticipated invoices that will be received in the following year to identify any potential reclassification situations. In this particular case, the project manager did identify this project, and anticipated payment request. At the time, this project was a PPRTA run project, and would not have had an impact on the county’s financial reports. Previously, Public Works had a very manual SEFA reporting process in place. Public Works just went live with a new Capital project tracking platform called eBuilder. eBuilder has a required field on the pay app approval screen that requires employees to enter the billing period start and end dates. When Managers go into eBuilder to approve payments, they are required to ensure the billing periods match the payment dates. In addition, as a double check, Public Works is working on customizing eBuilder to flag approvers if the invoice date has a different year listed than the billing period. Public Work has done training with employees to ensure employees understand the additional components of a progress billing pay application, to include timing issues with the review and approval process utilized. We have also reinforced the importance to communicate the correct year expenses were incurred when submitting to Accounts Payable and Accounting. eBuilder will allow Public Works to run reports showing expenses for the correct year. These reports will then be submitted to Accounting to assist with the SEFA preparation. Public Works is confident that all expenditures will be recorded correctly on the SEFA moving forward.

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.

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.

Views of Responsible Officials: NDRN’s finance staff turnover, coupled with the staff’s lack of formal training with NDRN’s accounting system, resulted in a lack of knowledge on how to prepare the actual schedule. However, it did not affect the staff’s ability to properly identify and categorize expenditures for invoicing purposes to the Federal government. Moving forward, NDRN finance fiscal staff will conduct regular internal SEFA reporting as part of the monthly reporting indicated in Finding 2023-002 above.

We provided the NOAA Award label and CFDA# as soon as we were able to obtain it from the program manager. We corrected the CFDA# for the Highway Planning and Construction as soon as we were able to obtain them from the MEDOT. The contract documents did not include that information. We reported the revenue for the State and Local Recovery Funds in the award column. We now know to put the unspent revenue in deferred. We did not know the $310,000 was Federal Funds, we will know for the future. We will be sure to include Covid-19 labels and all the award dates in the future. We will look for training to prepare a SEFA document, it will be on our professional development list in this year.

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

The City has immediately assigned Finance staff (Financial Analyst and Accounting Technician) to initiate the draft SEFA and work with administrating departments for thorough review. Departments will be requested to be as clear as possible on regular reconciliation of spending to the City's financial system throughout the year. After submission from an administrating department of a federal program, a reconciliation of federal monies spent to what is posted in the City's financial system will be required. Finance staff will review this reconciliation with the submitting department, after any corrections, submit to Finance management for a final review prior to submission for audit purposes. This updated process will be reviewed with all city departments during year-end review notifications sent out by the Finance Department or individually to departments with active federal programs.

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.

Responsible Person for Corrective Action: Lindsay Mitchell, Director of Fiscal & Facilities. Corrective Action to be Taken: All Fiscal team members will be attending various training courses around GAAP reporting guidelines. Training will be through the CPE website, also any other sources management can engage in through WiPFLi or CAPLAW. Reports will all be submitted after a review and approval from the Director of Fiscal and Facilities. Policies and procedures will be updated with the assistance of a fiscal consultant to ensure that these policies and procedures are followed through. Back up will be required for every entry and entry and backup will be scanned to a permanent document folder so it can be referenced so if there are any changes made there will be an audit trail for follow up. These new policies and procedures will be initialed by the fiscal team for acknowledgement of changes, and it will be part of the performance evaluation process. The anticipated completion date for this corrective action is September 30, 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

Internal controls have been put in place to ensure a thorough review over the review and preparation of the schedule of expenditures of federal awards to ensure all accurate awards are included as required. Responsible Official: Lisa Burnett Planned Completion Date: June 30, 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.