Corrective Action Plans

Carl Biber Chief Financial Officer 317 Western Boulevard Jacksonville, North Carolina 28546 Anticipated Completion Date: June 30, 2025 Annually, the Authority will perform additional verifications of the completeness of the Schedule of Expenditures of Federal awards by confirming directly with the mortgagee the balance as of year-end and activity for the year then ended.

2CFR 200.510(b) requires organizations to prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements, which must include the total of federal awards as determined in accordance with 2 CFR 200.502. The original SEFA prepared by the School District was not complete and accurate. The School District will implement a procedure to ensure that accounting records are closed timely, internal accounts are reconciled, and appropriate workpapers are prepared to support SEFA balances. The School District will implement these procedures for the 2025 fiscal year end.

The County has implemented a process of internal controls where expenditures are tracked in a manner that will coincide with reporting requirements for state expenditures for SEFA reporting.

Finding No: 2023 001 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirement: Other – Inaccurate reporting of the Schedule of Expenditures of Federal Awards Criteria According to 2 CFR 200.510(b), a recipient of federal awards is required to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the entity’s financial statements which must include the total federal awards expended as determined in accordance with 2 CFR 200.502. Additionally, 2 CFR 200.303 requires non federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. Conditions Found The System did not have adequate controls related to the identification and reporting of federal expenditures for the COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) program on the SEFA. Specifically, the System lacked controls to ensure expenditures incurred for COVID 19 Disaster Grants Public Assistance (Presidentially Declared Disasters) program were recognized on the SEFA when obligated. As a result, $16,310,090 of FEMA expenditures were omitted from the June 30, 2023 SEFA. Cause Management did not perform appropriate risk assessment procedures related to federal awards that have unique recognition criteria such as FEMA. Specifically, there was not a control in place to ensure FEMA expenditures were recognized on the SEFA based on when the FEMA award was both obligated and expenditures were incurred. Effect Failure to establish effective internal controls over the preparation of the SEFA may prevent the System from reporting accurate program information and completing an audit in accordance with the Uniform Guidance. Questioned Cost Not applicable Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation We recommend that the System strengthen its processes and internal controls over ensuring that proper recognition of expenditures have been reported completely and accurately on SEFA. View of Responsible Official Wellstar Health System, Inc. has implemented a control and process to ensure that expenditures are properly reflected on the SEFA. Corrective Action Plan Wellstar Health System, Inc. has implemented a control and process to ensure that expenditures are properly reflected on the SEFA at time of obligation. Anticipated Completion Date: Wellstar Health System, Inc has already implemented the corrective action. Name of Contact Person for Corrective Action: Beth Loudermilk, VP Financial Planning & Analysis

Finding 2023-001: Preparation of the Schedule of Expenditures of Federal Awards - Significant Deficiency in Internal Control Over Compliance Program: U.S. Department of Health and Human Services – Medicaid Cluster Response and Corrective Action Plan: Management agrees with finding and will develop a written policy and procedure for managing the existence of federal assistance within all contracts. Anticipated Completion Date: by June 30, 2026 Responsible Person: Virginia Lui VP, Controller

2023 006 Other – Inaccurate Reporting of the Schedule of Expenditures of Federal Awards Federal Agency: U.S. Department of Homeland Security - Pass Through – SNJ Office of Emergency Management Program Titles and ALN: Disaster Grants - Public Assistance (Presidentially Declared Disasters) (ALN 97.036) Grant Number: Grant #4488 Proj F#2105 and Grant #4614 Proj F#690 Contact Person: Erin Cuomo, Interim Vice President IP&O Business Services; 848-932-4981 Corrective Action: The Office for Research, through its Research Administration leadership in collaboration with Institutional Planning & Operations and University Finance will develop and implement a formal Standard Operating Procedure (SOP) to establish a consistent institutional framework for the administration and oversight of federally funded capital projects, emergency recovery programs, and other non-traditional sponsored funding mechanisms. The SOP will define roles and responsibilities, establish compliance requirements, and standardize processes to ensure alignment with applicable federal regulations and institutional policies The Senior Vice President for Research, the Interim Senior Vice President & Chief Operating Officer, and the University Controller will serve as the responsible executives for oversight, approval and implementation of this SOP. Anticipated Completion Date: Completed

Recommendation: We recommend the County implement a countywide system to allow for a more automated system of tracking federal expenditures, that may include updated processes to be developed to set up new organization codes which would require grant managers to provide the required information needed for accurate SEFA preparation. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented new process to ensure accurate preparation of their SEFA’s.

We will reconcile the reports submitted to the federal awarding agency to the expenditures recorded in the accounting records and SEFA to ensure accurate reports going forward.

Root Cause Management concurs that federal expenditures totaling approximately $5,842,346 under ALN 21.029 were omitted from the initially prepared SEFA, along with an additional $206,139 of other federal programs, for a total of $6,048,485. The omission resulted from incomplete grant tracking reports not reconciled to the general ledger and grant agreements; absence of an independent secondary review; and procedures that did not fully capture pass-through and subrecipient activity. Objective Design and implement effective internal controls to ensure the SEFA is complete, accurate, and in compliance with 2 CFR §200.510(b) and §200.303; prevent recurrence of material omissions; and sustain readiness for Single Audit reporting. 1. Comprehensive Reconciliation Process Implement a standardized monthly and year-end reconciliation that ties federal award expenditures (including drawdowns and indirect costs) to the general ledger, award agreements/portals, and program manager reports. Create a SEFA Reconciliation Workbook with crosswalks by ALN, passthrough entity, award number, program, and period of performance. 2. Federal Awards Inventory & Certification Maintain a centralized Federal Awards Inventory listing all awards by ALN, award number, passthrough entity, and funding stream. Require annual certifications from responsible leadership team members confirming completeness and accuracy of reported expenditures and period-of-performance coverage. 3. Formal Review Workflow (Independent of Preparer) Establish a documented two-tier review: (1) VP of Finance prepares SEFA and reconciliation; (2) Leadership Team Members perform independent reviews using a SEFA Checklist covering ALNs, pass-throughs, subrecipient disclosures, notes (basis, indirect cost rate), and period-of-performance matching. Evidence the review via dated sign-offs. 4. Subrecipient & Pass-through Controls The VP of Finance create procedures to identify all pass-through and subrecipient transactions. Maintain subrecipient listings with amounts passed through and ensure required disclosures (ALN, pass-through numbers) are captured in SEFA. Reconcile subrecipient agreements and payment registers to SEFA. Leadership Team Members perform independent reviews for accuracy and completeness. 5. Close Calendar & Training Adopt an annual SEFA close calendar with milestones (pre-close, interim, final). Provide annual training for finance and program staff on Uniform Guidance reporting requirements and the SEFA Checklist; include updates to OMB Compliance Supplement as applicable. 6. Monitoring & Continuous Improvement Quarterly CAP monitoring by VP of Finance with status reports to the Finance Committee. Track metrics (e.g., % variance between GL and SEFA, number of checklist exceptions) and remediate promptly. Conduct a pre-audit SEFA "dry run" at least 60 days before year-end close. Roles & Responsibilities • VP of Finance: CAP owner; oversight, quarterly monitoring, reports to Finance Committee, designs reconciliation and review workflow; ensures adherence to checklist and certifications; prepares SEFA, reconciliation workbook, and supporting schedules. • Responsible Leadership Team Member/Program Managers: Certify award activity and completeness; provide supporting documentation. Timeline & Milestones Immediate (within 30 days): Approve CAP; establish Federal Awards Inventory template; draft SEFA Checklist; schedule training. Short term (within 60-90 days): Implement monthly reconciliation; obtain program certifications; pilot independent review on QI data. By next year-end close: Execute full close calendar; complete pre-audit SEFA dry run; document reviewer sign-offs; present monitoring results to Finance Committee. Compliance References • 2 CFR §200.510(h): SEFA preparation requirements (completeness, ALN, pass-through, etc.). • 2 CFR §200.303: Internal controls over federal awards. Management Statement (for 2 CFR §200.511(c) submission) Management agrees with the finding and has initiated the corrective actions described herein. The CAP will be monitored quarterly by the VP of Finance, with status updates provided to those charged with governance until all actions are fully implemented and operating effectively.

Corrective Action Plan Action Item Responsible Party Monitoring Require the SEFA to be reconciled to grant expense schedules and underlying accounting records prior to submission. CFO Documented reconciliation Implement supervisory review procedures to verify the accuracy and completeness of amounts reported on the SEFA. CFO / Finance Management Review prior to submission Ensure supporting documentation for all federal expenditures reported on the SEFA is maintained in accordance with record-retention policies. CFO / Accounting Staff Periodic internal review Strengthen internal controls over federal grant reporting to improve the reliability of SEFA preparation and reduce the risk of recurrence. CFO / Board Finance Committee Annual oversight review ________________________________________ Management Response In FY 2026, management implemented updated and comprehensive policies and procedures designed to strengthen internal controls and promote consistent accounting and administrative practices. These updates establish clearer documentation requirements, defined responsibilities, and improved oversight to support compliance with applicable regulations and safeguard organizational records and financial information. In FY 2026, management also established a separate grant bank account to strengthen the segregation and monitoring of federal award funds, improving the tracking, accountability, and reconciliation of federal expenditures. In addition, management will update the organization’s Federal Financial Reporting Policy to formally include procedures for the preparation, reconciliation, and review of the Schedule of Expenditures of Federal Awards (SEFA) to ensure accuracy, consistency, and compliance with federal reporting requirements. ________________________________________ Responsible Official: Chief Financial Officer Expected Completion Date: FY 2026

2023 – 006: Reporting - Preparation of the Schedule of Expenditures of Federal Awards (SEFA) (Repeat Finding: 2021-007 and 2022-006) Condition: During fiscal year 2023, the Organization did not have adequate controls in place to ensure the SEFA accurately reflected each award's federal agency and assistance listing number. There were differences between the SEFA and the grant agreements/compliance supplements, requiring adjustments to the SEFA. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are now reconciled monthly. Each grant will have its own folder and required information to assure an accurate SEFA can be completed will be included. Management will reconcile SEFA amounts to the general ledger and review federal agency names and assistance listing numbers against grant documentation.

2023 - 007: Reporting: Preparation of the Schedule of Expenditures and Federal Awards (SEFA) (Repeat Finding:2019-007 and 2020-007, 2021-006 and 2022-008) Condition: During fiscal year 2023, the Governmental Department did not have sufficient controls to ensure the SEFA accurately reflected each award’s federal expenditures. There were differences noted in reconciling expenditures from the original SEFA to the trial balance. These errors were corrected through adjustments proposed as part of the audit, and the final version of the SEFA reconciles to the Governmental Department’s general ledger. Corrective Action Plan: Management of the Tribe realizes the importance of the SEFA and will be sure that the SEFA matches the general ledger and accurately reflects each awards federal expenses. With moving reconciliation processes to monthly from annual this will greatly increase the accuracy of the SEFA.

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Management acknowledges this oversight, which occurred during the implementation of a new program and at a time when staff were not fully aware that such expenditures must be reflected on the SEFA. Furthermore, certain capital expenditures paid directly through escrow were not recorded in the organization's accounting records. To remediate these issues, management has taken the following corrective actions: - Delivered targeted training to staff on the proper treatment and reporting of federally funded capital expenditures; - Updated internal closing and reporting procedures to incorporate a formal review of balance sheet activity; and - Updated internal closing and reporting procedures to incorporate a reconciliation to settlement statements when recording new property acquisitions; and - Strengthened internal controls to ensure all federally funded capital items are accurately captured in future SEFA submissions. Management is committed to maintaining compliance with federal reporting requirements and ensuring the completeness and accuracy of future SEFA filings.

Finding: 2023-002: Revised Schedule of Expenditures of Federal Awards (SEFA) Description of Finding: Expenditures reported on the SEFA required revision during the Single Audit due to some inaccuracies, including one omitted program, which occurred because review and reconciliation procedures were not fully sufficient. Cause: The underlying cause was insufficient internal controls over grant documentation review and the accounting of federal award activity. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian acknowledges the significance of this finding and the potential for noncompliance with Uniform Guidance with the grantors and Federal entities, as well as potential increased risk of omitted federal programs and incorrect major program determination. To remediate these issues, SacAsian will strengthen its internal controls over SEFA preparation by implementing a multi-layer review and reconciliation process. SEFA schedules will be prepared by the Director of Finance and reviewed by the newly engaged external CFO firm. Final review will be performed by the President & CEO. SacAsian will implement a more rigorous review of all grant agreements, including pass-through awards, to verify federal components and Assistance Listing Number (ALN) details to ensure all federally funded activity is fully identified and properly reported on the SEFA. The SEFA will be reconciled to the general ledger, federal award agreements, billings submitted, and other supporting documentation. In addition, directors overseeing federal programs will be required to confirm that all federal awards under their purview are completely and accurately reflected. These enhanced controls will be implemented for the 2024 audit and maintained for subsequent audit periods. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: December 2025

Finding Reference Number: 2023-003 Description of Finding: SEFA reporting Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the significance of this finding and the potential for noncompliance with Uniform Guidance with the grantors and Federal entities, as well as potential increased risk of omitted federal programs and incorrect major program determination. Moving forward, SEFA reporting will be reviewed and approved by multiple reviewers, including the President & CEO, Controller, and Director of Finance. Individual directors under relevant federal programs being reported on the SEFA will also be required to review that the information listed on the SEFA report is complete and accurate. This review process will be in place for the 2024 audit and subsequent audits. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: September 2025

2023-009- Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: American Rescue Plan Act / Coronavirus State Fiscal Recovery Fund (ARPA) Assistance Listing Number: 23.027 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ARPA expenditures, multiple transactions were identified as 2022 fiscal year expenditures that were included in the 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

2023-008 – Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Emergency Rental Assistance Program (ERAP) Assistance Listing Number: 23.023 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ERAP expenditures, six transactions were identified as prior fiscal-year expenditures that were included in the unadjusted 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-003 Federal Agency: U.S. Department of Treasury U.S. Department of Homeland Security ALN: 21.027 / 97.036 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: We have restated 2023 SEFA totals based on updates to the project funded within ALN 21.027 and for the project funded within 97.036. Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reporting

To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-002 (REVISED) Federal Program: Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 93.778 / 93.914 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reportin

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026

Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: Management fully understands the importance of internal controls to ensure the schedule of federal expenditures is complete and accurate. The Grants Department will amend its current written processes regarding award establishment to include requiring documentation indicating an award is federal funds prior to establishing the project in Infor CloudSuite Financials & Supply Management (Accounting software). Additionally, the Grants Department will routinely audit the database the department utilizes to record awards to ensure the field to note federal awards is properly updated. Furthermore, the SEFA will be reviewed with documented sign-off by each member of the Grants Team prior to submission. Contact person responsible for corrective action: Stephanie Cihon Anticipated Completion Date: October 31, 2025

Finding Number 2023-008 Subject Heading (Financial) or AL no. and program name (Federal) 93.778 Medicaid Cluster Planned Corrective Action The Schedule of Expenditures of Federal Awards (SEFA) errors were corrected on October 16, 2024. To ensure the support for the Schedule of Expenditures of Federal Awards is transferred accurately from the calculation worksheets and the other GAAP packages, we will implement a GAAP Package Z – SEFA Reviewer Checklist that will be included with the backup data of the GAAP Z. This will ensure the sources of data for the Schedule of Expenditures of Federal Awards are transferred correctly and tied back to their original source. Anticipated Completion Date 10/31/2024 Responsible Contact Person Calvin Cole, Financial Manager III

Finding Number 2023-009 Subject Heading (Financial) or AL no. and program name (Federal) 93.767 Children’s Health Insurance Program Planned Corrective Action The Schedule of Expenditures of Federal Awards (SEFA) errors were corrected on October 16, 2024. To ensure the support for the Schedule of Expenditures of Federal Awards is transferred accurately from the calculation worksheets and the other GAAP packages, we will implement a GAAP Package Z – SEFA Reviewer Checklist that will be included with the backup data of the GAAP Z. This will ensure the sources of data for the Schedule of Expenditures of Federal Awards are transferred correctly and tie back to their original source. Anticipated Completion Date 10/31/2024 Responsible Contact Person Calvin Cole, Financial Manager III

Finding Number 2023-211 Subject Heading (Financial) or AL no. and program name (Federal) 93.323: Epidemiology and Laboratory Capacity for Infectious Diseases Planned Corrective Action Action planned/taken in response to finding: For the year ending June 30, 2024 OSDE implemented a robust reconciliation process over the SEFA. With the new process, all federal expenditures and drawdowns reported on the SEFA / Schedule Z are reconciled to expenditure transactions and drawdown detail from the Statewide Accounting Software (PeopleSoft). The new process will ensure the SEFA / Schedule Z is appropriately supported by individual transactions and sufficient review is performed. The reconciliation is prepared by an OSDE contractor and reviewed and approved by the Comptroller before finalizing. Anticipated Completion Date 6/30/2024 Responsible Contact Person Shawn Richmond, Comptroller

Finding Number 2023-207 Subject Heading (Financial) or AL no. and program name (Federal) 93.323: Epidemiology and Laboratory Capacity for Infectious Diseases Planned Corrective Action The overstatement of expenditures on the SEFA is due to incorrect amounts being included on the report due to using incorrect PeopleSoft queries and a lack of proper staff training. As stated in the finding, transactions related to expenditures and draws on the grant are reported in incorrect accounting periods; this is due to general ledger entries not using a budget reference code causing an under/over statement of expenditures and revenues. To mitigate this issue going forward, management has established a cash report in Hyperion which is currently being used by the Accounting area to ensure grant draws are accurate. To ensure transactions are recorded in the correct accounting period, management is working to create a policy and procedure to ensure a budget reference code is used on all general ledger transactions. The budget reference code will also be added to the Hyperion cash report to ensure transactions are reported in the proper accounting period. Management is also actively seeking formal training opportunities for accounting staff related to the proper procedures for completing all ACFR schedules. Anticipated Completion Date 6/30/24 Responsible Contact Person Stefan Von Dollen, Interim CFO