Corrective Action Plans

Finding Number 2023-206 Subject Heading (Financial) or AL no. and program name (Federal) 93.268: Immunizations Cooperative Agreements 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

Finding Number 2023-202 Subject Heading (Financial) or AL no. and program name (Federal) ALN: 21.027 Federal Program name: Coronavirus State And Local Fiscal Recovery Funds (CSLFRF) Planned Corrective Action OWRB was granted approval by the legislature to use a custodial bank to ensure ARPA funds were provided quickly and efficiently to ARPA recipients. Historically, OWRB has used this successful process for securing and transacting funds for its clean and drinking water state revolving fund loans and its financial assistance programs. OWRB understands the issue with ARPA expenditure reporting. The posting dates for expenditures booked in PeopleSoft versus the dates ARPA project funds were released from the custodial bank for payment differed. This was because; to transfer ARPA funds to the bank, expenditures were booked using a purchase order in the PeopleSoft system. The purchase order process was then used to transfer funds to the custodial bank. This results in actual project expenditures being booked in the incorrected period for reporting standards. After initial transfers were made through the PeopleSoft system to the custodial bank, ARPA funds released from the bank for specified projects were on a different date. Funds were only released from the custodial bank upon approval by OWRB after review. The release dates for the ARPA project payments would only be in the custodial bank's accounting system and in OWRB's internal records but would not be reflected in the PeopleSoft accounting system. OWRB will meet with OMES to seek a remedy for this. The current method for the transfer and release of funds meets all necessary controls, however; it isn't adequate in reflecting the custodian's release dates without preparing a manual adjusting entry into the PeopleSoft system. Anticipated Completion Date 06/30/2025 Responsible Contact Person Cleve Pierce, Chief of Administrativ e Services/CFO Jessica Billingsley, Comptroller/F inancial Manager

Finding Number 2023-056 Subject Heading (Financial) or AL no. and program name (Federal) ALN: 21.027 Federal Program name: Coronavirus State And Local Fiscal Recovery Funds (CSLFRF) Planned Corrective Action Management Response The Oklahoma Office of Management and Enterprise Services – Grants Management Office (OMES-GMO), in coordination with the OMES Financial Reporting Unit (FRU), agrees with the finding. OMES agrees with the finding and concurs that the implementation of additional controls, along with clarity on process, is necessary to ensure accurate preparation and reporting of expenditures on the Schedule of Expenditures of Federal Awards (SEFA). OMES recognizes the importance of compliance with 2 CFR § 200.303, § 200.502(a), and § 200.510(b), which require entities to maintain effective internal controls and to accurately report federal expenditures based on when the underlying activities occur. Accurate SEFA reporting ensures transparency and accountability in the use of federal funds, including Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) under Assistance Listing #21.027. Actions Taken and Planned Improvements: • FY2024 Review and Remediation: OMES FRU is actively working with the agencies identified in this finding to review and, if necessary, amend their FY2024 GAAP Package Z submissions. Necessary updates to FY2024 SEFA will be made to reflect accurate expenditure reporting in line with federal requirements. OMES FRU will review specific instances with its partner agencies identified in the findings to substantiate or refute agency assertions concerning provided assistance and approvals received. •GAAP Package Z Template Enhancements (Effective FY2025): OMES FRU will revise the GAAP Package Z template to include a new reconciliation tab. This tab will require agencies to reconcile reported federal expenditures and cash balances to SRD (Summary of Receipts and Disbursements) reports. OMES FRU will review this reconciliation against data from PeopleSoft to verify accuracy. •Annual SEFA Training: Beginning in FY2025, OMES FRU will provide annual training to all agencies involved in federal reporting. The training will focus on SEFA requirements, GAAP Package Z completion, and reconciliation procedures. This timing aligns with agency preparation for the FY2025 GAAP Package submissions. Noteworthy Corrections: Agencies 340, 423, 677, 800, and 585 made SEFA corrections at the request of the State Auditor’s Office prior to the issuance of this finding. These amendments were submitted and processed in a timely manner and reflect the agencies' commitment to compliance. Agency-Specific Responses Individual responses have been submitted by several agencies listed in the finding, outlining corrective actions, reconciliations, and improvements made to internal controls. These responses are available upon request and have been reviewed by OMES FRU for accuracy and completeness. In addition, several agencies have submitted their own independent responses, which document internal improvements and provide additional context to their individual reporting discrepancies. The following agencies provided the following independent responses: 619: The 2023 SEFA was completed and submitted by OMES without the aid or approval of agency 619 and the ARPA Grant Manager. Agency 619 worked very closely with OMES on the 2024 SEFA to ensure that our internal records matched what is listed in PeopleSoft. Some edits had to be made but the SEFA was submitted with all parties in agreement. Agency 619 will continue to work closely with OMES in future reporting periods to ensure the most accurate expense totals are reported. 670: Agency 670 has taken corrective action by reviewing internal processes with assigned staff to ensure required forms are comprehensively reviewed for errors, omissions, and exceptions prior to filing with OMES CAR. agency 670 is willing and able to complete an updated OMES CAR form with accurate information. Anticipated Completion Date 06/30/2026 Responsible Contact Person OMES: Parker Wise, Felicia Clark 619: Sara Librandi, Kami Fullingim 670: Mike Powers, Mark Chronister, Erik Paulson

Finding Number 2023-011 Subject Heading (Financial) or AL no. and program name (Federal) 20.509 - Formula Grants for Rural Areas Planned Corrective Action We concur with the auditor’s recommendation. Staff will be trained on how to reconcile & identify discrepancies. Anticipated Completion Date September 2025 Responsible Contact Person Sam Ddamba

Finding Number: 2023-042 Finding Name: Inaccurate Reporting of Federal Expenditures Finding Condition(s): The Illinois Department of Employment Security (IDES) did not accurately report Federal expenditures under the Unemployment Insurance (UI) program. Name of Contact Person(s): Kelly McGrath, Manager of Accounting and Reporting – Illinois Department of Employment Security, Accounting and Reporting Corrective Action(s): The IDES has worked with its bank to address one of the underlying issues that prompted these adjustments and has updating its procedures for its GAAP package preparation. The IDES reviewed and considered this finding when preparing its fiscal year 2024 GAAP package. Proposed Completion Date: March 31, 2025 – Completed

Finding Number: 2023-012 Finding Name: Inaccurate Reporting of Federal Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not accurately report federal expenditures, including amounts provided to subrecipients, under the Supplemental Nutrition Assistance (SNAP) Cluster, the Supplemental Nutrition for Women, Infants, and Children (WIC) programs, the Vocational Rehabilitation (VR) program, the Temporary Assistance for Needy Families (TANF), the Child Care Development Funds (CCDF) Cluster, the Social Services Block Grants (SSBG), the Block Grants for Prevention and Treatment of Substance Abuse (SAPT) program, and the Disability Insurance/SSI (SSDI) Cluster. Specifically, the auditors noted differences between the expenditure amounts provided for audit by the IDHS and the Schedule of Expenditures of Federal Awards (SEFA) amounts reported to the IOC, differences relative to amounts provided to program subrecipients, the cash basis expenditures provided by the IDHS for audit procedures included accrued (not paid) expenditures, and amounts passed through to other State agencies from the IDHS provided by the IDHS for audit procedures included expenditures paid outside of the fiscal year. Finally, IDHS’ controls over reporting federal expenditures were not designed at a sufficient level of precision to ensure complete and accurate reporting in a timely manner. Name of Contact Person(s): Sarah Eves, Bureau Chief – Illinois Department of Human Services, Bureau of General Accounting Corrective Action(s): The IDHS has created a spreadsheet with all federal expenditure data grouped by assistance listing numbers (ALN). The spreadsheet also contains a tab with only the major program expenditure data, which is compared the IDHS’ SEFA totals. Any discrepancies between the reporting methodologies are identified and researched. Proposed Completion Date: September 30, 2024 – Completed

The City will review the process for identifying federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards. This will include inquiries of the Engineer’s Office.

SHLNFB will ensure that all Federal Awards are carefully reviewed to confirm that the Federal Assistance Listing Number is accurately stated, the pass-through entity identifying numbers are correct, and are included in the correct Cluster.

Corrective Actions Taken or Planned Management concurs with the finding and is currently in the process of updating the accounting system to incorporate grant-specific specific tracking codes to further align with federal reporting standards. As part of a layered approach to internal controls, Excel worksheets will continue to be used as a supplementary monitoring tool, providing an additional cross-check to the system-generated reports. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Expected Implementation date: November 20, 2025

The closing process will be improved to perform detailed reviews of the closing process and to obtain reliable and complete general ledger.

Clean Water State Revolving Fund – ALN: 66.458 Finding: Schedule of Expenditures of Federal Awards Preparation Recommendation: Procedures should be implemented to ensure completion of an entry to the Schedule of Federal Expenditures of Federal Awards to achieve a reliable reporting of total expenditures for an audit period. Action Taken: The City of Hartwell recognizes its responsibility to prepare and present an accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with Uniform Guidance. To address this finding, the City will implement formal written procedures for the preparation and review of the SEFA.

Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants management team, and implementing new policy and procedures for SEFA reporting. Finance and grants management staff will jointly review all grant activity at year-end to ensure proper inclusion in SEFA. Management acknowledges the importance of accurate SEFA reporting and is committed to strengthening internal controls to prevent similar issues in future reporting periods. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

Management’s Response and Corrective Action Plan: Grant review is included within the month-end close procedure referenced in the response to 2023-001. The procedure includes defined roles and responsibilities by position.

As stated in the finding (2023-005) the Village was unaware of the monies being Federal Monies as they were received from a State of Ohio distribution, and after a discussion with the auditors the Village prepared the required reports. The village, being a small municipality, does not receive federal funds routinely and I believe the Coronavirus funds will not be something the village anticipates receiving in the future. – Mayor M. Shane Patrone

The Board of County Commissioners, with the cooperation of all elected officials and officers responsible for the receipt or expenditure of federal funds, will evaluate the processes and procedures currently in place to ensure the accuracy of SEFA reporting and detect potential inaccuracies and/or misstatements.

The School District will review the Uniform Guidance requirements and ensure all expenditures are accurately reported on the School District’s Schedule of Expenditures of Federal Awards.

2023-02 Expenditures of Federal Awards Corrective Action Plan: Develop and implement procedures to maintain adequate accounting records that accurately track expenditures by individual Federal programs, ensuring compliance with reporting requirements and transparency in fund utilization. 1. Immediate Assessment: Conduct a comprehensive assessment of current accounting practices and records to identify deficiencies in tracking expenditures by Federal programs. Determine the scope and extent of inaccuracies or gaps in documentation. 2. Engage Accounting Expertise: Engage a third-party CPA firm experienced in governmental accounting and Federal grant compliance to assist in resolving the issue. 3. Review Federal Program Requirements: Review the requirements of each Federal program under which funds are received. Identify specific reporting and expenditure tracking requirements mandated by each program. 4. Develop Chart of Accounts: Develop or revise a detailed chart of accounts that clearly distinguishes expenditures by each Federal program. Assign unique codes or identifiers to transactions associated with each program. 5. Implement Segregation of Expenditures: Implement procedures to segregate expenditures by Federal program at the time of recording. Ensure all transactions are allocated accurately to the appropriate program based on the chart of accounts. 6. Document Expenditure Allocation: Document the allocation of expenditures to specific Federal programs clearly and comprehensively. Maintain supporting documentation such as invoices, receipts, and payroll records that substantiate the allocation. 7. Training and Capacity Building: Conduct training sessions for accounting staff involved in recording and reporting expenditures. Train them on the new procedures, chart of accounts, and the importance of accurately tracking expenditures by Federal program. 8. Regular Reconciliation and Reporting: Implement a process for regular reconciliation of expenditures with Federal program requirements. Ensure reconciliation is performed monthly or quarterly to identify discrepancies promptly. 9. Internal Controls and Monitoring: Strengthen internal controls to prevent future inaccuracies in expenditure tracking. Assign responsibility for oversight and monitoring of compliance with the new procedures. Timeline for Implementation: Ongoing: Maintain vigilance over compliance and adjust as needed. Conclusion: By implementing this corrective action plan, we aim to establish robust accounting practices that accurately track expenditures by individual Federal programs. This will ensure compliance with reporting requirements, enhance transparency in fund utilization, and mitigate risks associated with inaccurate financial reporting. This plan outlines our commitment to addressing the current deficiencies and establishing a sustainable framework for future operations. Responsible Party: Kimberley Chaffin, Executive Director Date of Implementation: October 1, 2023

VIEWS OF RESPONSIBLE OFFICIALS Regarding this finding as it relates to SEFA preparation, we similarly note that grant-level accounting and internal control procedures are supported by PRIFAS. Moreover, the grant-level accounting and internal control are being strengthened through initiatives set forth in the 2024 Certified Fiscal Plan, certified by FOMB. Section 3.1.2.4 (“Improve federal funds management”) calls for the consolidation of grant management under a centralized financial framework. This will improve transparency and visibility of federal and non-federal funds, enable accurate budgeting aligned with strategic priorities, and ensure compliance requirements are clearly understood by both individual agencies and the Puerto Rico Treasury Department. In conjunction with the ERP rollout, the Plan calls for establishing a central Grants Management Office tasked with enhancing oversight and compliance, supporting corrective-action follow-up on single audit findings, building local capacity to maximize federal funding, and codifying best practices. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Office of the Secretariat and Administrations

Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing Number 19.510 and 93.567 Criteria: The Code of Federal Regulations (CFR) Section 200.510(b) states in part, “The auditee must also prepare a schedule of federal expenditures for the period covered by the auditee’s consolidated financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Also, in accordance with CFR Section 200.302(b) - Financial Management, the auditees financial management system must provide 1) identification of all federal awards received and expended; 2) accurate, current, and complete disclosure of the financial results of each federal award or program; 3) records that identify adequately the source and application of funds for federally‐funded activities; 4) effective control over, and accountability for, all funds, property, and other assets; 5) comparison of expenditures with budget amounts for each Federal award; 6) written procedures to implement the requirements of section 200.305 and; 7) written procedures for determining the allowability of costs in accordance with Subpart E and the terms and conditions of the Federal award. Recipients of federal awards must submit accurate, complete and timely financial and performance reports. The Organization should have internal controls designed to ensure compliance with those provisions. The Organization should retain sufficient documentation such as invoice and allocation support for expenditures to retain documentation for audit purposes. Condition: During detail testing of expenditures, it was noted that the Organization did not maintain adequate documentation to support how certain costs were allocated to the federal program. Several transactions lacked sufficient detail, such as invoice or expense reimbursement form. Several expenditures selected for testing did not obtain sufficient approval by an individual at the Organization. It was noted that quarterly reports provided to the federal program were not reviewed by an individual at the Organization prior to submission to ensure accurate report of expenditures. Cause: The Organization does not have an adequate system in place to ensure quarterly reports have sufficient supporting documentation, proper approval/review, and accurate reporting prior to submission. Responsibilities for expenditure tracking were not clearly assigned, and there was no formal review process in place. The Organization is not following their Document Retention Policy. Effect: The effect of this condition increases the possibility that quarterly financial reports are misstated or inaccurate and increase the risk of noncompliance with federal requirements. The effect of this condition also increases the risk that expenditures are unallowable per the grant, federal regulations, or cost principles due to the insufficient support of proper approval retained. Questioned costs: None Repeat Finding: Yes - 2022-004 Recommendation: Policies and procedures should be in place to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved and reviewed. A formal review process should be established to ensure compliance. The Organization should following the Document Retention Policy that was put in place and required by law. Management Response: There is no disagreement with the audit finding. Management has taken steps to address these deficiencies in fiscal year 2025 including but not limited to: the implementation of a new accounting system that includes document retention and review/sign off logs, the engagement of a third-party CPA firm to provide client advisory and accounting services and the review and updating of accounting policies and procedures for best practices. Responsible Person for Corrective Action Plan: Marc Hall, Director of Operations Implementation Date for Corrective Action Plan: Fiscal year 2025

2023 – 004 Material Weakness in Internal Control Over Preparation, Reconciliation, and Retention of the Schedule of Expenditures of Federal Awards (SEFA) Recommendation: 4. Develop a Standardized SEFA Reconciliation Process – Implement formal policies and procedures requiring that SEFA expenditures be reconciled to the general ledger on a monthly basis, with documentation maintained for audit purposes. 5. Enhance System Controls for Grant Expenditures – Modify the financial system to allow for the proper segregation of state and federal expenditures from non-grant funds, ensuring that expenditures are properly classified at the time of entry. 6. Require Monthly Documentation Reviews – Establish a control requiring management to review and approve SEFA reconciliation schedules on a monthly or quarterly basis to ensure accuracy and completeness. 7. Implement a Centralized Documentation Retention Policy – Require that all SEFA-related reconciliation records, including general ledger tie-outs and manual adjustments, be retained in a centralized, accessible location. 8. Provide Grants Management Training – Conduct training for grants management and accounting personnel on SEFA preparation requirements, including Uniform Guidance compliance and best practices for documentation and reconciliation. Management View: Management partially agrees with the finding. While we acknowledge that documentation supporting SEFA reconciliation was incomplete, we believe that federal expenditures were properly accounted for. We would like to address some of the auditors’ points individually: • “The SEFA is prepared based on amounts requested for reimbursement instead of directly based on expenditures incurred.” Most grant awards do not fully fund the programs they support, most grant awards do not run concurrently with Prism Health North Texas’ fiscal year (i.e., with the Calendar Year), and most grant awards are not spent in equal monthly amounts. It is correct that the 2023 SEFA was based on grant-appropriate expenditures that occurred during Calendar Year 2023 and were submitted to those grant sponsors for reimbursement. This will not necessarily reach the full cost to Prism for each grant-supported program, nor is it likely to exactly match any annual grant award amount. • “Expenses recorded in the general ledger represent expenses incurred to operate the program in addition to direct grant expenditures; the Organization only requests reimbursement for direct program expenditures allowable under the program.” As we confirmed verbally with the audit partner on April 25, 2025, this statement is intended to provide information and context and is not a criticism or intended to point out any problem. As stated above, most grant awards do not fully fund the programs they support; therefore, the general ledger necessarily includes both expenses the sponsor will reimburse and expenses the sponsor will not reimburse. Nonetheless, we are enhancing our reconciliation procedures and documentation practices to fully meet audit requirements. Finding 2023-004 refers to the auditors’ assessment of the SEFA preparation and reconciliation processes that occurred in Calendar Year 2023. As of this writing, Prism Health North Texas has already changed its SEFA preparation and reconciliation processes and meets many of the recommendations above. Action Taken: 4. Documentation Retention – On April 25, 2025, management created a structured and easily accessible system for storing all relevant information for all grants management personnel. a. A logical naming system for files identifying the SEFA period, the funding agency and identified general ledger expenditures claimed on the SEFA. b. We are now documenting the difference between all GL transactions and those submitted for sponsor reimbursement (i.e., SEFA components) in a single document per fund code, arranged by fiscal year. Previously this documentation was kept by invoice and arranged by grant year. c. Management will continue to ensure all expenditure-related support, such as invoices and purchase orders, is saved electronically to all financial transactions. 5. SEFA Reconciliation – Management has decided to move from an annual to quarterly SEFA reconciliation process to enhance the frequency of management oversight in SEFA draft preparation. VP of Finance will prepare the SEFA for independent review by the CFO. This will be put into a written policy/procedure. 6. System Enhancements – Prism’s current accounting system does not accommodate this. However, Prism is already in the later stages of selecting a new Enterprise Resource Planning (ERP) solution, with this as one of our key selection criteria. Our new ERP should allow for expenditures within the same cost center to be identified as grant-reimbursable or non-grant-reimbursable at the time of entry. We have identified opportunities in new financial management software solutions that we are scheduled to demo May 12th and the 16th of 2025. Opportunities such as: a. The ability to tag grant-reimbursable transactions, to segment our award cost center into two important categories. i. The full cost to manage a specific program ii. Identified cost claimed on the SEFA b. Dedicated grant modules that will allow us to establish business rules and workflows to streamline and digitize critical aspects of grant management. 7. Staff Engagement – Cross department coordination meetings occur monthly between the Finance organization and the Grants Management team to continue to foster alignment and collaboration in our grant cycles. A general overview of SEFA, including how to prepare and organize the monthly reconciliations, has already occurred with some of the grants accountants. Anticipated Completion Date: We expect all but system enhancements to be in place by July 31st, 2025, to contribute significantly to the strength of our internal controls and stakeholder confidence in our SEFA reporting. Responsible Contact Person(s): • Name: General Laffitte • Title: Vice President of Finance and Accounting • Phone: 214-623-6896 • Address: 3900 Junius St. Ste. 300, Dallas, Texas 75246 • Name: Jana Voege • Title: Chief Financial Officer • Address: 3900 Junius St. Ste. 300, Dallas, Texas 75246

CORRECTIVE ACTION PLAN Name of auditee: Friends of the Mission Finding: 2023-003 Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: January 1, 2023 through December 31, 2023 CAP prepared by: Scott Thurmond, Executive Director Telephone: (916) 416-0901 Comments: Management agrees with the finding. Actions: Management has taken steps to ensure the SEFA is prepared accurately and timely.

Views of responsible officials and planned corrective actions: Management acknowledges the omission of the federally contract from the auditee’s prepared SEFA. Management is committed to properly preparing the SEFA, and to address this oversight, management will identify trainings for accounting personnel related to SEFA reporting and for those reviewing the schedule, to ensure its accuracy.

Finding Number: 2023-007 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: Reports in Workday along with new reconciliation workpapers will be utilized to ensure a complete and accurate SEFA in FY2025. Contact person responsible for corrective action: Laura Randall Anticipated Completion Date: 06/30/2025

Finding Number 2023-005 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