Corrective Action Plans

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

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

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

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

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

Department: Administrative and Financial Services Title: Internal control over CSLFRF reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will review contracts with the agencies to verify the classifications. Completion Date: June 30, 2024 Agency Contact: Marilyn Leimbach, Director, Security and Employment Service Center, DFPS, DAFS, 207-248-2556

Department: Administrative and Financial Services Title: Internal control over the submission of HAF Program SEFA reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will institute a more rigorous review process for the SEFA going forward. Completion Date: August 31, 2024 Agency Contact: Marilyn Leimbach, Director, Security and Employment Service Center, DFPS, DAFS, 207-248-2556

Department: Transportation Title: Internal control over DOT subrecipient and contractor determinations needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department has reviewed the standards for categorizing vendors and subrecipients. The Department has amended the process to include a substantive review of the initial categorization by a Financial Analyst before the report is finalized and transmitted. Completion Date: February 21, 2024 Agency Contact: Kathleen Malcolm, Financial Processing Director, DOT, 207-624-3292

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

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

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

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

Department of Education 2023-002 Title I, Special Education Grants to States, Career and Technical Education – Assistance Listing No. 84.010, 84.027, 84.048 Condition: The Schedule of Expenditures of Federal Awards (SEFA) contained errors and incorrect information which affected the major program determination. Auditors' Recommendation: We recommend the institution review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Mississippi State University will review and revise its current reporting procedures related to awards reflecting multiple ALNs and sources of funding. The Office of Sponsored Projects and Sponsored Programs Accounting will collaborate, on a case-by-case basis, to ensure federal expenditures are properly identified and classified for reporting on the Schedule of Federal Expenditures. Name(s) of the contact person(s) responsible for corrective action: Kacey Strickland, Executive Director for Research Administration and Jonathan Tucker, Director of Sponsored Programs Accounting Planned completion date for corrective action plan: June 30, 2024 If the Department of Education has questions regarding this plan, please call Jonathan Tucker at 662-325-1930

Department of Health and Human Services 2023-001 R&D Cluster – Assistance Listing No. 93.680, 93.084, 93.059 Condition: The Schedule of Expenditures of Federal Awards (SEFA) contained errors and incorrect information which affected the major program determination. Auditors’ Recommendation: We recommend the institution review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Post-Award Accounting, hired in November 2022, continues to review sponsored award procedures, including procedures and reports integral to our ERP system, Workday. These ongoing reviews will not only include the expenditure amounts reported for sponsored award on the SEFA but will also include the accuracy of other agreement terms and conditions that contribute to the SEFA preparation. A management review process has been implemented to further review agreement terms captured within the Workday ERP system. This additional management review takes place at the time of new award set-up when the manager reviews the new award attributes in Workday for accuracy and alignment to the notice of award document. Additionally, all existing awards, previously established within Workday, are being reviewed to ensure agreement terms are accurately recorded within Workday. UMMC is engaging a Workday Certified consulting firm to review the operational efficiency of Workday for Post-Award Accounting. The scope of this engagement will be to align our usage of Workday to industry best practices, including best practices for award set-up, management, and reporting. The scope of work is expected to be completed by December 31, 2024; however, our own internal reviews of data integrity will be completed by June 30, 2024, with any necessary corrections reflected in Workday. Name(s) of the contact person(s) responsible for corrective action: Julie Schwindt, Director, Post-Award Accounting Planned completion date for corrective action plan: June 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Julie Schwindt at 601-984-1058.

Program: Various, including AL 93.575, 93.596 – CCDF Cluster; AL 93.558 – Temporary Assistance for Needy Families –– Reporting Corrective Action Plan: State Accounting will continue to work with State agencies on correct coding and business unit setup to reduce agency errors. Contact: Philip Olsen Anticipated Completion Date: Ongoing

Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: United States Department of Housing and Urban Development Assistance Listing No.: 14.241, Housing Opportunities for Persons with AIDS Ascension Ministry Market: Illinois Pass-Through Grantor: Aids Foundation of Chicago Federal Grantor: United States Department of Justice Assistance Listing No.: 16.560, National Institute of Justice Research, Evaluation, and Development Project Grants Ascension Ministry Market: Texas Federal Grantor: United States Department of Justice Assistance Listing No.: 16.710, Public Safety Partnership and Community Policing Grants Ascension Ministry Market: Illinois Pass-Through Grantor: The Village of Arlington Heights Police Department Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Ascension Ministry Market: Maryland Pass-Through Grantor: Mayor and City Council of Baltimore, through MONSE Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.650, Accountable Health Communities Ascension Ministry Market: Illinois Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.958, Block Grants for Community Mental Health Services Ascension Ministry Market: Illinois Pass-Through Grantor: The State of Illinois Department of Human Services Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.039, Hazard Mitigation Grant Ascension Ministry Market: Florida Pass-Through Grantor: Florida Division of Emergency Management Views of responsible officials: The System will enhance its grant management award processes by revising its onboarding procedures and add additional controls to monitor the accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting. Award amounts were changed on the Schedule after management’s review was executed. Management will implement preventive controls to lock down market Schedule templates after management final review. Responsible Official: Rob Madsen, Director of Accounting and Reporting, Grants & Research COE Anticipated completion date: May 31, 2024

2023-003 Internal Control Over Financial Reporting Management Response: Management concurs with the recommendation above. Management will ensure policies and procedures over financial reporting which capture all required adjustments necessary to fairly present consolidated financial statements. Since their inception, the Academies had outsourced its accounting function to an outside company. Management has now moved that function in-house and hired a full-time finance director to oversee all accounting functions. The finance director will be responsible for monitoring all financial policies and procedures. Responsible Person: Preston Castille, Jr., Helix Community Schools, President Anticipated Remediation Date: Fiscal year ended June 30, 2024

Program:Various, including AL 20.509 – Formula Grants for Rural Areas and Tribal Transit Program – Reporting Corrective Action Planned: The transit will continue to provide training to all the personnel who handles the information needed to properly calculate the SEFA amounts for future audits. Anticipated Completion Date: June 30, 2024 Responsible Party: Christy Warner, Transit Administrator

2023-006 – Completeness and accuracy of certain programs on the Prior Year Schedules of Expenditures of Federal Awards (SEFA) - (Significant Deficiency) Cluster: Not applicable Sponsoring Agency: Department of Health and Human Services (DHHS) - Health Resources and Services Administration (HRSA), Department of Education (ED) and Federal Emergency Management Agency (FEMA) Award Names: COVID-19 Provider Relief Fund and ARP (ARP) Rural Distribution (PRF), COVID-19 Higher Education Emergency Relief Fund (HEERF) Student Portion, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) and Maternal and Child Health Federal Consolidated Programs Award Numbers: Various Assistance Listing Titles: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 Higher Education Emergency Relief Fund (HEERF) Student Aid Portion, COVID-19 HEERF Institutional Aid Portion, COVID-19 HEERF Minority Serving Institutions, and Maternal and Child Health Federal Consolidated Programs Assistance Listing Number: 93.498, 97.036, 84.425E, 84.425F, 84.425L, 93.110 Award Year: 2020-2021, 2021-2022, 2019-2020, 2021-2023 Pass-through entity: Not applicable Management has implemented additional reconciliation and review procedures over the last two years to improve the accuracy and completeness of the SEFA. · UCOP implemented an annual SEFA review process to include the systemwide Controller and campus Controllers. UCOP also distributed one interim SEFA draft to the External Fund Managers (EFMs) that had historically been tasked with only a year-end review. · UCOP continued to reconcile atypical federal programs (e.g., PRF, FEMA, etc.) and included in the fiscal year 2023 SEFA drafts for campus Controller review. Beginning in FY 2024, UCOP will implement more comprehensive financial reporting controls as follows: · Interim SEFA reports, inclusive of atypical programs, will be prepared centrally and distributed to campuses for review and alignment with campus records. Campus management will be tasked with the responsibility for overall review and signoff for both interim and final SEFA reports. · The Systemwide Controller will also be included in the review process by performing an overall review and signoff for both interim and final SEFA reports. With respect to the specific findings in FY2023 for atypical / nonrecurring federal programs, the following actions have been and/or will be taken: • FEMA: A reconciliation process was implemented within UCOP in FY2023, the result of which was the discovery of the understatement referenced in the finding. FEMA expenses are now reconciled to, and obligation dates retrieved from, the Federal FEMA Grants Portal to ensure project expenses are accurately reported in the proper fiscal year. Data from the State portal is distributed to campuses for validation. UCOP has also reminded campus and medical center Controllers of the reporting requirements and will cover this topic again in future trainings. Additionally, UCOP will remind campuses and medical centers of the requirement to account for the FEMA project in the federal fund range at the time of obligation to trigger SEFA reporting. • PRF – A reconciliation process was implemented by UCOP in FY2022 and the reconciliation itself was completed in FY2023, the result of which was the discovery of the understatement referenced in the finding. PRF expenses reported by campuses are now reconciled to the HRSA online portal which will continue for the duration of the program. UCOP has also reminded campus and medical center Controllers of their responsibility to report on these dollars for their entire enterprise (Faculty Practice Group, School of Medicine, etc.). As with all other federal funding, PRF amounts will continue to be part of the SEFA reports distributed to campuses for review and signoff. Coordination between campuses and medical centers will be expected for this review and signoff. • HEERF – while the program ended in FY2023, UCOP will apply lessons learned to any future “special” funding. When atypical programs such as this are awarded in the future, UCOP will provide more consistent guidance upfront and establish more consistent accounting and reporting requirements for campuses and the medical centers to follow. Requirements will include regular reporting of these dollars to UCOP with a reconciliation of campus ledgers to any sponsor reporting. As with all other federal funding, amounts will be part of the SEFA reports distributed to campuses for review and signoff. • Program Income – UCOP will develop and conduct expanded training to campus Controllers, EFMs and their staff to include SEFA requirements generally, including treatment for program income (and other SEFA exclusions), new review procedures, etc. UCOP will target training for the spring of 2024. For inquiries regarding this finding, please contact Barbara Cevallos at barbara.cevallos@ucop.edu who is responsible for the corrective action.

Prior to the year-end of June 30, 2023, Eagle Academy PCS had several federal grants that were approved and open for drawdown in May 2023. These were all related to grants budget to be reimbursed to the school during the 2022-2023 school year. Due to the late approval of the grants, the school and management didn’t have enough time to submit reimbursement requests and submit amendments. The amendments were submitted during the SB&Company’s audit preparation period. As a result, these amendments were all pending approval even though the expenditures already incurred in FY2023. Management has contracted with a third-party vendor that will be responsible for managing all grant reporting, applications, amendments, and reconciliations. This will strengthen the school year end closing process.

Condition: The SEFA for the year ended June 30, 2023 was not accurately prepared, as it originally included federal expenditures that were not on the cash basis. Planned Corrective Action: The corrective action has been implemented to revise internal procedures to prepare the SEFA on a cash basis for future fiscal years. This includes the creation of a reconciliation schedule to the financial statements which are prepared on an accrual basis. Contact person responsible for corrective action: Jeremy Baker, Director of Finance Anticipated Completion Date: 1/15/2024

Criteria: According to 2 CFR Subpart F Section 200.51Ob, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period that includes all amounts spent on federal programs during the reporting period. Condition: The initial SEFA provided for audit did not agree to the accounting system general ledger expenditures for certain awards. In addition, not all federal awards were appropriately identified and included on the SEFA. Cause: PPHS had significant turnover in finance personnel during the 22-23 school year. In addition, the SEFA was prepared utilizing federal award revenue. Lastly, one award was incorrectly identified as other revenue instead of federal award revenue. Effect: The total federal award expenditures reported on the initial SEFA were reduced by $198,208. The following awards were reduced on the SEFA to agree to award expenditures by the following amounts: National School Lunch Program 10.555 $125,864, Charter Schools Program 84.282A $32,555, Elementary and Secondary School Emergency Relief 84.425D $92,405, and Emergency Connectivity Fund 32.009 $109,450. The following award was added to the SEFA Coronavirus State and Local Fiscal Recovery Funds 21.027 $164,766. Corrective Action Plan - PPHS had significant turnover in finance personnel during the 22-23 school year. For FY24, we contracted with accounting consultants to assist with improving grant tracking and reporting. We posted a Staff Accountant position in January 2023 to assist with internal grant management and are hoping to fill this position in FY24 03. Contact Person(s) Responsible for CAP- Todd Burleson, Financial Controller. Anticipated completion date - Processes were improved in FY24 through assistance from accounting consultants. We anticipate hiring a Staff Accountant before 3/31/24.

Federal Program Title: Research and Development Cluster ALN: Various Recommendation: We recommend the University evaluate its cutoff procedures to ensure federal costs are identified and reported in the correct fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Boise State University will evaluate our cutoff and accrual procedures to ensure costs are identified and reported in the correct fiscal year. Name(s) of the contact person(s) responsible for corrective action: Jen Lutke, Assistant Director, Post Award: jenniferlutke@boisestate.edu Planned completion date for corrective action plan: June 2024

SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Department of Environmental Protection (DEP) Assistance Listing Number 15.252 Effective March 2024, DEP will develop and implement a standard operating procedure to track indirect costs. DEP will create a separate spreadsheet to track indirect costs to be included in the year ending SEFA reporting. DEP will attend training sessions conducted by the West Virginia Financial and Accounting Reporting Section to ensure all expenses are reported correctly on the SEFA. Additional training from accredited educational institutions will also be researched if necessary.

Condition: The schedule of expenditures of federal awards (SEFA) was not complete and accurate. Planned Corrective Action: The City will be implementing a procedure whereby the Controller’s Office receives copies of all contracts to ensure all reporting requirements are met and financial deliverables are completed according to the schedules. Contact person responsible for corrective action: Brandy Ruth Anticipated Completion Date: June 2024