Corrective Action Plans

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

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