Corrective Action Plans

I was a newly elected official in 2023 with no prior training in the County Clerk’s office. After this finding was brought to my attention, I created a process where all grants received are tracked as are the expenditures for each grant so they can accurately be reported.

I was not the clerk in 2023, so I don’t feel as I can respond, however, I will work to see this is resolved. We are implementing new software to better track all financials.

Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity 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 Federal awards expended as determined in accordance with CFR Section 200.502(a) and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Planned Corrective Action: County management will develop a closing process to ensure all federal expenditures are identified, recorded, and reconciled on the SEFA. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

The Board of Directors hired Gorman Management Company (GMC) on March 1, 2024, to operate the property, Ardmore Village. GMC has extensive experience in the on-site and financial management of properties like Ardmore Village. Specifically, GMC has procedures in place to maintain compliance with the regulations applicable to the Section 8/202 program and the FHA Section 223f program. GMC is well versed with CFR §200.512 (single audit data collection form), HUD Handbooks 4350.3, 4370.2 and 4381.5. GMC manages over 40 properties that have similar reporting and auditing requirements. All of the issues related to these findings will cure through GM C's policies and procedures.

Finding No. 2023-006: Inaccurate Reporting on the Supplementary Schedule of Expenditures of Federal Awards ALN and Program Expenditures: 97.036 ($5,258,177) Program Name: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Corrective Action: Process Improvements: - The University will establish a Supplementary Schedule of Expenditures of Federal Awards (SEFA) controls narrative to formalize preparation and reconciliation processes of SEFA data. - The central University Research Administration team (URA), in coordination with Finance and Administration, will review SEFA preparation and data collection processes and establish a formalized reconciliation process. - Biannually, URA will conduct third party searches to verify funding received at each entity. Expected Implementation: August 2024 – December 2024 Contact: Jennifer A. Ponting (Associate Vice President, Research Administration)

Due to no fault of Southern Workforce Board, Inc., and circumstances beyond the previous CAP's control, the audit report for the period ending 6/30/2023 was not completed as required. Upon notification of prior audit firm closing, Southern Workforce Board, Inc. performed an immediate procurement by soliciting a Request for Proposal to 13 audit firms. Upon completion of the procurement, Michael Green, CPA was selected to perform the 6/30/2023 audit as soon as their schedule would allow. Upon successful completions of 6/30/2023 audit report, the audit process for the period ending 6/30/2024 will proceed on time. Southern Workforce Board, Inc. will ensure in the future that the audit firm selected will be able to perform the planned audits in a timely manner in the future.

Material Weakness over Schedule of Expenditures of Federal Awards (SEFA) Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday is “live” as of August 2022, the City is currently working to refine the software and fully utilize functionality. The Workday grants modules requires the grant funding source be defined prior to grant approval and fields are available for the AL titles and numbers and sub-recipients’ information. The implementation of the Workday grants modules centralizes much of the grant management function by requiring the agencies to upload the grant documents into Workday. The City has: • Held weekly meetings for two years with agency grant representatives to design and configure the Workday grant module. • Uploaded the grant award, sponsor information and grant budget data into a Workday. • Implemented a “new grant” request which uses a Workday business process. • In the process of reviewing and correcting recoverable costs per grant award so it is properly recorded. • Within Workday we are able to track grant performance period, CFDA, manage and capture grant related expenditures and calculate automated billing to sponsors on recoverable costs Business processes have been developed and implemented in Workday’s grant management module to include: Definition of the grant funding source by creating a system-generated grant work tag (identifier) upon receipt of the Sponsor’s Notice of Award; populated fields in Workday with passthrough award data with Prime Sponsor and Bill to sponsor Billing data, and modification of the create award process to add the Grants Management Office to final approval. In FY 24 the City implemented a citywide Grants Management Committee coordinated by the Mayor's Office of Performance and Innovation. Through feedback from this workgroup we identified an expanded scope of responsibility for the Grants Management Office; including oversight and compliance, technology, training and budget monitoring. In the short term a new Grants Director position was created and onboarding is to occur in the first quarter of FY25. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City. Completion Date: June 2024

Condition: The Authority did not identify that they were subject to an audit under the Uniform Guidance (U.G.) and a schedule of expenditures of federal awards (SEFA) was not prepared by management. Recommendation: The Authority should review federal, state, and local grants to determine if they are federally funded and, if federally funded, utilize the account number outlined in the State of Michigan chart of accounts to track federal funding. Planned Corrective Action: A schedule of federal awards will be created to track total costs covered by federal awards beginning in FY24. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

The Treasurer will review the Schedule of Expenditures of Federal Awards to ensure all federal awards are being reported and the expenditures are properly reported.

Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Finding: 2023-011 Contact Person: Sarah Castillo Grants Accounting Officer Emergency Operations Center (EOC) Finance Division Phone: (562) 570-5479 Email: Sarah.Castillo@longbeach.gov Planned Actions: The Emergency Operations Center (EOC) Finance division acknowledges there has been deficiencies in the manner we report expenditures related to a declared disaster on the SEFA, which will be addressed by issuing a Financial Management Disaster Procedure Manual that will include a narrative on this specific matter. The manual will be published on our City Intranet and utilized for all City Staff as a resource for all future disasters that occur. Revisions to the Procedure Manual will be made as needed to ensure we are up to date with the latest compliance changes. Expected Completion Date: 12/31/2024

Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Department of Agriculture Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Expenditures of federal awards and not be detected and corrected. Because the Auditee’s SEFA was completed incorrectly, and not reconciled to the general ledger the SEFA was materially misstated, prior to auditors’ correction recommendations.   Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • No reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: October 1, 2024 Responsible Person: Director of Business Services, Yamhill County School District No. 8

This audit has taught me a lot concerning what is required with the SEFA report in the County Budget process. I will print out a copy of all Community Development Block Grant Funds that were expensed in the year in a report from QuickBooks. I will include those with the SEFA (Schedule of Expenditures of Federal Awards) report. I will also follow up with Alan Lutes, Executive Director with Ozark Foothills Regional Planning Commission, when I complete the SEFA report and have their office review the report to make sure all Community Development Block Grant Funds are included that were expenses that year from their office. In addition, I will include all supporting documents in the budget process to review with the County Commissioners at the time of the budget approval.

Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Department of Agriculture Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Expenditures of federal awards and not be detected and corrected. Because the Auditee’s SEFA was completed incorrectly, and not reconciled to the general ledger the SEFA was materially misstated, prior to auditors’ correction recommendations.   Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • No reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: October 1, 2024 Responsible Person: Director of Business Services, Yamhill County School District No. 8

Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 66.468 Drinking Water State Revolving Fund Name of Federal Agency: Environmental Protection Agency Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was not presented for audit. The City was unaware that funds borrowed through Business Oregon were federally sourced. Cause: The loan documents that were provided to the City were modified and date back several years. No individual, including those employed by the City, project managers engaged by the City, and pass-through managers were apparently aware that the loan proceeds were from federal sources. Consequently, no internal controls were designed or implemented regarding accounting for or preparation of the SEFA. The City did not provide a reconciliation of the expenditures of federal awards with amounts reported on the City’s general ledger. Effect or Potential Effect: Expenditures of federal awards and not be detected and corrected. Because the Auditee’s SEFA was completed incorrectly, and not reconciled to the general ledger the SEFA was materially misstated, prior to auditors’ correction recommendations.   Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • No SEFA was originally presented for auditors. • No reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: Yes 2022-002 Recommendation: We recommend that the City establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The City should provide appropriate training to staff who are assigned to prepare and review the SEFA. City’s Response: The City acknowledges the deficiencies. Corrective Action Plan: The City will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: October 1, 2024 Responsible Person: City Manager

Highway Planning and Construction - Assistance Listing No. 20.205; Passed through Pennsylvania Department of Transportation, Grant Period - Year Ended December 31, 2023. Corrective Action, Person Responsible, and Anticipated Completion Date: See deficiency 2023-002. SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Condition: Although management prepared a draft of the SEFA, it was incomplete and contained inaccurate information. Corrective Action: We will correct the process of preparing the draft SEFA for next year’s audit and now know the proper way to complete it. Persons Responsible: Bill Burdett, Township Manager Anticipated Completion Date: Beginning January 1, 2025

Finding 2023-002 Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 21.027 / 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 Reporting

Material Weakness, Inaccurate Schedule of Expenditures Of Federal Awards (The SEFA) Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls by implementing additional training and oversight of personnel to ensure the SEFA accurately reflects all federal expenditures for the fiscal year properly. The County is in the process of implementing an accounting software package with a corresponding month and year-end closing process to ensure balances are reconciled and reviewed.

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

2023-001 – Preparation of the Schedule of Expenditures of Federal Awards Individual Responsible for Corrective Action Plan Jennifer Maher, CFO Londilia McCoy-Scott, Director of Contract and Grant Accounting Anticipated Completion Date: December 31, 2024 Corrective Action Plan: In reconciling the 2023 grant expenditure activity, management identified that some grant expenditures from 2022 were not included in the 2022 Schedule and self-disclosed this anomaly to the auditor. These expenditures were then incorporated in the 2023 Schedule to ensure that they were reported as timely as possible. Grants management staff from Finance and Program departments are meeting monthly to ensure that the expenditures are recorded in the appropriate year.

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-004 Significant Deficiency in Internal Control—Schedule of Expenditures of Federal Awards (SEFA) Program(s): National Bioterrorism Hospital Preparedness Program (ALN 93.889); Immunization Cooperative Agreements (ALN 93. 268); COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)(ALN 93. 323); Child Support Services (ALN 93. 563); State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (ALN 10.561) Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matter Compliance Finding Condition: While testing the SEFA, we noted that internal controls were not operating effectively over the preparation of the SEFA. In addition, we noted the following errors in the original SEFA we received for the audit: • $1,284,631 of expenditures were improperly included in ALN 93.889 when the amount should have been included in ALN 93.268. • $30,394 of expenditures was improperly included in ALN 93.889 when the amount should have been included in ALN 93.323. • $626,894 of expenditures related to ALN 93.563 was missing from the schedule. • $61,290 of expenditures related to ALN 10.561 was missing from the schedule. Hennepin County’s Corrective Action Planned in Response to Finding: The County will continue to strengthen controls over the preparation of the SEFA. Hennepin County Employee Responsible for the CAP: Elena Doran Planned Completion Date for CAP: September 30, 2024

During our review of the December 31, 2023 Schedule of Expenditures of Federal Awards (SEFA) prepared by management, we noted that controls over the preparation of the SEFA were not properly designed resulting in adjustments to the SEFA for amounts passed through to subrecipients that were identified during the audit. Recommendation: We recommend management review current internal controls over preparation and tracking of federal expenditures to ensure that all federal awards are captured and reported in the correct period and that internal controls are properly designed to detect and correct errors to the SEFA. Views of Responsible Officials and Planned Corrective Action: ACT accepts the auditors' recommendation. In preparing the SEFA for future Single Audit periods, ACT will update its processes to include a more rigorous review of the SEFA schedule prior to submission to the auditors. The process will include preparation of the SEFA by ACT’s accounting team, followed by a review and signoff by ACT’s Program Officer and the CEO. An internal schedule prepared by the accounting team that totals amounts separately for beneficiary payments and for subrecipient pass-through payments will be included as part of the review process for the SEFA and presented for signoff by the Program Officer and CEO. For further discussion, please contact Heather Peeler, President and CEO at healther.peeler@actforalexandria.org. 703-739-7778.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Office of Administration Audit Finding Number: 2023-011 OA Statewide SEFA Name of the contact person responsible for corrective action: Stacy Neal Anticipated completion date for corrective action: September 30, 2024 Corrective action planned is as follows: We agree. DOA completed a materially correct SEFA within historically consistent timeframes including providing the document 3 weeks earlier than last year. However, after recent discussions with SAO, DOA does acknowledge a materially correct draft is needed by October to support an efficient single audit and we will provide the document on that timeframe next audit. DOA further recognizes that there are always opportunities for improved training, reduced turnover, and efficient communications.

Management recognizes the importance of maintaining proper documentation for grant expenditures and has implemented the following corrective measures to address the deficiency: 1. Development of Comprehensive Documentation Guidelines: We have developed detailed guidelines outlining the specific documentation requirements for all grant-related expenditures. This includes mandatory documentation such as receipts, invoices, contracts, and timekeeping records, as well as detailed descriptions of each expense. 2. Centralized Repository for Grant Documentation: A centralized, secure digital repository has been established to store all grant-related documentation. All departments are now required to upload supporting documents immediately after incurring expenses, ensuring they are readily accessible for review and audit purposes. 3. Staff Training on Documentation Requirements: We have initiated a mandatory training program for all fiscal staff involved in grant management. This training covers the specific documentation and reporting requirements for federal, state, and private grants, emphasizing the importance of complete and accurate records. 4. Strengthened Review and Approval Process: We have enhanced the internal review process for grant expenditures. All grant-related transactions will be subject to a secondary review by the controller and Chief Financial Officer to ensure that the necessary supporting documents are included and expenditures are properly classified and documented. Management will closely monitor adherence to the new documentation policies and conduct quarterly audits to assess the completeness and accuracy of the records. Any discrepancies or missing documentation will be addressed promptly, and corrective actions will be taken to prevent recurrence. Management is fully committed to maintaining detailed and accurate records for all grant expenditures. The actions outlined above are designed to strengthen internal controls, ensure compliance with grant requirements, and support future audits with comprehensive documentation.

To address the identified weaknesses and strengthen internal controls over the preparation of the SEFA, management has initiated the following actions: 1. Establishment of Formal Policies and Procedures: We have developed and implemented a formal, written policy for the preparation and review of the SEFA. This policy outlines clear roles, responsibilities, and timelines for all departments involved in the process. 2. Centralization of Data Collection: We are centralizing the process of collecting expenditure data, which will be overseen by a designated team within the fiscal department. This will ensure consistency and accuracy in reporting across all departments. 3. Staff Training and Development: Key personnel involved in SEFA preparation are undergoing specialized training on federal, state, and city compliance requirements. This includes training on the proper classification of awards and expenditures. 4. Internal Review and Monitoring: A second layer of review has been introduced to verify the accuracy and completeness of the SEFA before it is submitted. A senior financial officer will perform this review, ensuring that any discrepancies are identified and corrected before submission. Management will implement ongoing monitoring to ensure adherence to the new policies and procedures. Quarterly reviews will be conducted to assess the accuracy of the data and the efficiency of the control measures. Management is committed to maintaining robust internal controls over the preparation of the SEFA to ensure the timely and accurate reporting of federal, state, and city awards. The actions outlined above are designed to prevent the recurrence of this deficiency and ensure full compliance with regulatory requirements.

Management Response Expenditure amounts in the Schedule of Expenditures of Federal Awards (SEFA) included reimbursable costs allocable to the contract only. Revisions were made during the audit process for costs in excess of the contract award amount and post award costs. Identification of subrecipients vs contractors is addressed in the response to finding 2023-005. The new monitoring policy includes the difference between the two and provides for education in identifying the services appropriately. Corrective Action Plan This was the first time the organization had to prepare the SEFA and was inexperienced in the requirements. The Garden has hired a new Director of Finance who will attend training specific to federal grants reporting in order to ensure that the 2024 SEFA is prepared correctly. The Garden has now documented its Federal Subrecipient Monitoring Policy. Education on and reverification of proper processes regarding federal subrecipient monitoring transactions will be taken by all principal investigators. Contact person(s) responsible for the corrective action: Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org. Anticipated Completion Date: The Director of Finance is registered for a September 2024 training on federal grants. The subrecipient policy is in writing. Education on that policy will be complete by August 31, 2024.