Corrective Action Plans

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

2022 - 008: Reporting: Preparation of the Schedule of Expenditures and Federal Awards (SEFA) (Repeat Finding:2019-007 and 2020-007 and 2021-006) Condition: During fiscal year 2022, the Governmental Department did not have sufficient controls to ensure the SEFA accurately reflected each award’s federal expenditures. There were differences noted in reconciling expenditures from the original SEFA to the trial balance, and it was discovered that certain adjustments for grants receivable, unearned revenues and grant revenue had not been made in order to properly report total federal expenditures. These errors were corrected through adjustments proposed as part of the audit, and the final version of the SEFA reconciles to the Governmental Department’s general ledger. Corrective Action Plan: Management of the Tribe realizes the importance of the SEFA and will be sure that the SEFA matches the general ledger and accurately reflect each awards federal expenses. The internal task list to be developed will include reconciliations from the trial balance to the SEFA on a least a quarterly basis

Responsible Parties: Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover) Gateway’s Management will utilize the implemented Matrix duties and responsibilities Grid to help monitor the documentation of required procedures and Standard Operating Procedures approved by the Board of Directors. The health center will use the approved Financial Policies and Procedures Manual as its Standard Operating Procedures. The Health Center’s Management employs key management staff that reflects the size and composition of a health center. Ongoing evaluations will be used to monitor the qualifications of the staff. This Audit is a late submission, however with the submission a qualified Chief Financial Officer is in place and has the qualifications needed to assess and train staff accordingly and provide recommended changes to the department. This new Chief Financial Officer will serve as a technical resource to assist with the implementation of all the resolutions to the findings of the 2022 and 2023 audits

Finding Number: 2022-003 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: The federal funding was not received until fiscal year 2023 while some expenditures were incurred in fiscal year 2022. The timing of events contributed to the oversight on the 2022 SEFA. WakeMed has reeducated staff on the preparation of the SEFA in order to prevent this error from reoccurring.Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

Action Taken: Management is in the process of instituting additional procedures to ensure all awards are assessed not only to identify whether sources of funds are Federal, requiring inclusion on the SEFA, but also to identify continuing compliance period when applicable. Management has also conducted internal training relative to applicable 2 CFR 200 regulations and requirements and will continue to provide periodic staff training to ensure continued compliance. Anticipated Completion Date: Management estimates that additional processes will be in place by December 31, 2024.

The Township Fiscal Officer will prepare the SEFA or contract with a CPA firm to have the SEFA prepared going forward.

Management accepts this finding. A detailed set of procedures was documented immediately after the discovery of this error in preparing the Schedule. Included in these procedures, a query is run of research projects. This query is sent to Sponsored Research Services (SRS) to review to verify the reporting status and AL numbers, and other items are correct and complete. Once SRS has verified the data in the query is complete and accurate, then the Controller’s office will proceed with preparing the Schedule as well as reconciling it to the Statement of Activities (SOA) In the procedures, we have added that SRS and the Controller, and/or Chief Financial Officer review the Schedule prior to initiation of the audit review process.

Internal communication processes for direct pay projects were used in conjunction with ODOT reports to capture these offsetting revenues and expenditures as well as the additions to capital assets in 2023.

RE: Corrective Action Plan for Single Audit for the Year Ended December 31, 2022 (REF #2022-001) Finding: One federal award expenditure amount was incorrectly reported on the initial Schedule of Expenditures of Federal Awards (SEFA). Total expenditures of $2.1 million reported for the Coronavirus State and Local Fiscal Recovery Fund were increased by $3.4 million to bring the final expenditures total for the cluster to $5.5 million for the year ended December 31, 2022. Cause: Internal controls and review processes were not in place to ensure the accuracy of expenditures reported on the annual SEFA. Recommendation: Management should implement procedures to help ensure that controls are in place that will allow for the accurate preparation of the SEFA. We recommend that the County perform a detailed analysis of expenditures for all significant awards on an annual basis. Corrective Action Plan: Effective immediately, the County will put in additional controls and verify all grants are monitored under additional scrutiny and are reported accurately in quarterly reports and the County’s Annual Comprehensive Financial Report (ACFR). Staff Responsible for Implementation: Matt Davis, County Auditor; Mike Sloan, Senior Associate; Jordan Wilson, Grant Associate Implementation Date: December 31, 2024 Status: In progress

We recommend that management either 1) provide training for its key accounting personnel so that they will be able to prepare SEFA and CYEFR for the County and/or 2) contract with an accountant or firm that has the relevant skills, knowledge and experience to prepare the SEFA and CYEFR. We further recommend that the Board of Commissioners enforce the County’s policy of requiring that all accounting records and related supporting documentation be made available to the County Treasurer so that there is a process in which all of the County’s financial activity pertaining to grants is compiled, reconciled and included in a complete set of grant financial reports utilized to prepare the SEFA and CYEFR for the County.

Federal Award Finding and Questioned Costs Finding Reference: 2022-004 – Other finding – SEFA Preparation Federal Program Information Federal Agencies: United States Department of Homeland Security Awards: Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) Award Periods: January 20, 2020 – May 11, 2023 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation The System should update its policies and procedures and internal controls, specifically the process to accumulate and report FEMA expenditures of federal awards to be in accordance with the FEMA Schedule requirements outlined above. View of responsible officials The System agrees with the comment and has developed a plan to correct the finding. Corrective Action Planned The System has trained all applicable staff on the appropriate interpretation of FEMA Public Assistance Grant Program guidance for reporting Assistance Listing 97.036 expenditures in the SEFA. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Planned completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2024

The School District will review the Uniform Guidance requirements and ensure all expenditures are accurately reported on the School District’s federal schedule.

Finding 2022-003: Reconciliation of Accounts Federal Program: Research and Development Cluster (Education and Human Resources)Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1500529 (9/1/2015 – 8/31/2022), 1640791 (9/15/2016 – 8/31/2022) Condition: The year-end schedules for federal grants receivable, net assets, and for vacation payable were not reconciled and needed to be revised and updated. Views of Responsible Officials and Planned Corrective Actions: The outstanding liability due to NSF of $115,244 will be reimbursed when AAPT files the next drawn down request. Anticipated date of drawn down will be by July 31,2024. The senior accountant will be trained to prepare entries previously prepared by the CFO The senior accountant will reconcile accounts, and provide updated current schedules. The CFO will review and approve the entries and schedules prepared by the Senior accountant. Anticipated Completion Date: 10/15/2024 Responsible Official: Michael Brosnan, CFO

The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditors firm to comply with such requirements.

AUDIT FINDINGS 2022-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, review controls over the accuracy and completeness of the Schedule were not designed to operate at an appropriate level of precision for the discretely presented component unit. As a result, $1,795,854 of FEMA expenditures was inadvertently omitted from the December 31, 2022 Schedule. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Implement a control of management review at an appropriate level of precision for the discretely presented component unit in order to ensure the accuracy and completeness of the Schedule. Anticipated Completion Date: September 2023 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2022-001.

Fremont County was assessed a Federal Awards Finding for the 2022 Audit year by Certified Public Accountants, Logan and Associates, LLC, for Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.512(a) and 200.510(b) . The regulation requires the County to determine the amount of Federal awards expenditures during the year and to properly report these expenditures in the schedule of expenditures of federal awards. After the assessment Fremont County has identified areas of improvement including internal controls. Staff members will implement monthly controls to be in compliance with the Federal Award requirement moving forward with the grant administrator. Staff members will also be encouraged to take annual Federal Award courses provided by Colorado Government Finance Officers Association or other similar entities. Fremont County will continue to enhance and streamline training for new and existing personnel, in the finance department, and implement new preventive controls. Fremont County believes these steps will improve timely and accurate submission for the Federal Awards.

Views of Responsible Officials QHS agrees with the finding and accepts the recommendation.

Finding 2022-003: Reconciliation of Accounts Federal Program: Research and Development Cluster: 47.076 Condition: The year-end schedules for federal grants receivable, for net assets, and for vacation payable were not reconciled and needed to be revised and updated. Views of Responsible Officials and Planned Corrective Actions: The outstanding liability due to NSF of $115,244 will be reimbursed when AAPT files the next drawn down request. Anticipated date of drawn down will be by July 31,2024. The senior accountant will be trained to prepare entries previously prepared by the CFO The senior accountant will reconcile accounts, and provide updated current schedules. The CFO will review and approve the entries and schedules prepared by the Senior accountant. Anticipated Completion Date: 08/01/2024 Responsible Official: Michael Brosnan, CFO

Finding: 2022-001 Material Weakness over SEFA Preparation Federal Agency: U.S. Department of State Federal Program: Overseas Refugee Assistance Program for Near East (ALN 19.519) Contact Person: Corey Dillow, Senior Managing Director, Financial Controller Criteria 2 CFR 200.510 (b)(3) requires non-Federal entities receiving Federal award to (at minimum) provide total Federal awards expended for each individual Federal program and the Assistance Listings Number. Internal controls around the identification of ALNs and reporting of the SEFA should ensure proper presentation for each ALN number. Condition and Context During our planning meetings with management, we were notified that an award was recorded to an incorrect ALN in the 2022 Schedule of Expenditures of Federal Awards. The 2022 Schedule of Expenditures of Federal Awards was corrected and an additional major program, Overseas Refugee Assistance Program for Near East (ALN 19.519), was identified. Corrective Action: As result of the finding, management will be implementing the below steps to further refine internal controls in the identification and reporting of ALNs in the SEFA by: 1. Reinforcing the importance of ALN assignment and tracking through training. 2. Including the ALN attribute as a required element for award setup reviews. 3. Conducting periodic checks of ALNs to source agreements. 4. Documenting and performing additional SEFA data quality checks. Anticipated Completion Date: July 2024

All future federal expenditures will be reconciled to the disbursement ledger.

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 TRANSPARANCY 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 SUPPORITNG 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 PERFOMRED MONTHLY OR QUARTERLY TO IDENTIFY DISCREPANCIES PROMPTLY. 9. INTERNAL CONTROLS AND MONITORING: STREGTHEN 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.

We agree with the auditors’ finding, moving forward all SEFA's will be reviewed by 2 team members to ensure accuracy.

Federal Program Special Education Cluster - Passed through the Berks County Intermediate Unit ALNs 84.027 and 84.173 Education Stabilization Fund - Passed through the Pennsylvania Department of Education ALN 84.425 Criteria Per the Uniform Guidance 2 CFR 200.510, the auditee is required to prepare a schedule of expenditures of federal awards (SEFA). Condition The District prepared a SEFA and provided information relating to the federal programs including grant agreements and other supporting documentation. However, the SEFA prepared by the auditee required material adjustments as a result of audit procedures. Cause The District had turnover in the assistant business manager and other business office positions during and subsequent to year end. As a result of the turnover, certain account reconciliations were not performed prior to the audit, which included amounts reported on the SEFA. Effect Amounts reported on the SEFA provided by the auditee were not accurate. The SEFA was subsequently updated through audit procedures, including inquiry and review of grant documentation of awards received and amounts expended. Questioned Costs None. Context A SEFA was prepared by management; however, several adjustments were required in order for the schedule to accurately reflect the current year activity. Repeat Finding No. Recommendation In order to meet Uniform Guidance requirements, the District should prepare the SEFA from the grant award documentation and any other relevant information including the assistance listing numbers, grant award amounts, grant amounts received, grant amounts expended, and grant revenue recorded. The amounts reported in the SEFA should reconcile to the general ledger. Management Response Exeter Township School District had turnover in their business office during FY22 and in the first part of FY23, new employees were hired and trained. The new Assistant Business Manager is undergoing training in grant management, allowable costs, funding streams and report preparation. The Business Administrator will review all grant reports prepared by the Assistant Business Manager and oversee the preparation of the SEFA utilizing the grant reports that reconcile to the general ledger, information included in grant award agreements, and grant amounts received.

Finding 2022-006The Corporation management agreed with the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls. The below wording was added to the SEFA Preparation Memo, which is used to prepare the SEFA each year.a. Grants listed on the prior year are reviewed to determine if the grant is still active or if the grant has closed out.i. For grants that have closed the ending dates of the grant are verified, and current year activity is reviewed to ensure that all activity for that grant has been properly accounted for.Responsible Personnel include Harley McCoige, Controller and Cortney Couture, Director of Accounting.

The UWGC Senior Director of Finance will prepare the SEFA in accordance with an accrual basis of accounting to be consistent with the presentation of the financial statements. The UWGC Chief Financial Officer will perform a second review to ensure that Federal funds are reported in the correct time period and an accrual basis of accounting is utilized for the accurate completion of the Schedule of Federal Awards prior to being presented for audit.