Corrective Action Plans

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.

Corrective action plan: The Department will work with their accounting consultant to properly prepare the SEFA. The Department will verify all Assistance Listing Numbers and make all necessary adjustments prior to submitting the SEFA to the auditors. Personnel responsible for corrective action: Lisa Donham (Finance Manager) and contracted CPA consultant Estimated corrective action completion date: February 28, 2025

Research Administration will implement a new standard operating procedure to review and update labor distribution allocations on a quarterly basis to timely identify any changes required to prevent any manual adjustments in future periods. The process for effort certification has also been created to generate statements that will be verified each quarter to confirm effort allocations are correct. The Accounting department will update the review procedures for the preparation of the draft Schedule of Federal Awards (SEFA) to include an additional level of review by the Assistant Vice President, Accounting. Her review process will include a focus on manual adjustments if required to reconcile the draft SEFA to the underlying general ledger accounting details to ensure the completeness and accuracy. Corrective action to ensure timely effort reporting changes will be complete by November 30, 2024. Corrective action to ensure a complete and accurate SEFA will occur during the preparation of December 31, 2024, draft SEFA.

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-003 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the City prepare financial statements that reflect its financial position, results of operations or changes in net position, and, where appropriate, cash flows for the fiscal year audited, including the Schedule of Expenditures of Federal Awards (SEFA) for the year ended December 31, 2023, which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. Management is responsible for establishing and maintaining effective internal controls over compliance with requirements applicable to federal programs, including separately tracking federal expenditures within the finance system to provide for accurate preparation of the SEFA. Corrective Action Plan Actions Planned – The City plans to review its internal control procedures over reporting and verify completeness of expenditures reported on the SEFA in the future. Official Responsible – Sally Vogel, Finance Director. Planned Completion Date – December 31, 2024. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – Sally Vogel, Finance Director, will continue to work with staff to review its internal control procedures over reporting and verify completeness of expenditures reported on the SEFA in the future.

2023-003 Reporting Compliance Requirement Finding Summary The School did not have sufficient controls in place to ensure completeness of the Schedule of Expenditures of Federal Awards (SEFA) and compliance with this requirement. The School’s SEFA was understated by $507,980 in federal expenditures related to the Comprehensive Literacy Development federal program. Corrective Action Plan Actions Planned – The School has implemented new processes and procedures in 2024 which address this internal control finding to comply with the Uniform Guidance in the future. Official Responsible – Matthew Cisewski, Executive Director. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The School agrees with this finding. Plan to Monitor – The School’s Executive Director, Matthew Cisewski, will ensure the new process and procedures implemented address internal controls and procedures in this area to ensure future federal grant compliance.

2023-001: Congressional Directives SEFA Reporting Federal Agency: Department of Health and Human Services (“HHS”), Health Resources and Services Administration (“HRSA”) Assistance Listing Program Title: Congressional Directives Federal Award Project Title: Community Project Funding/ Congressionally Directed Spending ‐ Construction Assistance Listing Number: 93.493 Federal Award Identification Numbers: CE146569, CE152406, CE152466 Management acknowledges that during the fiscal year ending December 31, 2023, Jamaica Hospital Medical Center (“Jamaica”) did not properly apply the accrual basis of accounting for the Congressional Directives Grant, which affected the accuracy of reporting on the Schedule of Expenditures of Federal Awards (SEFA). To prevent future errors in SEFA reporting related to the accrual basis of accounting, Jamaica will implement the following controls and procedures: 1. Appointment of Grant Coordinator In 2024, James Farrell was hired as the Assistant Director of Development and Contract Management. Mr. Farrell will serve as the primary coordinator for all grant-related requirements, ensuring expenses are reported on the accrual basis of accounting on the SEFA. 2. Implementation Timeline These controls and procedures will be fully implemented by the end of the third quarter of 2024. Management responsible for corrective action plan: James Farrel, Assistant Director of Development and Contract Management (jfarrel1@jhmc.org) Manzar Sassani, Vice President of Finance (msassani@jhmc.org) Mark Abboud (maboud@jhmc.org) Yesenia Torres (ytorres@jhmc.org)

Condition: The schedule of expenditures of federal awards (SEFA) was not complete and accurate. Planned Corrective Action: The Albion College Business Office has established revised procedures for SEFA funds, in tandem with the Financial Aid Office, in which all Federal Awards and Grants will be reconciled on a quarterly basis, to be completed no later than the end of the first proceeding month of the quarter. The procedures create a dual-control process for the drawdown, recordation, and reporting of SEFA funds. Additionally, in FY24, the Perkins portfolio was divested. The Perkins Close-out will be part of the FY24 Single Audit. Contact person responsible for corrective action: W. Scott Roberts Anticipated Completion Date: 06/30/2024

Appendix A - Management’s Corrective Action Plan Year Ended December 31, 2023 2023-001 Significant Deficiency in Compliance and Internal Control over Compliance with Reporting (Preparation of the Schedule of Expenditures of Federal Awards) Corrective Actions: 1. Utilize attribute/field in accounting system: • Leverage the existing attribute/field in the accounting system to capture R&D/cluster classification information for each federal award. • Completed 2. Provide training and awareness: • Educate relevant staff on the importance of accurate award classification, including the criteria for R&D/cluster classification and procedures for tracking and SEFA reporting. • Initial training completed; ongoing regular sessions planned 3. Reinforce award classification during award setup: • Ensure award classification is consistently considered and accurately captured during the award setup process. • Provide clear instructions and reminders to encourage staff to complete this critical step. • Ongoing 4. Regularly review and verify award classifications: • Perform regular internal audits, reviews, and verifications to ensure award classifications are accurate, consistent, and compliant with established procedures. • Ongoing, with initial review completed within 90 days Individual(s) Responsible for Corrective Action Plan Name: Robert M. Buchanan Position: Vice President, Controller, and Treasurer Contact number: (202) 261-5322

No response was provided.

2023-004 – SEFA REPORTING Recommendation: We recommend that the Council implement controls over financial reporting, including the SEFA, to ensure the accuracy of financial data. Action Taken: As part of the agreement with Matheny and Company, the Senior Manager will review all period-end documents and financial reports to ensure that transactions, including SEFA documentation, are recorded and reported in the correct fiscal year.

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS 2023-005 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the Academy prepare appropriate financial statements, including the Schedule of Expenditures of Federal Awards (SEFA) for the year ended June 30, 2023, which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. Management is responsible for establishing and maintaining effective internal controls over compliance with requirements applicable to federal programs, including separately tracking federal expenditures within the finance system to provide for accurate preparation of the SEFA. During our audit, we noted the Academy did not have sufficient controls in place to ensure completeness of the SEFA and compliance with this requirement. The Academy’s SEFA was understated by $158,815 in federal expenditures related to the Emergency Connectivity Fund federal program. Corrective Action Plan Actions Planned – The Academy will implement new processes and procedures which address this internal control finding to comply with the Uniform Guidance in the future. Official Responsible – The Academy’s Executive Director, Farhiya Einte. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The Academy agrees with this finding. Plan to Monitor – The Academy’s Executive Director, Farhiya Einte, will assure appropriate internal controls and procedures are in place to ensure compliance with reporting compliance requirements in the future.

Views of Responsible Officials and Planned Corrective Actions: In 2024 during the SEFA analysis and in discussion with auditors it was determined that a USG-funded contract, attached to a grant, was incorrectly left off the SEFA. This was amended as soon as the mistake was noted. AL is required to submit financial statements to a non-US Government donor by June of each calendar year. To comply with this grant stipulation AL starts pre-audit document checks in early January and full fieldwork in mid-February following our financial year close on December 31. While the majority of our annual financial statement is complete by mid-January we have one outstanding USG grant which only reports at the end of February for an end-of-January quarter close. As a result, we are only able to provide a preliminary SEFA when the auditors request the first document checks in January. For FY 2025 we will request that the auditors start with a basic audit of Financial Statements and then submit the SEFA once all the quarterly reports have been submitted to USG. Anticipated Completion Date: Already decided for FY 2024 audit. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.

Finding 2023-002 Significant Deficiency: Schedule of Expenditures of Federal Awards (SEFA) – Control Finding; Personnel Responsible for Corrective Action: Pete Vujcich, Public Works Division Manager; Anticipated Completion Date: June 30, 2024; Corrective Action Plan: In 2021, El Paso County recognized and appropriated $4 million from a CDOT grant (Fed) and $831,501 of local match that was provided by PPRTA (reimbursement) for construction on the South Academy widening project. The overall South Academy project is funded by PPRTA but managed by El Paso County. In May of 2023, PPRTA issued a Purchase Order for $59,965,997.99 to SEMA Construction and the construction contract with SEMA was executed. In December of 2023, SEMA performed work on the project resulting in billings of $4,456,362.07. A payment application was sent to the construction management firm (Wilson & Company) on January 17, 2024 from SEMA. This payment request was rejected due to insufficient certified payrolls. On February 27, 2024, Public Works received an invoice package with all required documentation. During February 2024, Public Works realized that PPRTA would not be able to submit for reimbursement because the IGA was directed to the County and not PPRTA. At that point, the project manager requested a 2024 Purchase Order to pay this invoice. On March 6, 2024, Public Works submitted the 2024 invoice along with a 2024 Purchase Order to Accounts Payable requesting payment was made to SEMA. At that point, the payment was issued and booked to 2024 without recognition of the actual work performance period. Since the invoice was booked in 2024, the expenditure was also not reflected on the 2023 SEFA. As soon as this expenditure was brought to our attention, we immediately requested Accounting record the $4.5 million on the 2023 SEFA. Standard operating procedures include a request of all project managers to identify any anticipated invoices that will be received in the following year to identify any potential reclassification situations. In this particular case, the project manager did identify this project, and anticipated payment request. At the time, this project was a PPRTA run project, and would not have had an impact on the county’s financial reports. Previously, Public Works had a very manual SEFA reporting process in place. Public Works just went live with a new Capital project tracking platform called eBuilder. eBuilder has a required field on the pay app approval screen that requires employees to enter the billing period start and end dates. When Managers go into eBuilder to approve payments, they are required to ensure the billing periods match the payment dates. In addition, as a double check, Public Works is working on customizing eBuilder to flag approvers if the invoice date has a different year listed than the billing period. Public Work has done training with employees to ensure employees understand the additional components of a progress billing pay application, to include timing issues with the review and approval process utilized. We have also reinforced the importance to communicate the correct year expenses were incurred when submitting to Accounts Payable and Accounting. eBuilder will allow Public Works to run reports showing expenses for the correct year. These reports will then be submitted to Accounting to assist with the SEFA preparation. Public Works is confident that all expenditures will be recorded correctly on the SEFA moving forward.

The Township will establish controls to determine federal revenues and if an audit under the Uniform Guidance is required. The anticipated completion date is June 30, 2024.

Responsible Party: JCCS PC & Sara Hudson Anticipated Completion Date: February 29, 2024 Corrective Action Plan: For the fiscal year ending June 30, 2023, the organization prepared a draft of the SEFA with the intent of finalizing it with the assistance of the auditor. We were unaware this would result in a finding in the audit. The organization will work with JCCS PC going forward to independently prepare the annual SEFA.

Management Response: The Tulare County Regional Transit Agency (TCRTA) is working to ensure creation of a ledger that establishes internal control by specifying multiple departments and units. The creation of this ledger will ensure that incoming revenue is properly recorded whereas on the expenditure end TCRTA will work to book expenses in a correct fashion whereby tagging back to the restricted unit thus facilitating the flow of restricted revenues appropriately with matching expenditure. Views of Responsible Officials and Corrective Action: The Tulare County Regional Transit Agency (TCRTA) will ensure multiple levels of review before submitting Federal and State expenditures to the auditor-controller/treasurer-tax collector’s (ACTTC) Office for reporting purposes. This will include detailed reviews of the expenditures to ensure they are categorized appropriately and recorded accurately. TCRTA will coordinate ACTTC Office to provide additional training to staff regarding reporting requirements, and TCRTA will implement additional review procedures when compiling the Financial Closing and Reporting Process and either directly or indirectly compiling the Schedule of Expenditures of Federal Awards (SEFA).

Condition: The FEMA expenditures on the schedule of expenditures of federal awards (SEFA) initially presented for audit were not complete and accurate. Planned Corrective Action: Seek training from our auditors on the proper recording of obligated expenditures. Contact person responsible for corrective action: Laura Randall Anticipated Completion Date: 06/14/2024

We agree that, due to data entry errors, the SEFA provided at the start of the single audit did not include the appropriate and applicable federal expenditures. We will be more diligent in the preparation of the SEFA to help prevent the potential for inadvertently misrepresenting the total federal expenditures and avoid the necessity for adjustments to the SEFA in future audits. At the issuance of the reports, we have enhanced our internal controls and processes related to the preparation of the SEFA to prevent this situation in future years. Our goal is to eliminate any errors to ensure that all applicable federal expenditures are complete and accurate.

2023-002 [2022‐002]—PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presented in Schedule of Expenditures of Federal Awards. Award Number and Program Award Year: All presented in Schedule of Expenditures of Federal Awards. Compliance Requirement: Other – Schedule of Expenditures of Federal Awards preparation Statement of Condition During our audit, we reviewed the Coalition’s federal grants report for the fiscal year and identified the federal grants, Assistance Listing #s (AL#s) and the amounts of the federal expenditures and all of the other items required to properly present the Schedule of Expenditures of Federal Awards (SEFA). We then had the finance staff of the Coalition confirm the correctness of the SEFA. Despite the confirmation of accuracy, additional federal expenditures and grouping of grant expenditures were identified after several reviews of the SEFA.Criteria 2 CFR 200.510 indicates that the auditee must 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 2 CFR 200.502, Basis for Determining Federal Awards Expended. Per 2 CFR 200.502, the determination of when a federal award is expended should be based on when the activity related to the federal award occurs. Generally, the activity pertains to events that require the non-federal entity to comply with federal statutes, regulations, and the terms and conditions of federal awards, such as expenditure/expense transactions associated with awards. In addition, 2 CFR Part 200.303 requires the program to establish and maintain effective internal controls over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of federal awards. Effect Without an established process governed by effective internal controls, the Coalition may not prevent or detect material misstatements on its SEFA in a timely manner. In addition, the errors could result in improper selections of major program(s) for the single audit and a substandard single audit. Cause Historically, the Coalition has requested the auditor assist in identifying accruals related to federal grant expenditures as the organization has maintained these records on a cash basis. As the organization has taken more responsibility on maintaining its federal grant expenditures on an accrual basis, an incomplete SEFA has been provided. Recommendation We recommend the Coalition prepare the Schedule of Expenditures of Federal Awards and submit this to the auditor for testing. The SEFA should include the name of the grant, name of grantor, the AL #, the pass-through number if applicable and a reconciliation of the federal revenues and expenditures to the Coalition’s general ledger. The Coalition staff should perform more detailed reviews of the reports to ensure they properly reflect grant receipts and expenditures. This review should be performed by someone other than the preparer and should include documented evidence of agreeing the reported data to the accounting records. We further recommend training for those individuals involved in the preparation and review of the reports to ensure they are fully aware of the requirements. View of Responsible Officials and Corrective Action Plan: The corrective Action Plan will be carried out in the 2024 Fiscal Year and information will be given to the auditors when requested for the next audit. The Coalition will ensure that all information needed for the SEFA is kept and entered accurately (this process has already begun). When the fiscal year closes out, the Coalition will provide the auditors with a test SEFA to confirm that the information we are collecting throughout the year and are asserting are the correct numbers for our federal grants, is indeed the correct information. Corrective Action Plan Timeline: Completed by December 13, 2024 (Final copy of the SEFA will not be given to the auditors until requested for the 2024 Audit) Designation Of Employee Position Responsible For Meeting Deadline: Executive Director will oversee this project and work directly with NMCEH finance staff work closely with the auditors to make sure that the information saved and shared is correct. Type of Finding: (F) Significant Deficiency in Internal Control over Compliance of Federal Awards. Questioned Costs: None

We take the findings and recommendations of the disinterested third party auditor very seriously. Going forward, all federal awards will be reconciled quarterly to ensure they comply with the Schedule of Financial Assistance and individual grant funding requirements. We will work with our auditors early to determine acceptable documentation requirements and do random sampling internally, throughout the year, to determine appropriateness of all cash receipts, general expenditures, payroll expenditures, and allocated costs.

Views of Responsible Officials: NDRN’s finance staff turnover, coupled with the staff’s lack of formal training with NDRN’s accounting system, resulted in a lack of knowledge on how to prepare the actual schedule. However, it did not affect the staff’s ability to properly identify and categorize expenditures for invoicing purposes to the Federal government. Moving forward, NDRN finance fiscal staff will conduct regular internal SEFA reporting as part of the monthly reporting indicated in Finding 2023-002 above.

We provided the NOAA Award label and CFDA# as soon as we were able to obtain it from the program manager. We corrected the CFDA# for the Highway Planning and Construction as soon as we were able to obtain them from the MEDOT. The contract documents did not include that information. We reported the revenue for the State and Local Recovery Funds in the award column. We now know to put the unspent revenue in deferred. We did not know the $310,000 was Federal Funds, we will know for the future. We will be sure to include Covid-19 labels and all the award dates in the future. We will look for training to prepare a SEFA document, it will be on our professional development list in this year.

Actions Planned – The City will continue efforts to appropriately identify whether funding is federal, state or locally sourced and properly account for the funds. Official Responsible – Amy Sevig, Deputy Finance Manager Planned Completion Date – December 31, 2024 Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – Amy Sevig, Deputy Finance Officer, will oversee the process to ensure the City is in compliance with reporting requirements.