Corrective Action Plans

MANAGEMENT’S VIEWS AND CORRECTIVE ACTION PLAN Finding 2023-001 – Federal Award Omitted from Schedule of Expenditures of Federal Awards Award: Medical Assistance Program Federal Agency: Department of Health and Human Services Assistance Listing Number: 93.778 University of Alabama Health Services Foundation, P.C. Management acknowledges and agrees with the finding as presented. Dating back to FY 2020, a single grant was improperly omitted from the Schedule of Expenditures of Federal Awards (the “Schedule”). Upon identification of this omission, Management reached out to the respective pass-through entity. In June 2024, Management corresponded with the Office of Contracts and Grants at the Alabama Department of Mental Health to discuss the finding and reached an agreement that prior year reports would remain unchanged and the Schedule for the year ended September 30, 2023, would only present the current year expenditures of the grant. In June 2024, we incorporated a comprehensive review and reconciliation of all amounts recorded in a fiscal year. This captured federally sourced revenue and expenditures recorded throughout the institution and were to be reported on the Schedule. Further, funded sources identified through this reconciliation were reviewed in depth to confirm federal financial compliance requirements are being met or were corrected immediately. Education to key stakeholders also took place to spread awareness of the compliance requirements regarding federally funded sources that are to be reported on the Schedule. At the completion of each fiscal period, grants accounting, in collaboration with general accounting, will prepare a comprehensive reconciliation of grant revenue recorded throughout the organization. Grant accounting and general accounting personnel will jointly review any and all changes to grant contracts to identify payment changes. Funding sources will be reviewed in depth to confirm federal financial compliance requirements are being met.

The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation from PMS will provide a history of the approval flow. Accountants will not have the authority to certify the reports in PMS. The HSSC Comptroller, the Accounting Manager, the AFO and the Budget Staff will perform a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and appropriately identify expenditures for subrecipients, if applicable. Additionally, DBH is working with OCP (Office of Contracting and Procurement), to attach to DC Health’s contract to implement a grants management system that is on the Salesforce platform. The system will automate workflow and enable “alerts” to notify users when reports are due. If the notification is not acted on, the system will automatically escalate the alert to senior management. In the interim, DBH is working through the Districts Grants Management Advisory Board to identify DIFS reports (e.g., DIFS report for FFATA, Subrecipient Grant Report R071). To note, all programmatic data that was used for the PPR was available to the auditors. The supporting documentation for the chart that included spending for administrative and data costs had not been saved, which was the source of the finding. Contact - FAPIIS and FFATA: Renee Evans Jackman, Director of Grants Management, FFR (SF-425) and SEFA: Barbara Roberson, HSSC Accounting Officer, PPR: Sharon Hunt, State Opioid Treatment Authority Estimated Completion Date - Grants Management System is due to be implemented on January 1, 2025. See Corrective Action Plan for chart/table

The Department of Employment Services (DOES) concurs to this finding. Management is committed to closely monitoring the PNG clearing account and implementing timely adjustments at the source as necessary. We will also evaluate and enhance internal controls pertaining to subledgers and the General Ledger (GL). Regular reconciliations, reviews, and adjustments will be conducted to ensure alignment between subledger and General Ledger amounts, and to maintain consistency between SEFA amounts and Federal reports. The fiscal year 2023 SEFA has been revised to accurately reflect federal expenditures, and management will ensure ongoing compliance with established controls to ensure the fair presentation of SEFA data moving forward. Contact - Shilonda Wiggins, Agency Fiscal Officer Estimated Completion Date - September 30, 2024 See Corrective Action Plan for chart/table

The City has immediately assigned Finance staff (Financial Analyst and Accounting Technician) to initiate the draft SEFA and work with administrating departments for thorough review. Departments will be requested to be as clear as possible on regular reconciliation of spending to the City's financial system throughout the year. After submission from an administrating department of a federal program, a reconciliation of federal monies spent to what is posted in the City's financial system will be required. Finance staff will review this reconciliation with the submitting department, after any corrections, submit to Finance management for a final review prior to submission for audit purposes. This updated process will be reviewed with all city departments during year-end review notifications sent out by the Finance Department or individually to departments with active federal programs.

2023-005 - Internal Control Over Compliance and Compliance – Reporting (Preparation of the Schedule of Expenditures of Federal Awards) Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: December 2024 Management’s Corrective Action Plan NGA has begun to produce quarterly versions of the Statement of Federal Awards (SEFA). This routine process has enabled staff to proactively identify new awards and lapsed agreements to keep the SEFA current. Given the importance of this schedule to NGA’s continued management of federal funds, we have emphasized and trained staff to follow all applicable federal requirements when managing funds on this schedule. We expect our action plan to continue until December 2024 as we have encountered several issues this fiscal year that required reconciliation of prior years.

Responsible Person for Corrective Action: Lindsay Mitchell, Director of Fiscal & Facilities. Corrective Action to be Taken: All Fiscal team members will be attending various training courses around GAAP reporting guidelines. Training will be through the CPE website, also any other sources management can engage in through WiPFLi or CAPLAW. Reports will all be submitted after a review and approval from the Director of Fiscal and Facilities. Policies and procedures will be updated with the assistance of a fiscal consultant to ensure that these policies and procedures are followed through. Back up will be required for every entry and entry and backup will be scanned to a permanent document folder so it can be referenced so if there are any changes made there will be an audit trail for follow up. These new policies and procedures will be initialed by the fiscal team for acknowledgement of changes, and it will be part of the performance evaluation process. The anticipated completion date for this corrective action is September 30, 2024.

2023-002 – Internal Control over Compliance and Compliance with Period of Performance Contact Name – Jeff Kaufman Position – Global Controller Contact – jkaufman@corusinternational.org Estimated date of completion: September 30, 2024 Corrective Action Plan – Corus management concurs with this finding and reaffirms its commitment to responsible stewardship of funding awarded to Corus by the United States Government and other donors. There are occasions when Corus may anticipate successfully negotiating a program extension with the USG or other donors. In the event there are immediate needs of the program’s potential beneficiaries, Corus may decide to utilize its own unrestricted funds in expectation that if the extension is obtained, these funds will be reimbursable under the terms of the extension. Corus recognizes that there is no guarantee that the program will be extended; thus, it understands that it incurs the expenses at its own risk. As a point of emphasis, while the expenses referenced in this finding were incorrectly coded such that this spending was erroneously included on the SEFA, Corus did not draw on USG funding to recover these expenses, the expenses were funded by Corus’ own unrestricted resources. Action steps to be implemented during the Corus 2024 fiscal year include: • The steps outlined in response to 2023-01 should also ensure proper account coding of expenses and timely monitoring of program spending against available obligated funds as well as program expiration dates.

2023-002 - Internal Controls Over Compliance and Compliance with Reporting - Preparation of the Schedule of Expenditures of Federal Awards Contact Name: Charlie Feeney Position: Chief Financial Officer Telephone Number: (202) 796 2496 Corrective Action Plan – Management is establishing additional review procedures to ensure that SEFA schedule is accurate and fairly stated when submitted. Estimated Completion – September 30, 2024

Internal controls have been put in place to ensure a thorough review over the review and preparation of the schedule of expenditures of federal awards to ensure all accurate awards are included as required. Responsible Official: Lisa Burnett Planned Completion Date: June 30, 2024

Ryan White HIV/AIDS Program Part A SEFA reporting Management’s Views and Corrective Action Plan Management’s Views and Opinion Sunset Park agrees that the draft SEFA amount for this program was not reflective of the total reimbursement received under this award. Sunset Park also agrees with the recommendation to ensure that grants reimbursed by methods other than cost reimbursement are reported and aligned with deliverable or allowable activities for SEFA purposes. Corrective Action Plan Sunset Park will conduct semi-annual reviews in January and May for awards that are not based on cost reimbursement. The purpose of these reviews is to ensure that the amounts reported on the SEFA align with the allowable activities that are not based on cost reimbursement. This process will ensure proper reporting that is in line with the reimbursement policies of the granting agency. Furthermore, the Director of Grants and the Grants Fiscal Team will review all award terms to ensure an accurate reporting structure for accounting and SEFA reporting purposes. Timeline for Action Plan Date of Completion: 08/31/2024 Responsible Individual Leonardo Arias Email: Leonardo.Arias@nyulangone.org

Tapestry 360 Health will improve the timely submission of the Single Audit Reporting Package by ensuring that grant programs are tracked and reported in detail monthly, resulting in fewer errors for the SEFA. Tapestry will also perform a hard close semi-annually that will allow us to perform a mid-year analysis and reconciliation. Furthermore, contracts will be stored in a central, organized manner to facilitate the consistent use of the documents as reference. Finance and the Grants Development team will meet monthly regarding grant programs to review dates, terms, budget, for each program. The anticipated completion date to correct the Finding 2023-002 is August 15th, 2024.

Tapestry management will review the SEFA and its corresponding contracts to aide in the attestation of compliance. To further enhance timely submission, Tapestry will use technology and automation to aid the tracking and organization of grant programs. Technological upgrades include using the general ledger to uniquely identify Federal grants and enhance fiscal reporting, using software to store and organize contracts. The anticipated completion date to correct the Finding 2023-004 is August 15th, 2024.

Prior to submitting the SEFA each year, a Staff Accountant in ATCC’s Finance & Accounting team will prepare the SEFA, it will be reviewed and approved by ATCC’s Federal Solutions Finance team and the CFO/Controller for completeness, accuracy, and compliance with CFR Section 200.510(b), confirm consistency with the trial balance, and correct any inconsistencies prior to submitting the SEFA report.

Preparation of Schedule of Expenditures and Federal Awards Name of Federal Program or Cluster Disaster Grants-Public Assistance (Presidentially Declared Disasters) Disaster Grants through FEMA are managed by rules and processes that are not easily accounted for in traditional accounting systems. Procedures will be strengthened to fully and accurately identify all federal program expenditures and record in the appropriate accounting funds. Procedures will be implemented to prepare documentation necessary to support the information in the financial statements earlier and more accurately, for the information to be completed, available and provided to auditors for the audit. Persons responsible: Wilfred Bourne, C.F.O.; Dennis Bent, Director of Accounting Expected Completion date: December, 2024

1. Upon receipt of all grants, FCFS will confirm with the awarding agency the status of subrecipient versus non-subrecipient to determine inclusion in the Schedule of Expenditures of Federal Awards (SEFA). Person Responsible: Carrie Krepps, Executive Director or Sarah Johnson, Operations Director. Timeline for Completion: All current contracts for FY24 have been reviewed; new contracts will be reviewed upon receipt 2. FCFS will prepare quarterly reports for the board detailing grant spend down for both restricted and nonrestricted funding. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations Director; FCFS Board. Timeline for Completion: To begin April 23, 2024, board meeting 3. Grant invoicing will be prepared by the Fiscal Officer and reviewed by the Operations Director prior to submission. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations. Timeline for Completion: August 2023 4. FCFS will submit to quarterly fiscal review by a 3rd party accounting firm to identify potential weakness in fiscal protocol. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations; Pinion Accounting Services. Timeline for Completion: July 2024 for quarterlies ending June 30, 2024. 5. FCFS will employ a 3rd-party accounting firm to help in audit preparation and closing year-end books, including SEFA preparation before submitting any financial documentation to the auditor. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations; Pinion Accounting Services. Timeline for Completion: Pinion has signed letter of engagement and will begin on yearend closeout assistance July 2024

Finding Number: 2023-004 Condition: The schedule of expenditures of federal awards (SEFA) was inaccurate. Planned Corrective Action: Management would like to point out that this finding is related to finding 2023-001. The accrual of additional grant invoices resulted in parallel updates to our SEFA schedule. Therefore, this finding is a direct result of finding 2023-001. As an aside, our current process for reporting SEFA is manual. We are investing in a new accounting system, in which the SEFA information will not require manual intervention and thus reduce any potential entry errors in the future. Contact person responsible for corrective action: Colette Champine, CFO Anticipated Completion Date: Already completed

Identifying Number: 2023-004 Finding: SEFA Reporting Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls for regular review of the general ledger of their programs and reconcile to the vouchers prior to submission to the granting agency. Anticipated Implementation and Responsible Official: June 30, 2024, Suresh Sharma, Chief Financial Officer

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.

The migration to a new general ledger financial reporting system is an isolated incident and given the improved reporting capabilities the change in product provided a positive impact. UWGC experienced turnover for the program manager position that created a learning curve that was addressed but resulted in audit completion delay. UWGC has an experienced manager currently overseeing the program who will follow policies and procedures as prescribed and on a timely basis to allow for prompt reporting submission.

UWGC experienced a staffing turnover during the 2024 fiscal year of the manager responsible for the reporting on the SEFA. The manager tracked financial reports on a cash basis causing a timing difference with not recognizing accounts payable. The finance team accounted for expenses in the appropriate period, therefore the Finance team will crosscheck reports for timing difference prior to submission to governing agency.

Finding Number: 2023-003 Condition: The schedule of expenditures of federal awards (SEFA) was not complete. Planned Corrective Action: The College will ensure that the schedule of federal awards (SEFA is reviewed for completeness. Going forward, the SEFA will be compared with the prior year SEFA and a separate schedule of new awards for the current fiscal period. The results of this comparison will be reviewed by the grants office, the controller’s office and the Vice President’s office. This will increase the level of reviews to a three-tiered process which should address issues of completeness of the SEFA. Contact person responsible for corrective action: Ms. Jackie Brown, Ms. Deborah McKenzie, and Dr. Sharron T. Burnett Anticipated Completion Date: 06/30/2024

The YWCA will implement the following changes in its accounting procedures: The Schedule of Expenditures of Federal Awards (SEFA) will be reviewed for accuracy by either the CFO or CEO after it is produced, to ensure that all federal awards are included, and that the amounts on the schedule are accurate.

Views of Responsible Officials: IW has developed and implemented enhanced procedures for the preparation of the SEFA. These procedures include detailed steps for ensuring that all costs related to Federal awards are fully allocated in the general ledger at the time of transaction and prior to SEFA preparation. This process is designed to prevent any future discrepancies between the SEFA and the general ledger. To further strengthen our internal controls over Federal award management, IW has instituted regular monthly reviews of expenditures charged to Federal awards. This review process includes verifying that expenditures are correctly allocated and supported in the general ledger, thereby ensuring the accuracy and completeness of the SEFA.

MNCASA and MACC will implement a review process for accruals and reversals; this review process will occur at the end of each month and the end of the fiscal year. This process will ensure that the ledger matches the SEFA reporting, accruals, and reversals and is done in a timely manner. MNCASA and MACC staff will also attend a training session on SEFA prepartation to increase our knowledge and ensure proper reporting.

Management response to finding 2023-001: Accuracy of expenditures on the Schedule of Expenditures of Federal Awards and submission of special reports for the Head Start Program Cluster Name: Head Start Federal Awarding Agency: Department of Health and Human Services Award Name: Head Start and Early Head Start, COVID (P.L. 116-260) Award Number: 09CH010228-05-05, 09CH011831-02-03, 09HE000328-01-00 Award Years: 2019-2021, 2021-2022, 2021-2023 Assistance Listing Title: Head Start Assistance Listing Number: 93.600 Pass-through entities: Not applicable As described in finding 2023-001, the University inadvertently charged and drew down budgeted capital expenditures from Head Start awards before actual expenditures were incurred by the University. Additionally, the University charged expenditures to a Head Start award after liquidation extensions had expired. The adjustments required to correct these errors were identified in the subsequent fiscal year, resulting in expenditures on the fiscal year 2023 Schedule of Expenditures of Federal Awards (SEFA) being overstated. The University will take the necessary corrective actions as described below to ensure the accuracy of expenditures reported on the SEFA. Finally, as described in finding 2023-001, the University did not identify and track reports required to be submitted for Head Start awards. The corrective actions described below will ensure all award specific reporting requirements are met. Although the University has limited federal awards that are utilized to fund capital expenditures, the Office of Sponsored Projects Accounting and Facility Planning and Management will perform a full review of the current Head Start capital construction accounting policies and practices to ensure they comply with the Uniform Guidance and the terms and conditions of federal awards before June 30, 2024. Reinforcement of the University’s policies and practices will ensure proper grant accounting, and thus, will prevent SEFA reporting adjustments from having to be made. Faculty leadership responsible for overseeing the Head Start program at the University will fill current vacant financial management positions within the Head Start program as soon as possible (with a three month target), undergo a full review of program requirements with all staff, and modify and develop new internal controls related to this finding. Specifically, before July 2024, Head Start fiscal personnel along with faculty leadership will develop a reporting schedule specific to Head Start awards, provide training and resources to staff involved with reporting, implement internal controls related to the reconciliation and validation of reported data prior to report submission, and strengthen internal controls related to the allocability of expenditures to awards (particularly in situations where liquidation extensions or expenditure carry forwards have been granted). Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu