Corrective Action Plans

Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: United States Department of Housing and Urban Development Assistance Listing No.: 14.241, Housing Opportunities for Persons with AIDS Ascension Ministry Market: Illinois Pass-Through Grantor: Aids Foundation of Chicago Federal Grantor: United States Department of Justice Assistance Listing No.: 16.560, National Institute of Justice Research, Evaluation, and Development Project Grants Ascension Ministry Market: Texas Federal Grantor: United States Department of Justice Assistance Listing No.: 16.710, Public Safety Partnership and Community Policing Grants Ascension Ministry Market: Illinois Pass-Through Grantor: The Village of Arlington Heights Police Department Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Ascension Ministry Market: Maryland Pass-Through Grantor: Mayor and City Council of Baltimore, through MONSE Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.650, Accountable Health Communities Ascension Ministry Market: Illinois Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.958, Block Grants for Community Mental Health Services Ascension Ministry Market: Illinois Pass-Through Grantor: The State of Illinois Department of Human Services Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.039, Hazard Mitigation Grant Ascension Ministry Market: Florida Pass-Through Grantor: Florida Division of Emergency Management Views of responsible officials: The System will enhance its grant management award processes by revising its onboarding procedures and add additional controls to monitor the accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting. Award amounts were changed on the Schedule after management’s review was executed. Management will implement preventive controls to lock down market Schedule templates after management final review. Responsible Official: Rob Madsen, Director of Accounting and Reporting, Grants & Research COE Anticipated completion date: May 31, 2024

2023-003 Internal Control Over Financial Reporting Management Response: Management concurs with the recommendation above. Management will ensure policies and procedures over financial reporting which capture all required adjustments necessary to fairly present consolidated financial statements. Since their inception, the Academies had outsourced its accounting function to an outside company. Management has now moved that function in-house and hired a full-time finance director to oversee all accounting functions. The finance director will be responsible for monitoring all financial policies and procedures. Responsible Person: Preston Castille, Jr., Helix Community Schools, President Anticipated Remediation Date: Fiscal year ended June 30, 2024

Program:Various, including AL 20.509 – Formula Grants for Rural Areas and Tribal Transit Program – Reporting Corrective Action Planned: The transit will continue to provide training to all the personnel who handles the information needed to properly calculate the SEFA amounts for future audits. Anticipated Completion Date: June 30, 2024 Responsible Party: Christy Warner, Transit Administrator

2023-006 – Completeness and accuracy of certain programs on the Prior Year Schedules of Expenditures of Federal Awards (SEFA) - (Significant Deficiency) Cluster: Not applicable Sponsoring Agency: Department of Health and Human Services (DHHS) - Health Resources and Services Administration (HRSA), Department of Education (ED) and Federal Emergency Management Agency (FEMA) Award Names: COVID-19 Provider Relief Fund and ARP (ARP) Rural Distribution (PRF), COVID-19 Higher Education Emergency Relief Fund (HEERF) Student Portion, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) and Maternal and Child Health Federal Consolidated Programs Award Numbers: Various Assistance Listing Titles: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 Higher Education Emergency Relief Fund (HEERF) Student Aid Portion, COVID-19 HEERF Institutional Aid Portion, COVID-19 HEERF Minority Serving Institutions, and Maternal and Child Health Federal Consolidated Programs Assistance Listing Number: 93.498, 97.036, 84.425E, 84.425F, 84.425L, 93.110 Award Year: 2020-2021, 2021-2022, 2019-2020, 2021-2023 Pass-through entity: Not applicable Management has implemented additional reconciliation and review procedures over the last two years to improve the accuracy and completeness of the SEFA. · UCOP implemented an annual SEFA review process to include the systemwide Controller and campus Controllers. UCOP also distributed one interim SEFA draft to the External Fund Managers (EFMs) that had historically been tasked with only a year-end review. · UCOP continued to reconcile atypical federal programs (e.g., PRF, FEMA, etc.) and included in the fiscal year 2023 SEFA drafts for campus Controller review. Beginning in FY 2024, UCOP will implement more comprehensive financial reporting controls as follows: · Interim SEFA reports, inclusive of atypical programs, will be prepared centrally and distributed to campuses for review and alignment with campus records. Campus management will be tasked with the responsibility for overall review and signoff for both interim and final SEFA reports. · The Systemwide Controller will also be included in the review process by performing an overall review and signoff for both interim and final SEFA reports. With respect to the specific findings in FY2023 for atypical / nonrecurring federal programs, the following actions have been and/or will be taken: • FEMA: A reconciliation process was implemented within UCOP in FY2023, the result of which was the discovery of the understatement referenced in the finding. FEMA expenses are now reconciled to, and obligation dates retrieved from, the Federal FEMA Grants Portal to ensure project expenses are accurately reported in the proper fiscal year. Data from the State portal is distributed to campuses for validation. UCOP has also reminded campus and medical center Controllers of the reporting requirements and will cover this topic again in future trainings. Additionally, UCOP will remind campuses and medical centers of the requirement to account for the FEMA project in the federal fund range at the time of obligation to trigger SEFA reporting. • PRF – A reconciliation process was implemented by UCOP in FY2022 and the reconciliation itself was completed in FY2023, the result of which was the discovery of the understatement referenced in the finding. PRF expenses reported by campuses are now reconciled to the HRSA online portal which will continue for the duration of the program. UCOP has also reminded campus and medical center Controllers of their responsibility to report on these dollars for their entire enterprise (Faculty Practice Group, School of Medicine, etc.). As with all other federal funding, PRF amounts will continue to be part of the SEFA reports distributed to campuses for review and signoff. Coordination between campuses and medical centers will be expected for this review and signoff. • HEERF – while the program ended in FY2023, UCOP will apply lessons learned to any future “special” funding. When atypical programs such as this are awarded in the future, UCOP will provide more consistent guidance upfront and establish more consistent accounting and reporting requirements for campuses and the medical centers to follow. Requirements will include regular reporting of these dollars to UCOP with a reconciliation of campus ledgers to any sponsor reporting. As with all other federal funding, amounts will be part of the SEFA reports distributed to campuses for review and signoff. • Program Income – UCOP will develop and conduct expanded training to campus Controllers, EFMs and their staff to include SEFA requirements generally, including treatment for program income (and other SEFA exclusions), new review procedures, etc. UCOP will target training for the spring of 2024. For inquiries regarding this finding, please contact Barbara Cevallos at barbara.cevallos@ucop.edu who is responsible for the corrective action.

Prior to the year-end of June 30, 2023, Eagle Academy PCS had several federal grants that were approved and open for drawdown in May 2023. These were all related to grants budget to be reimbursed to the school during the 2022-2023 school year. Due to the late approval of the grants, the school and management didn’t have enough time to submit reimbursement requests and submit amendments. The amendments were submitted during the SB&Company’s audit preparation period. As a result, these amendments were all pending approval even though the expenditures already incurred in FY2023. Management has contracted with a third-party vendor that will be responsible for managing all grant reporting, applications, amendments, and reconciliations. This will strengthen the school year end closing process.

Condition: The SEFA for the year ended June 30, 2023 was not accurately prepared, as it originally included federal expenditures that were not on the cash basis. Planned Corrective Action: The corrective action has been implemented to revise internal procedures to prepare the SEFA on a cash basis for future fiscal years. This includes the creation of a reconciliation schedule to the financial statements which are prepared on an accrual basis. Contact person responsible for corrective action: Jeremy Baker, Director of Finance Anticipated Completion Date: 1/15/2024

Criteria: According to 2 CFR Subpart F Section 200.51Ob, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period that includes all amounts spent on federal programs during the reporting period. Condition: The initial SEFA provided for audit did not agree to the accounting system general ledger expenditures for certain awards. In addition, not all federal awards were appropriately identified and included on the SEFA. Cause: PPHS had significant turnover in finance personnel during the 22-23 school year. In addition, the SEFA was prepared utilizing federal award revenue. Lastly, one award was incorrectly identified as other revenue instead of federal award revenue. Effect: The total federal award expenditures reported on the initial SEFA were reduced by $198,208. The following awards were reduced on the SEFA to agree to award expenditures by the following amounts: National School Lunch Program 10.555 $125,864, Charter Schools Program 84.282A $32,555, Elementary and Secondary School Emergency Relief 84.425D $92,405, and Emergency Connectivity Fund 32.009 $109,450. The following award was added to the SEFA Coronavirus State and Local Fiscal Recovery Funds 21.027 $164,766. Corrective Action Plan - PPHS had significant turnover in finance personnel during the 22-23 school year. For FY24, we contracted with accounting consultants to assist with improving grant tracking and reporting. We posted a Staff Accountant position in January 2023 to assist with internal grant management and are hoping to fill this position in FY24 03. Contact Person(s) Responsible for CAP- Todd Burleson, Financial Controller. Anticipated completion date - Processes were improved in FY24 through assistance from accounting consultants. We anticipate hiring a Staff Accountant before 3/31/24.

Federal Program Title: Research and Development Cluster ALN: Various Recommendation: We recommend the University evaluate its cutoff procedures to ensure federal costs are identified and reported in the correct fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Boise State University will evaluate our cutoff and accrual procedures to ensure costs are identified and reported in the correct fiscal year. Name(s) of the contact person(s) responsible for corrective action: Jen Lutke, Assistant Director, Post Award: jenniferlutke@boisestate.edu Planned completion date for corrective action plan: June 2024

SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Department of Environmental Protection (DEP) Assistance Listing Number 15.252 Effective March 2024, DEP will develop and implement a standard operating procedure to track indirect costs. DEP will create a separate spreadsheet to track indirect costs to be included in the year ending SEFA reporting. DEP will attend training sessions conducted by the West Virginia Financial and Accounting Reporting Section to ensure all expenses are reported correctly on the SEFA. Additional training from accredited educational institutions will also be researched if necessary.

Condition: The schedule of expenditures of federal awards (SEFA) was not complete and accurate. Planned Corrective Action: The City will be implementing a procedure whereby the Controller’s Office receives copies of all contracts to ensure all reporting requirements are met and financial deliverables are completed according to the schedules. Contact person responsible for corrective action: Brandy Ruth Anticipated Completion Date: June 2024

Identification of federal program: U.S. DEPARTMENT OF AGRICULTURE passed through the Indiana Department of Education Child Nutrition Cluster 10.553 & 10.555, U.S. DEPARTMENT OF EDUCATION passed through the Indiana Department of Education Title I, Part A 84.010A, Student Support and Academic Enrichment Program (Title IV) 84.424, Charter Schools Program 84.282D, Education Stabilization Fund 84.425D& 84.425U. Criteria: According to 2 CFR Subpart F Section 200.510b, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period that includes all amounts spent on federal programs during the reporting period. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was overstated by $42,585.Cause: The School included depreciation expense within amounts reported on the SEFA which is not an allowable cost under Uniform Guidance. Effect: An audit adjustment was made to reduce the reported amount on the SEFA for the Child Nutrition Cluster (10.553, 10.555) by $5,988, the Title I, Part A grant (84.010A) by $378, the Student Support and Academic Enrichment Program - Title IV (84.424) by $581, Charter Schools Grant (84.282D) by $95, COVID-19 Elementary and Secondary School Emergency Relief (ESSER II) Fund (84.425D) by $29,896, and the COVID -19 ARP Elementary and Secondary School Emergency Relief (ARP ESSER) Fund (84.425U) by $5,647. Recommendation: We recommend that the School's accountant review and become familiar with Uniform Guidance and CFR 200 requirements to assist with including the accurate expenditure information in the Schedule. In addition, we recommend that the accountant reconcile federal award expenditures to the claims that were filed for the year. Action Taken: Dugger Union Community Schools plans to follow the recommendation given and work with our accountant to do our best to avoid further discrepancies.

Condition: The SEFA for the year ended June 30, 2023 was not accurately prepared as it originally included expenditures that were improperly excluded from the SEFA for the year ended June 30, 2022. Planned Corrective Action: Additional Supervisory Review of Expenditures Contact person responsible for corrective action: Deanna Korth Anticipated Completion Date: 09/30/2023

Condition: The schedule of expenditures of federal awards (SEFA) was not complete. Planned Corrective Action: The School District will develop a checklist, or a report downloaded from the General Ledger, of all federally funded grants, and will compare the grants listed on this report with the grants listed on the Schedule of Expenditures of Federal Awards (SEFA) to ensure that all grants are reflected on both documents. Additionally, the Assistant Superintendent will review, date and sign a copy of the SEFA document prior to its submission, and the Business Office will retain this signed paper copy in its audit file annually. Contact person responsible for corrective action: Michael Zopf Anticipated Completion Date: June 30, 2024

Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300 Estimated completion date: June 30, 2024 Corrective Action: Management will continue to stress the importance of following the detailed procedures for preparation and review of the SEFA. Responsibility for compiling the SEFA was assigned to a Senior Program Accounting Manager who is tasked with assuring the SEFA and all support reconciliation are complete and accurate. Both the Director of Program Accounting and the Executive Director of Finance/Controller will review the SEFA for completeness, accuracy, and compliance with CFR Section §200.510(b).

Views of Responsible Officials and Planned Corrective Action: The School agrees with this finding. Lisa Hendricks, the Director of Finance, and the 3rd party accountant will work closely to develop a grant tracking system that determines the source of the grant funds prior to expending any of the funds.

Finding: 2023-001: SEFA – Material Weakness The SEFA prepared by management included an incorrect Assistance Listing (AL) number for one grant. Federal grant AL NO. 20.513 Enhanced Mobility of Seniors and Individuals with Disabilities was incorrectly identified as AL No 20.507 Mobility Management. While both grants are from the Federal Transit Agency, they fall under different clusters in the Office of Management and Budget’s Compliance Supplement and thus have different audit requirements. Auditor Recommendation: We recommend management verify with the grantor the AL number of the grant. This can be done by obtaining the information from grant documents, or direct communication with the grantor. We further recommend the SEFA be reviewed for accuracy by an individual not included in the SEFA preparation process. Review should be notate with initials and date. Contact Person Responsible for the Corrective Action: Lisa Cappellari, Chief Financial Officer, LisaC@paratransit.org Management Response and Corrective Action Plan: After the end of Fiscal Year 23-24 on 6/30/2024, Jody Wadley, Finance and Grants Manager, will start the preparation of the FY24 SEFA and make sure all components are correct. Lisa Cappellari, Chief Financial Officer, will review the SEFA for accuracy, checking grant documents and directly contacting the granting agency if necessary. Once each component of the SEFA is thoroughly reviewed, Lisa Cappellari will initial and date.

Failure to Inform Auditors of the Need for A Single Audit Recommendation: We recommend that Counseling Clinic updates and maintains a SEFA or other tracking protocol of total expenditures on a federal level throughout the year. Action Taken: Management is now properly tracking grant expenditures and can accurately state quantities of grant expenditures.

Recommendation: We recommend that Minnesota Land Trust review its internal controls to ensure the SEFA captures all federal awards expended at the correct amounts in accordance with 2 CFR 200.510(b) Schedule of expenditures of Federal awards and CFR 200.502, Basis for determining Federal awards expended. Actions to be Taken: The Minnesota Land Trust will add additional internal controls to ensure a complete listing of federal expenditures is easy to provide and that the listing is reviewed by the Finance Department prior to audit fieldwork. Timeline for Completion: A complete listing of federal expenditures to be available from our accounting software (i.e., automatically) by October 31, 2023. Contact person responsible for corrective action: Claire Colliander

Response to Finding 2023-003 - Schedule of Expenditures of Federal Awards (SEFA) Preparation The district will strive for monthly requests for reimbursement for all applicable federal funds, thus creating awareness of the funds and potential issues before they arise. The District Director of Finance will be responsible for overseeing the implementation of these responses and anticipates corrective dates to be immediate. Person(s) responsible for action: Lanell Farmer/Director of Finance

Description of Finding: The school did not adequately track its expenditures of federal awards and did not prepare a complete SEFA as of the year end. Statement of Concurrence or Nonconcurrence: The school agrees with the audit finding as presented. Corrective Action: While the school’s chart of accounts includes specific accounts for grants and Title I funds, the chart of accounts did not explicitly list all federal revenue (Title I, ESSER Grant, USDA, and Federal Facility Grant). The school has already updated the chart of accounts to account for all federal funds with appropriate identification of revenue sources. This will allow the school to accurately account for monthly revenue and expenditures relating to federal funding sources, along with accurate monthly financial reporting of federal fund usage and expenses. Name of Contact Person: Chaz Patterson-Ellis, Chief Financial Officer, 678-466-7300, chaz.patterson@chatthillscharter.org. Projected Completion Date: Sept 30, 2023. Chaz Patterson-Ellis, Chief Financial Officer.

Management agrees with the finding and is in the process of revising internal controls to address SEFA preparation.

Judge Lucas Response: This was an oversight on our part. Steps have been taken to fully comply with all SEFA reporting in the future.

This was a simple mistake in reporting the SEFA revenue instead of the expenditures. Since discovering expenditures are required this will not be an issue going forward.

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Management acknowledges this oversight, which occurred during the implementation of a new program and at a time when staff were not fully aware that such expenditures must be reflected on the SEFA. Furthermore, certain capital expenditures paid directly through escrow were not recorded in the organization's accounting records. To remediate these issues, management has taken the following corrective actions: - Delivered targeted training to staff on the proper treatment and reporting of federally funded capital expenditures; - Updated internal closing and reporting procedures to incorporate a formal review of balance sheet activity; and - Updated internal closing and reporting procedures to incorporate a reconciliation to settlement statements when recording new property acquisitions; and - Strengthened internal controls to ensure all federally funded capital items are accurately captured in future SEFA submissions. Management is committed to maintaining compliance with federal reporting requirements and ensuring the completeness and accuracy of future SEFA filings.

Finding: During the audit of the auditee's SEFA for the year ended December 31, 2022, we noted discrepancies related to incorrect identification of Assistance Listing Numbers for certain grants, as well as difficulty providing initial supporting detail for balances of expenditures for certain Federal programs. The auditee lacks sufficient internal controls over the preparation and review of the SEFA. Specifically, there is no established process to reconcile federal expenditures reported on the SEFA to the auditee's underlying accounting records. A formal review process involving an individual independent of the preparation was not conducted to ensure the SEFA was complete and accurate before submission to the auditors. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to establish and document a formal, multilevel review process for the preparation of the SEFA. Baltimore Medical System recently hired a new grant accountant who will be responsible for the preparation of the SEFA. • The Controller will perform a detailed reconciliation of the SEFA’s data to the general ledger and supporting grant documents. • The Grant Accountant will develop a central repository that includes all grant contracts/awards and a summary document which contains the grant name, grantee, award amount and period, Assistance Listing Numbers, pass-through entity and subrecipient information. • Train relevant staff on the SEFA requirements governed by the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for the Federal Awards (2 CFR Part 200, 200.510(b)). Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO