Corrective Action Plans

2024-011 Program: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Homeland Security Pass Through: California Office of Emergency Services Award No. and Year: 059-00000 Compliance Requirements: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria: In accordance with the 2024 OMB Compliance Supplement, nonfederal entities must record expenditures on the Schedule of Expenditures of Federal Awards (SEFA) when (1) FEMA has approved the nonfederal entity’s Project, and (2) the nonfederal entity has incurred the eligible expenditures. FEMA’s approval of a subaward is indicated when FEMA obligates the federal share of the eligible project cost to the recipient. Federal awards expended in years subsequent to the fiscal year in which the Project is approved are to be recorded on the nonfederal entity’s SEFA in those subsequent years. In addition, section 200.303 of the Uniform Guidance states that recipients and subrecipients must establish effective internal control over the federal awards, including controls over the accuracy of program information and expenditure amounts. Condition: During our audit procedures performed over the Schedule of Expenditures of Federal Awards and expenditures reported for the Disaster Grants – Public Assistance (Presidentially Declared Disasters) we noted the County reported expenditures totaling $5,820,436 that should have been reported on the FY 2023 SEFA, as the granting agency approved the expenditures in FY 2023 and the County incurred the expenditures prior to June 30, 2023. Cause: The County lacks adequate internal controls to ensure the SEFA is completely and accurately stated. Effect: The initial FY 2024 SEFA provided was overstated by $5,820,436. However, we noted these expenditures would not have had a material effect on the FY 2023 SEFA. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures on the SEFA were reconciled to supporting records. Repeat Finding from Prior Years: No. Recommendation: We the recommend that the County establish policies and implement internal controls to ensure that expenditures are reported on the SEFA in accordance with program requirements. Management Response and Corrective Action: 1. Person Responsible: Trevor Richardson, OCPW Emergency Manager 2. Corrective Action Plan: Due to the change in reporting guidance, we will now report the full amount of the award in the fiscal year it is approved, based on the obligation letter, instead of on a cash basis. 3. Anticipated Implementation date: Effective immediately for FY24-25.

Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control over Financial Reporting/ Compliance • Contact Person Responsible: Frank Antuono, Business Manager • Corrective Action to be Taken: The District will establish formal written policies and procedures for the preparation of the Schedule of Expenditures of Federal Awards (SEFA) in compliance with 2 CFR 200.51 0(a). These procedures will: o Identify all sources of federal revenue o We have added the assigned federal funding source codes to our district budget operation in CSIU, which will now allow us to track these expenditures back to our internally controlled spreadsheets as verification of expenditures. o Track expenditures using dedicated account codes in the general ledger o Assign responsibility for monthly reconciliation and schedule preparation o Include a secondary review of the SEFA by someone other than the preparer The Business Office will undergo training on SEFA requirements and reconciliation practices. These changes will ensure complete and accurate reporting of federal expenditures for all future reporting periods.

Finding Reference 2024-05 Corrective Action Plan: The Authority started quarterly reconciliation reports between General Ledger accounts and the Schedule of Federal Awards. The reconciliation process includes the participation of various offices that manage and monitor federal grants. Additionally, as part of the accounting closing procedures, the Authority is reconciling the financial data from major federal programs as FHWA and Federal Transit Administration (FTA) with the information entered in the General Ledger accounts on a monthly basis. All personnel involved in the administration of these programs, for which federal funds are expended, should receive adequate training on federal compliance and reporting requirements related to such programs. In addition, an individual will be assigned responsible for monitoring compliance with all related federal requirements. Responsible: Mr. Angel M. Felix Cruz, Finance Office Auxiliary Director Ms. Maria Del R. Ramos Ocasio, Accounting and Finance Manager Planned Implementation Date: In process. Expected to be completed on or before June 30, 2025.

YCIPTA will make the proper journal entries within QuickBooks to reflect the bus purchase properly.

2024-012 Higher Education – Institutional Aid – Federal Assistance Listing 84.031 – SEFA Reporting Recommendation: We recommend that the University review and revise their current procedures in place and provide training to employees within the grant and finance functions related to the grant reconciliation and recording process to ensure expenditures are recorded in the correct period on the SEFA. Explanation of disagreement with audit finding: There is no disagreement to the audit finding. Action taken in response to finding: Restricted Funds Accounting (RFA) team has restructured with new leadership and added all new staff. RFA will train new staff, develop and update policies and procedures, and automate processes within ERP systems, as appropriate. RFA is creating current and updated SOPS for each task and making sure the current staff is learning processes the correct way; this includes reconciliation and recording in the correct period. Automate process within the ERP systems, as applicable. Name(s) of the contact person(s) responsible for corrective action: Director of Accounting, Tonya A. Cardwell Planned completion date for corrective action plan: December 2026

2024-010 Research and Development Cluster – Federal Assistance Listing Nos. Various – Schedule of Expenditures of Federal Awards Recommendation: We recommend the University establish a policy to review grant agreements to ensure that the grants are being classified appropriately on the SEFA Explanation of disagreement with audit finding: There is no disagreement to the audit finding. Action taken in response to finding: Restricted Funds Accounting (RFA) team has restructured with new leadership and added all new staff. RFA will train new staff, develop and update policies and procedures, and automate processes within ERP systems, as appropriate. RFA is creating current and updated SOPS for each task and making sure the current staff is learning processes the correct way; this includes reconciliation and recording in the correct period. Automate process within the ERP systems, as applicable. Name(s) of the contact person(s) responsible for corrective action: Director of Accounting, Tonya A. Cardwell Planned completion date for corrective action plan: December 2026

Condition: The SEFA for the year ended June 30, 2024 was not accurately prepared, as it originally included federal expenditures that were not on the cash basis. Planned Corrective Action: The corrective actions implemented for capital grants will be expanded to include the operating grants. Contact person responsible for corrective action: Joseph Khouzami Anticipated Completion Date: March 1, 2025

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 Fish and Wildlife Cluster (Assistance Listing #15.605, #15.611, #15.626) State Agency: NH Fish and Game Department Audit Contact: Kathy LaBonte Title: Business Division Chief Telephone: 603 271-2274 E-mail address: kathy.a.labonte@wildlife.nh.gov Audit Report Reference: 2024-006 – SEFA Reporting Anticipated Completion Date: Completed Corrective Action Planned: Improved internal controls to evaluate amounts reported on the SEFA have been implemented. We concur in part with the finding: A. Out-of-period expenditure amounts were incorrectly included on the SEFA. These amounts have been identified and corrections have been made. B. Same as above. C. The Department partially concurs. For one grant, W108-L2 / F21AF04030, the amount understated is actually $5,431. As previously explained, a portion of the amount listed as understated, was a Donation to the purchase of property, and not a direct Department Expenditure. ($112.500.00). Corrections have been made to the SEFA. D. Only the total Federal share of expenditures were reported on the SEFA. The Department does perform reconciliations and pre-audits of information entered into QuickBooks to verify data is complete and accurate. Improved internal controls to evaluate the amounts reported on the SEFA have been implemented.

Community Health Services will add a historical tracking mechanism for multi-year grants so that Assistance Lising numbers are tracked each year with explanations for changes. The tracking mechanism will be updated with contracts, contract amendments and purchase order releases. The tracking mechanism will feed into the annual Schedule of Expenditures of Federal Awards preparation spreadsheet that is provided to Yavapai County Finance.

The City internally identify improvement opportunities in managing grants. As a part of the City’s grant oversight improvement efforts, the City began implementing various processes and internal controls surrounding grant monitoring, which improves the SEFA drafting process and mitigates risks of future inaccuracies. These efforts began in early 2024 and include the following: • Creation of a grant policy that provides City staff with guidance, information, and expectations surrounding grants. • Creation of a master grants database that lists the general ledger fund, applicable project ledger references, status, grant type, start/end dates, granting agency, pass-through agency, grant name, assistance listing numbers, grant amounts, and the grant manager for each grant. This database is now used to verify the completeness and accuracy of the SEFA (beginning FY24). • Formal quarterly monitoring. Each quarter, the City will formally review the grants database with department contacts and grant managers to verify the completeness and accuracy of the database. The City is formalizing this process and plans to include department signoffs evidencing the review process. If any items are missing, the missing component will be identified and added to the database on a timely basis. The City will also utilize this quarterly process to review the grants policy to ensure grant managers are aware of the requirements related to their grants. • The City is in the process of formalizing the SEFA drafting process utilized during the FY24 SEFA preparation, which includes additional mitigating procedures such as reviewing all next FY federal receipts to ensure none of them relate to the SEFA year federal expenditures. Personnel Responsible for Implementation: Marvin Lopez Position of Responsible Personnel: Deputy Administrative Services Director (Fiscal Services) Expected Date of Implementation: June 30, 2025

The Universities of Wisconsin (UW) will revise and strengthen documented procedures for preparing the Schedule of Expenditures of Federal Awards (SEFA) to include additional steps to accurately identify grant activity between UW universities and grant activity between UW universities and other state agencies. Additionally, documented procedures to accurately identify the grant reporting cluster will be revised. Additional training and guidance will be provided to UW university and administration stakeholders on revised documented procedures as a critical part of the improvement in the SEFA reporting process. Anticipated Completion Date: November 2025 Person responsible for corrective action: Josh Smith Senior Associate Vice President for Finance Universities of Wisconsin josh.smith@wisconsin.edu

Department: Defense, Veterans and Emergency Management Title: Internal control over the submission of DG – PA program Schedule of Expenditures of Federal Awards information needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Maine Emergency Management Agency (MEMA) and Department of Defense, Veterans and Emergency Management will collaborate on a SEFA reporting process that allows for comprehensive review of SEFA details by MEMA and/or Security and Employment Service Center (SESC) subject matter experts prior to submission to OSC. MEMA will distribute copies of the corrected reporting SOP to subject matter experts within MEMA/DVEM and SESC. MEMA/SESC subject matter experts will perform a comprehensive review of SEFA details for FY2025 reporting. Completion Date: May 1, 2025, May 15, 2025, and June 15, 2025, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507

Department: Administrative and Financial Services Title: Internal control over CSLFRF reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Security and Employment Service Center will review contracts with the agencies to verify the classifications. Completion Date: June 30, 2025 Agency Contact: Marilyn Leimbach, Director, Security and Employment Service Center, DFPS, DAFS, 207-248-2556

Department: Labor Administrative and Financial Services Title: Internal control over Unemployment Insurance financial reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Security and Employment Service Center will further expand the procedures used to prepare and review the SEFA. Completion Date: August 1, 2025 Agency Contact: Marilyn Leimbach, Director, Security and Employment Service Center, DFPS, DAFS, 207-248-2556

2024-001- Organizations are required to prepare an accurate schedule of sources and uses of federal awards and the schedule of expenditures of federal awards. Recommendation: Catholic Charities management should add a step to the SEFA preparation process for reconciling the SEFA to government funding source total per the general ledger. Action Taken: Catholic Charities year end closing process now has a schedule that reconciles the SEFA to governmental funding source total to the general ledger. Name of responsible person: Daniel O'Brien, Chief Financial Officer Anticipated completion date: March 1, 2025 If there are questions regarding this plan, please call Catholic Charities of Los Angeles's, Chief Financial Officer at (213) 251-3410. Sincerely yours, Daniel O'Brien Chief Financial Officer

Management will review and update processes and procedures over reporting and additional training will be provided as needed to prevent future findings.

The Organization will implement procedures to ensure that the SEFA is properly prepared.

Corrective Action Plan: Several steps have been taken to address the need for timely and accurate reporting. The steps taken and listed below will allow management to properly administer grants and file audit and data collection timely in the future. Turnover of finance staff occurred. Management acquired the services of an outside firm to address the deficiencies in the records and to correct and establish a system in order to prevent further occurrences of late reconciliations and untimely reporting. Management has restructuring the finance department with two positions, hiring a Director of Finance and Grants & Contracts Analyst. Additional steps implemented and processes improved in order to establish a system of recording and reporting all financial events: • Payroll entry is streamlined including contemporaneous entry. • Credit cards – Reporting and recording is established in a file so that purchases are logged at the initialization of each purchase. • Reconciliation of all balance sheet accounts are maintained on a current month basis. • A checklist is established for monthly steps. This checklist is maintained by Finance and forwarded to the CEO along with the monthly financial reports. • A thorough review of separation of duties for internal controls was conducted. Implementation is an ongoing process as is analyzing improvements. Persons Responsible: Jolyana Begay-Kroupa, CEO Katherine Gray, Finance Director Estimated Completion Date: June 30, 2025

Views Of Responsible Officials and Corrective Action Plan Response: Youth Shelters and Family Services, Inc. (YSFS) acknowledges the finding and agrees that improvements are needed in preparing the Schedule of Expenditures of Federal Awards (SEFA). YSFS is committed to ensuring compliance with 2 CFR 200.510(b) and will take the necessary steps to enhance the accuracy and timeliness of SEFA preparation. Corrective Action Plan: To address the identified deficiencies, YSFS will develop processes to aid in the implementation of the following corrective actions: 1. Establish a Formal SEFA Preparation Process: • Develop and implement a standardized SEFA preparation procedure, including all required elements (a federal portion of expenditures, grant name, grantor name, Assistance Listing number, and pass-through entity information). • Assign clear responsibilities for SEFA preparation and review to designated finance personnel. • SEFA will be prepared quarterly, rather than waiting until year-end, to allow for ongoing review and corrections. 2. Improve Internal Controls Over SEFA Preparation: • Implement a reconciliation process to compare SEFA expenditures with the federal revenues and expenditures. • Review and update QuickBooks job categories regularly to ensure proper coding of federal expenditures. • Establish a dual-review process where a second finance team member or external consultant reviews SEFA for accuracy before submission. 3. Training and Capacity Building: • Provide training to finance staff on Uniform Guidance requirements for SEFA preparation. • Ensure staff are familiar with federal grant compliance requirements and reporting obligations. 4. Enhance Monitoring and Accountability: • Set internal deadlines for SEFA preparation to prevent delays. • Conduct periodic internal reviews of federal grant expenditures to ensure compliance and accuracy. • Management oversight of SEFA preparation is required to ensure completeness and correctness. Finding resolved timeline: YSFS aims to develop a process to implement these corrective actions and have an accurate, timely SEFA process by June 30, 2025, to ensure compliance with federal regulations in the upcoming fiscal year. Designation of employee position responsible for meeting this deadline: Heather Hoffman, Julie Weigand, and an external consultant will oversee and ensure this corrective action plan's development and successful implementation.

Program: Various, including AL 10.542 – COVID-19 Pandemic EBT Food Benefits; AL 10.551 – Supplemental Nutrition Assistance Program; AL 93.566 – Refugee and Entrant Assistance State/Replacement Designee Administered Programs – Reporting Corrective Action Plan: State Accounting will continue to work with State agencies on correct coding and business unit setup to reduce agency errors. Contact: Philip Olsen Anticipated Completion Date: Continuous review performed.

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

Share Food Program has developed procedures and processes to manage, maintain, and reconcile the Financial Statements to the Schedule of Expenditures of Federal Awards as part of our year end closing procedures. This was implemented, and it is expected that the June 30, 2025 reporting will be timely and accurate.

Finding 2024-001 Information on the Federal Program: Federal Program: HIV - Related Training and Technical Assistance - Aids Education and Training Centers Assistance Listing: 93.145 Federal Agency: U.S. Department of Health and Human Services – Health Resources and Services Administration (HRSA) Grant Award Number:6 U1OHA30535-08-01 Award Periods: July 1, 2023 through June 30, 2024 Pass-Through Agency: Columbia University Grant Award Number: U1SHA46532 Award Periods: September 1, 2023 through August 31, 2024 Corrective Action Plan: Department of Health and Human Services – Health Resources and Services Administration (HRSA) updated the award template utilizing a new federal format. Modification of this federal award template has allowed HRSA to indicate/flag (item 18 in the Notice of Grant Award - R&D “no”) whether the federal program is R&D in a manner not previously recorded or visible. This indicator flag now indicates AETC is non-R&D, therefore, we have reflected it appropriately in the FY24 SEFA. We will strengthen our controls for monitoring the cluster to ensure appropriate classification paying attention to any indications in the Notice of Grant Award. Paula Yarbrough, VUMC Director – Grants and Contract will be responsible for the implementation by fiscal year-end 2025.

Management agrees with the findings and will take the necessary corrective actions. The Organization will create an internal control mechanism to track Federal Awards throughout the year in order to prevent and detect any potential material misstatements and make it available to the auditors at the end of the year.

The SEFA report will have the accountants enter the appropriate SEFA numbers and expenses and have them reviewed by the CFO as an internal control. The report run from the accounting system will add a line for just federal grants on the auditor's report, and the rest of state and private grants will be under other grants. Person(s) Responsible: Irma Morin, CEO and Wanda Davis, CFO Timing for Implementation: Immediately