Corrective Action Plans

Schedule of Corrective Action Plan For the Year Ended June 30, 2023 Finding 2023-002: Material Weakness over Activities Allowed or Unallowed and Allowable Cost/Cost Principle (Payroll) Responsible Official’s Response and Corrective Action Plan We concur with the finding related to deficiencies in our time tracking Process. We have implemented a time tracking system using QuickBooks Time starting in the fourth quarter of fiscal year 2024. This system is designed to accurately capture, and record employees’ hours worked by project/grant. Comprehensive training sessions have been conducted for all affected employees to ensure they are proficient in using the new time tracking system. Supervisors have received additional training on monitoring and verifying time entries. Planned Implementation Date of Corrective Action Plan April 1, 2024 Person Responsible for Corrective Action Plan Caryn York, Executive Director

Finding 2023-001: Significant deficiency over Procurement and Suspension and Debarment Responsible Official’s Response and Corrective Action Plan We concur with the finding. Due to the transition in the accounting department, we were not aware of these specific criteria at the time. We were notified of these requirements after the end of fiscal year 2023. To address this issue, WE in the World implemented a procurement policy as of March 2024. We will continue to use this comprehensive process during fiscal year 2024 and beyond to ensure proper documentation and compliance with procurement regulations. This process will include: 1. Ensuring that all sole source vendor selections are properly documented and justified. 2. Verifying and maintaining records that confirm vendors are not debarred or suspended from doing business with the Federal Government before entering into contractual agreements. We are committed to improving our procedures and ensuring compliance with all applicable regulations moving forward. Planned Implementation Date of Corrective Action Plan Instituted March 2024 Person Responsible for Corrective Action Plan Marta Bustos Kuperwasser Finance Director

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-013 CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: A- Risk Assessments DHSS disagrees with this recommendation because the risk assessment process performed by BCFNA is in compliance with the substance and spirit of federal regulations – both of the federal funding agency, USDA, and 2 CFR 200, Uniform Grant Guidance. BCFNA risk assessments consider relevant information and are used to determine the extent and timing of monitoring as set out in the Nutritionist Manual. The BCFNA risk-based monitoring approach already allows for monitoring subrecipients more frequently than required by USDA. 2 CFR 200.332 states pass-through entities are to evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: (1) The subrecipient's prior experience with the same or similar subawards; (2) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (3) Whether the subrecipient has new personnel or new or substantially changed systems; and (4) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). The BCFNA formal risk assessment process takes into consideration the results of current and previous experience with the same subaward (item 1 in the suggested criteria) as well as whether the subrecipient has new personnel or new or substantially changed systems (item 3 in the suggested criteria). These observations are made when performing onsite monitoring by Nutritionists who are familiar with the program, its requirements and its participants, and are trained in recognizing significant issues. BCFNA also takes into consideration the results of the subrecipient’s prior experience with similar subawards in other programs such as SFSP, NSLP and Child Care Licensing Reviews (item 1 in the suggested criteria), audit results (item 2 in the suggested criteria) as well as the results of Technical Assistance Reviews offered to new subrecipients which could move up the planned monitoring schedule. B- Subrecipient Monitoring Procedures DHSS disagrees with this recommendation. The State Auditor’s Office (SAO) states in this finding, “While our review found the sample monitoring reviews were performed in accordance with the policies and procedures outlined in the Internal Nutritionist Manual we identified areas where these policies and procedures could be strengthened and improved...” The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve it’s process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This is incongruent with the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher-ranking requirements set forth by specific federal grant funders and awards. In addition, the DHSS has a strong system of internal controls documented in the Nutritionist Manual which is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” The DHSS through BCFNA has and will continue to review, strengthen and enforce subrecipient monitoring procedures in accordance with federal program requirements and management evaluation. BCFNA has and continues to exceed what is required by the federal awarding agency by implementing a risk-based monitoring plan that allows for more frequent onsite monitoring than required by the USDA. In addition, even though COVID waivers allowed for monitoring to be suspended during the COVID Public Health Emergency, the BCFNA continued to monitor through the use of desk reviews. BCFNA also returned to onsite monitoring months before it was required by the USDA. Furthermore, BCFNA has recently hired a financial manager to help identify red flags with new and returning sponsors and recently enhanced training and technical assistance opportunities based on issues found during monitoring. Corrective Action Plans Due to the size of the CACFP program it is imperative that a risk-based approach be used in performing monitoring and follow up activities. DHSS through BCFNA follows up and ensures that subrecipients take timely and appropriate action on all deficiencies detected through on-site reviews of the subrecipient using a risk-based approach approved by the USDA. Standard practices are in compliance with federal regulations. Physical verification or review of supporting documentation immediately at the time of submission to verify the CAP is not a federal requirement. Follow-up during the next scheduled review is in accordance with USDA regulations and BCFNA policy and procedure. BCFNA reviews Corrective Action Plans (CAPs) submitted by subrecipients to ensure they are acceptable and correct noted issues. Supporting documentation of CAP implementation may be reviewed by BCFNA’s trained Nutritionist performing the monitoring reviews prior to the next monitoring visit if deemed necessary, or during the next onsite monitoring visit. This follow up is timely and appropriate because the scheduling of the next monitoring visit is determined by the USDA-approved risk-based approach. For example, subrecipients that had significantly deficient issues in their monitoring will be reviewed onsite within 90 days to verify whether corrective actions have been taken and if not, move towards termination. The corrective action plans of other subrecipients that were deemed to not be as significant by the Nutritionist, such as using the wrong percent of milk, are verified at the next monitoring review which could range from 1 to 3 years. The criteria used by the SAO do not specify what is timely or appropriate and allows for BCFNA’s professional judgement and discretion of what is timely and appropriate. Claims testing BCFNA standard practice is test only the selected month(s) claim(s) per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. Actual noncompliance has not been noted in regards to testing. The BCFNA Nutritionist Manual allows for expanded testing if needed and BCFNA does perform expanded testing if deemed necessary. However, the USDA risk-based monitoring approach implemented by BCFNA sets prompt follow-up standards for significant deficiencies to determine if addressed, and if not, move on to termination. Overclaim recoupment BCFNA standard practice is to pursue recoupment of overclaims of only the test month per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. In addition, BCFNA officials pursue recoupment of overclaims for facilities/sponsors with terminated contracts on a case-by-case basis, taking into consideration various factors. BCFNA strives to maintain an appropriate balance between adequate monitoring and not creating barriers to program participation per USDA and the Paperwork Reduction Act. Starting the termination process is more effective than performing additional testing and pursuing historically unsuccessful recoupment of overclaims. CACFP is an important program that provides healthy meals to children and adults. The CACFP plays a vital role in improving the quality of day care and making it more affordable for many low-income families. This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults who are enrolled for care at participating child care centers, day care homes, emergency shelters and adult day care centers. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. USDA prohibits creating barriers to program participation and provision of services. The steps over and above the USDA requirements suggested by the SAO would place significant barriers to participation in the CACFP program and in turn cause harm to needy children and adults. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies.

Personnel Responsibile for Corrective Action: Janice Meier, Manager of Financial Services. Anticipated Completion Date: June 2024.Tracking and reporting ARPA expenditures includes many steps: - Assistant City Manager and Law approve projects submitted for use of ARPA funds. - Projects approved for full or partial funding from ARPA funds are approved by City Council as either part of the CIP/MIP budget approval or as a standalone item. - Listing of projects and amounts to be funded by ARPA is provided to Finance Manager. - Contracting - Project Manager notifies the Law Department if the resulting contract is funded by ARPA funds. - Law Department approves contracts as to form (including review of required ARPA language. - Finance Manager reviews expenditures for each project. Expenditures would have been routed to appropriate individuals and approved in the finance system. - Finance Manager determines fuding to be moved to project based on expenditures made and allocated ARPA funds remaining for project. - Project expenditures over the ARPA funding will be funded through other sources. - Finance Manager enters current quarter and life to date information into SLFRF reporting. Second quarter 2024 and future submissions will be approved by the Director of Finance and Budget prior to entering into SLFRF system.

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

Newmarket Housing Authority Audit Finding Response: Finding reviewed with program specialist and manager with following action plan in place to ensure key EIV reports are run on a scheduled basis and appropriate actions are taken; • Policies and procedures surrounding EIV reviewed. • Program specialist implemented the use of "tickler" reminders on outlook calendar to prompt EIV reports within 90 days for new move-ins. • The Manager will monitor monthly and quarterly to ensure EIV report is run for all move-ins and recertifications.

The Organization has implemented a reivew of summary reimbursement reports

BHA Audit Finding Response: Finding reviewed with program specialist and manager with following action plan in place to ensure key EIV reports are run on a scheduled basis and appropriate actions are taken; Policies and procedures surrounding EIV reviewed. Program specialist implemented the use of "tickler" reminders on outlook calendar to prompt EIV reports within 90 days for new move-ins. The manager will monitor monthly and quarterly to ensure EIV report is run for all move-ins and recertifications.

The Agency of Human Services receives funding under ALNs 93.775, 93.777, and 93.778 and is responsible for reporting the federal interest liability for these programs to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of the annual interest rate. Going forward, the Agency of Human Services will obtain the annual interest rate directly from the CMIA website: Cash Management Improvement Act - Annual Interest Rates (treasury.gov). The Department of Finance and Management will also verify the Agency of Human Services’ submission prior to submitting the CMIA Annual Report to the US Department of the Treasury. Position Responsible for Implementation of Corrective Action Candace Elmquist Financial Director Candace.Elmquist@vermont.gov Peter Moino Director of Internal Audit Peter.Moino@vermont.gov Date of Implementation of Corrective Action: Completed: 2/6/2024

The Agency of Human Services receives funding under ALN 93.568 and is responsible for reporting the federal interest liability for this program to the Department of Finance and Management. The Agency of Human Services previously relied on the Department of Finance and Management for notification of the annual interest rate. Going forward, the Agency of Human Services will obtain the annual interest rate directly from the CMIA website: Cash Management Improvement Act - Annual Interest Rates (treasury.gov). The Department of Finance and Management will also verify the Agency of Human Services’ submission prior to submitting the CMIA Annual Report to the US Department of the Treasury. Position Responsible for Implementation of Corrective Action Candace Elmquist Financial Director Candace.Elmquist@vermont.gov Peter Moino Director of Internal Audit Peter.Moino@vermont.gov Date of Implementation of Corrective Action: Completed: 2/6/2024

In March 2023, AOE implemented a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deputy CFO will perform a reconciliation at least two times a year. Position Responsible for Implementation of Corrective Action Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: 3/15/2023

In March 2023, AOE implemented a new process that is more automated to ensure accuracy and timeliness of our CMIA draws. We have created a new draw sheet that will be more easily loaded and will be reconciled a couple times a year. The Deputy CFO or person assigned by the Deputy CFO will perform a reconciliation at least two times a year. Name: Sean Cousino Position: Deputy CFO Email: sean.couisno@vermont.gov Phone Number: 802 595-3693 Date of Implementation of Corrective Action: March 15, 2023

Summary of finding: CODA Inc. did not have an internal control to review and approve the report prepared prior to submission through the Provider Relief Fund Portal. This led to the report reporting the incorrect eligible expenses for Period 4. Planned corrective action: CODA Inc. Additional levels of review will be implemented. The report will be prepared by accountant #1. The information in the report will be reviewed, approved, and uploaded by accountant #2. Director of Finance will perform a final review of uploaded information and will perform the final submission. Additional levels of review should ensure accuracy of information reported going forward. Contact person: Jenny Bickler, Director of Finance Completion date for action: The process is in place effective January 2024.

Program: AL 97.036 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Subrecipient Monitoring Corrective Action Plan: The Agency’s top priority is to respond to its vacancy needs by continuing working with department Human Resources to find, hire, and train viable candidates who can perform these important functions. Contact: Erv Portis Anticipated Completion Date: Ongoing

Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.

2023-001 ALN 14.850 Public and Indian Housing – Allowable Costs/Cost Principles Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. The Authority requires all checks to be signed by the Executive Director as primary signer or Financial Operations manager / Director of Finance as secondary signer as well as chairman of Board in emergency role if primary or secondary is unavailable, all of whom are approved as a bank signatory. All checks under $10,000 require one signature from primary check signer (Executive Director / President-CEO) and All non-recurring monthly expenses over $10,000 require two signatures for approval consisting of any combination Executive Director as primary signer or Financial Operations manager / Director of Finance as secondary signer, or as chairman of Board in emergency role if primary or secondary is unavailable. Person Responsible for Correction of Finding: Mr. Keon Jackson, Executive Director Projected Completion Date: June 30, 2024

The Center became aware of a discrepancy between the annual ESSER financial reporting and the quarterly reports during the audit. While the quarterly reports to the CDE were accurately reported and expenditures accurately recorded, the annual performance report was created manually, and reported full allocations per fund, in error during 2023 by the Center’s back-office service providers without review from Center’s management. Upon the Center’s communication with the CDE, the CDE has notified that “according to the U.S. Department of Education for ESSER Annual Reporting, there will be an opportunity to correct the Year 3 report that was submitted in March of 2023. The U.S. Department of Education requires that we submit Year 4 data to them first. This data will be collected in March of 2024. At that time, the LEA should report to the best of their ability, based on the previously reported expenditures. Depending on the previous amount reported, this may mean the LEA is not yet able to fully report applicable expenditures. This will be corrected later. Following the initial Year 4 submission, the U.S. Department of Education will allow for a Year 3 correction period. At this time, the LEA will be able to correct the Year 3 report. Finally, there will be a Year 4 correction period. This correction period will be based on any changes reported during the Year 3 correction period, to allow for a final true up of Year 4 reporting based on actual expenditures.” Therefore, the correction will be made in March of 2024. In the future, the Center’s back-office service providers will be utilizing a stricter rule for cross-checking reports, and will send reports (quarterly and annual) to the Center for a third review before submitting. The Center will also make the correction in March of 2024 per the CDE’s and U.S. Department of Education direction.

Corrective Action Responsible Party: Executive Director Finding has reoccurred as the finding was issued and corrective action plan was implemented after the time period of the single audit for time period ending December 31, 2022.The single audit requirement was new to KMNH as a result of ESG CV funding. KMNH has updated internal controls to carefully monitor the $1,000,000 federal dollar threshold which requires organizations to comply with the Uniform Guidance with respect to the submission deadline on single audit reports.

The Organization acknowledges that the unexpected resignation of the former independent auditor, and the subsequent domino effect of a delay in securing a new independent auditor, the delay in the new independent auditor’s completion of the final June 30, 2022 audit report, and the issuance of the Organization’s single audit report delayed the related Data Collection Form for the year ending June 30, 2022, beyond the nine-month deadline stipulated by the Uniform Guidance. The Organization has established internal compliance controls---the oversight of the process for timely filing with the director of administrative operations, chief executive officer, Board finance sub-committee and full Board.

Vacant positions have been filled and new staff have been assigned to the task of preparing of the SEFA. In addition, the new ERP platform has been operational for 15 months, thereby streamlining the year-end closing process.

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

The Organization agrees with the finding and recommendation as outlined above. In November 2023, the Organization updated and communicated changes to the Federal Awards Policies and Procedures Manual to ensure all controls are adequate to ensure compliance with federal statutes, regulations, and Uniform Guidance requirements. This was the first year the Organization has been subject to the single audit requirement. The Organization worked with the audit firm to ensure proper reporting and controls were in place. We understand it is our responsibility to ensure our single audit is completed within the required timeline and will work closely with future CPA teams to adhere to required timeframes. In January 2024, the Board of Directors approved the updated version of our Federal Awards Policies and Procedures Manual. The Organization has communicated the policies and procedures to ensure organizational compliance with the updated guidelines. As of March 2024, for fiscal year ended 2023, the Organization has prepared the SEFA and will present these materials concurrent with our regular audit schedule. The SEFA will be updated throughout each fiscal year as new federal funds are awarded. The Organization will continue to identify areas of opportunity to improve compliance with federal requirements.

Planned Corrective Action: Team Rubicon will institute during the grant intake process an assessment of whether a grant designates Team Rubicon as either a contractor or a subrecipient. Additionally, management will assess with grantors whether funds are federally sourced and whether a Single Audit (or any other compliance audit) is a necessary requirement or result of receiving the funding. Management will further ensure that any and all compliance requirements for government-funded grants or awards are communicated and adhered to across the organization. Management will also ensure the evaluation and monitoring of compliance with federal awards through strengthening related internal controls and processes.

Finding 2022-001 Significant Deficiency in Internal Control over Compliance, - Cash Management Progoram Research and Development Program Cluster: Renewable Energy Research and Development Planned Corrective Action Plan To prevent and detect any potential noncompliance with cash management requirements, the President & CEO will review and approve grant reimbursements before uploaded to grantor on VIPERS. Completion Date Already implemented.

Views of Responsible Officials and Planned Corrective Action