ONTRACK, INC. DBA CONTINUUM BEHAVIORAL HEALTH AND RECOVERY SERVICESNon-Profit

ONTRACK, INC. Corrective Action Plan Finding 2025-001: Personnel Cost Documentation Single Audit — Year Ended June 30, 2025 Finding Reference 2025-001 Federal Agency Department of Health and Human Services Program Mental and Behavioral Health Education and Training (CFDA 93.732) Awards Affected FAIN M0142512 / M0255242 — All award years Questioned Costs $46,045 (payroll and fringe benefit charges, FY ended June 30, 2025) Responsible Official Mark Bell, Director of Finance CAP Prepared By OnTrack, Inc. Mark Bell, Director of Finance Date Prepared March 9, 2026 1. Management Response and Concurrence OnTrack, Inc. has reviewed Finding 2025-001 and acknowledges that the documentation maintained during the audit period did not fully satisfy the after-the-fact review requirements of 2 CFR §200.430(g), as interpreted by Clark Nuber during the course of the audit. Management accepts the finding in principle and is committed to strengthening its internal controls and documentation practices going forward. OnTrack respectfully notes, however, that the personnel cost allocation methodology in use during the audit period was designed to operate within the framework of 2 CFR §200.430(g)(1)(viii), which expressly permits the use of budget-based estimates for interim accounting provided that the organization’s system of internal controls includes after-the-fact review processes to confirm that charges are accurate, allowable, and properly allocated. OnTrack’s position is that such monitoring processes were in place during the audit period, and that actual effort by charged employees consistently met or exceeded the amounts allocated to the grant. No evidence of overcharging or unallowable costs has been identified. The $46,045 in questioned costs represents compensation charges that were properly earned and allocable to the BHWET program; the deficiency identified in the finding is one of documentation adequacy rather than cost allowability. 2. Root Cause Analysis The root cause of the documentation gap identified in Finding 2025-001 was the absence of a formalized, written policy governing after-the-fact personnel activity certification for federally funded positions. While monitoring activities were performed in practice, including supervisory review of employee schedules, calendar records, email correspondence, and clinical supervision logs, these processes were not captured in a formal policy document or a standardized certification form that would produce an auditable evidence trail sufficient to meet the requirements of 2 CFR §200.430(g). Specifically, the following control gaps were present during the audit period: • No standardized Personnel Activity Certification form requiring dual signatures (employee and supervisor). • No defined frequency or deadline for completion of after-the-fact reviews. • No formal variance threshold triggering payroll adjustments. • No centralized documentation filing protocol for retaining certification evidence with grant records. These gaps created a situation in which monitoring activity occurred but was not documented in a form that could be readily examined during audit fieldwork. 3. Corrective Action Steps 3.1 Personnel Activity Certification Policy (Completed) OnTrack has adopted a formal Personnel Activity Certification Policy for Federally Funded Grant Programs, effective [Date of Adoption]. The policy directly addresses each control gap identified in the finding and establishes a comprehensive framework for documenting and certifying personnel activity for all employees charged to the BHWET grants. Key elements of the policy include: • Monthly Personnel Activity Certifications completed within 30 days of period-end, covering all employees charged in whole or in part to the BHWET grants. • Dual-signature certification form requiring attestation by both the employee and a supervisor with direct, first-hand knowledge of the employee’s work activities. • Defined 5% variance threshold: if actual effort falls materially below the budgeted FTE allocation, the Finance Director initiates a payroll adjustment within 60 days. • Segregation of duties among the Finance Director (payroll processing), Project Director (activity review and certification), and Executive Director (final oversight). • Centralized filing of certifications, Personnel Activity Schedules, and supporting documentation with grant records, retained in accordance with 2 CFR §200.334. • Annual policy review to reflect changes in grant requirements, organizational structure, or applicable regulations. A copy of the adopted Personnel Activity Certification Policy, including the certification form (Exhibit A) and supporting documentation (Exhibit B), is attached to this Corrective Action Plan. 3.2 Retroactive Documentation for Audit Period (Completed) To the extent practicable, OnTrack compiled and organized available documentation and provided this information to Clark Nuber. This included calendar records, email correspondence, supervision logs, and employee schedules to support the reasonableness of personnel charges during the audit period.. Management acknowledges that this retroactive compilation does not fully cure the documentation deficiency identified in the finding; however, it is intended to preserve the evidentiary basis for the organization’s position that actual effort met or exceeded amounts charged. 3.3 Staff Training and Implementation (In Progress) OnTrack will conduct training for all employees and supervisors whose compensation is charged to Federal grants, covering the requirements of the Personnel Activity Certification Policy, the certification process and timeline, and the documentation standards required by 2 CFR §200.430(g). Training will be completed within 60 days of policy adoption and annually thereafter. 3.4 Payroll System Enhancement (Planned) OnTrack will evaluate enhancements to its payroll and accounting systems (UKG and Sage Intacct) to facilitate improved tracking of grant-specific allocations and to generate period-end allocation reports that can serve as a basis for certification review. This evaluation will be completed within 90 days of policy adoption, with any system changes implemented within the current grant budget period. 4. Implementation Timeline Corrective Action Responsible Party Target Date Status Adopt Personnel Activity Certification Policy Finance Director / Exec. Director March 9, 2026 Complete Distribute policy and certification forms to all affected employees Finance Director / Project Director March 23, 2026 In Progress Complete staff training on certification requirements Project Director/Director of Development and Grant Administration April 9, 2026 Planned Complete first monthly Personnel Activity Certifications under new policy All charged employees / Supervisors May 15, 2026 Planned Compile retroactive documentation for FY2025 audit period Finance Director March 9, 2026 Completed Evaluate payroll system enhancements (UKG / Sage Intacct) Finance Director June 30, 2026 Planned Annual policy review (ongoing) Finance Director Annually Ongoing 5. Questioned Costs — Management Position The $46,045 in questioned costs identified in the finding represents payroll and fringe benefit charges for employees who performed direct program administrative functions integral to the BHWET federal award. OnTrack’s position is that these costs are allowable, allocable, and reasonable under 2 CFR Part 200, Subpart E, and that the questioned costs designation reflects a documentation deficiency rather than the presence of unallowable charges. 6. Ongoing Monitoring and Oversight To ensure sustained compliance with the corrective actions described in this plan, OnTrack will implement the following ongoing monitoring procedures: • The Director of Program Development and Grant Administration will review Personnel Activity Certifications for completeness and timeliness within 15 days of each monthly deadline, and will follow up with supervisors or employees on any missing or incomplete certifications. • Personnel cost allocations will be reviewed against approved grant budgets on a quarterly basis; material variances will be reported to the Project Director and Executive Director. • The status of corrective action implementation will be reported to the OnTrack Board of Directors at the next regularly scheduled board meeting following policy adoption, and quarterly thereafter until all planned actions are complete. • Compliance with the Personnel Activity Certification Policy will be assessed as part of the organization’s annual internal control review. 7. Certification The undersigned certify that the information contained in this Corrective Action Plan is accurate and complete, and that OnTrack, Inc. is committed to implementing the corrective actions described herein within the timelines specified. ________________________________ Date: ____________ Sommer Wolcott, Executive Director ________________________________ Date: ____________ Mark Bell, Director of Finance

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Develop and Implement a Formal Procurement Policy o A written procurement policy will be developed that aligns with 2 CFR 200.317 - 200.327, ensuring compliance with federal, state, and local regulations. 2. Enhance Internal Controls for Procurement Compliance o All procurement transactions will be reviewed and approved by designated personnel to verify compliance before finalizing agreements. o A procurement checklist will be used for each transaction to ensure that required documentation is maintained. 3. Mandatory Suspension and Debarment Verification o The Organization will implement procedures to verify all vendors against the System for Award Management (SAM.gov) database before entering into contracts. o Documentation of suspension and debarment searches will be retained in the procurement files. Anticipated Completion Date September 30, 2025

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Establish FSRS Reporting Policy and Procedures o The Organization will develop and implement a formal Subaward Reporting Policy to ensure that all first-tier subawards of $30,000 or more are reported in FSRS in compliance with 2 CFR Part 170. 2. Assign Responsibility and Oversight o A specific staff member within the Grants department will be designated as the FSRS Reporting Coordinator and will be responsible for verifying the completeness and accuracy of subaward reporting and for timely submission to FSRS. o A pre-submission review will be conducted by the FSRS Reporting Coordinator to verify that subawards over $30,000 are captured and reported. 3. Implement Internal Controls and Review Checkpoints o All subawards will be reviewed as part of the pre-award and post-award grant workflow to determine FSRS applicability. o A pre-submission review will be conducted by the Grants Compliance Officer to verify that subawards over $30,000 are captured and reported. 4. Monitoring and Audit Trail Documentation o FSRS submissions will be documented and retained in the grant file along with confirmation of submission and reporting screenshots. Anticipated Completion Date September 30, 2025