Corrective Action Plans

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over reporting be enhanced to ensure evidence is maintained to support the reports and review performed over the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of re-evaluating the reporting process to ensure documentation is maintained to support the reporting requirements. Name of the contact person responsible for corrective action: Lisa Katz, Chief Program Officer Planned completion date for corrective action plan: Currently underway and planned to be completed by June 30, 2024.

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

Finding 2023-003: Overpayments to Landlords (Significant Deficiency) Corrective Action Plan: DHA Management has worked with our financial institution to ensure that the positive pay function is working and duplicate payments will not be posted to Landlord accounts. Name of Responsible Person: Cheron Corbett Completion Date: July 31, 2023

FINDING 2023-002 Information on the federal program: Subject: Child and Adult Care Food Program Federal Agency: Department of Agriculture Federal Program: Child and Adult Care Food Program Assistance Listing Number: 10.558 Federal Award Numbers and Years (Or Other Identifying Number): FY2022, FY2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Procurement and Suspension and Debarment Audit Finding: Material Weakness, Qualified Opinion Condition: There was not an effective control in place to review underlying transaction detail billed by the food service management compliance to verify compliance with Activities Allowed or Unallowed requirements. There was also not an effective control in place to monitor and review the food service management company followed procurement and suspension and debarment regulations. Context: As a result of the COVID-19 pandemic, waivers from the federal government provided free meals to all students through the Summer Food Service Program and allowed meals to be consumed off-site. Due to the changing regulations, the USDA and IDOE required School Corporations to implement an Integrity Plan for any schools providing Grab and Go Meals which includes inquiring of any adult requesting meals without children present as to how many children under the age of 18 would be served. Prior to March 2020, the School Corporation was using a point-of-sale system to record meals served. Starting in March 2020, the School Corporation was authorized by IDOE to utilize a clicker to track meals served. During the summer months of 2021, the School Corporation was also authorized by IDOE to provide meal pickup service on Wednesdays from 3 – 6 p.m. for 5 days’ worth of meal for both breakfast and lunch, resulting in 10 meals being served per child under the age of 18 each week. In June 2021, the Indiana Department of Education performed an unannounced meal site observation and a second, announced meal site review noting several program compliance and administrative issues. In July 2021, the IDOE performed a targeted review of the Summer Food Service Program for the period of March 2020 through May 2021 noting the following program compliance issues. • Meals were distributed without ensuring they were going to children ages 18 and younger as required by SFSP regulations. • Meals were taken off site to be distributed/dropped off at non—approved locations. • Meals were distributed and claimed on days when no meal service was approved, • Meals were distributed outside of approved meal service times. • Some meals were not distributed in household size quantities to the parent or guardian but distributed in bulk to large groups and knowingly transported in unsafe and unsanitary ways. • Meal count records were incomplete, unsigned, or missing required information. • Meal production was not adjusted when attendance fluctuations were noted. • Different menu items were ordered for and distributed to a specific group of individuals that was not the same as the planned menu. • Menu planning did not consider food inventory on hand and MSD of Pike Township’s access to USDA Foods (commodities) to reduce overall food costs. • Unauthorized donation, distribution, and disposal of foods purchased with federal funds was made without MSD Pike administration knowledge or approval. The review also noted a lack of administrative oversight of the food service management company contract including the following issues: • Food service management company representatives were making decisions regarding child nutrition program operations without consulting MSD of Pike Township administration. This practice was ongoing and occurred over several administrations. • Potential unallowable expenditures were noted in a review of monthly itemized invoices presented to MSD of Pike Township for recent payment. Items for personal consumption of food service management employees such as coffee, energy drinks, donuts, lunches, and even unauthorized travel expenses were presented but are considered unallowable expenditures from the food service account. As a result of the review, a total of $623,724 was disallowed for unsupported meal claims from September 2020 through May 2021 from the Child and Adult Care Food Program (CACFP) for At-Risk suppers reimbursed through the CACFP program. The School Corporation and IDOE agreed to a repayment plan to repay the disallowed costs identified which was paid in December 2021. Activities Allowed or Unallowed, Allowable Costs/Cost Principles During the testing of activities allowed or unallowed and allowed costs/cost principles, we selected 6 monthly invoices from the food service management company during the audit period. We noted there was not an internal control in place by School Corporation personnel to obtain and view the underlying support of transactions charged by the food service management company to verify the transaction was for a business purpose. The School Corporation did not obtain and review source documents, such as invoices or proof of payment for vendor transactions or a schedule of employees, assigned locations, salaries, and hours to be worked for payroll transactions submitted by the food service management company for reimbursement. We also selected a sample of 40 vendor transactions charged to Fund 0800 to test which were not related to the food service management company and incurred directly by the School Corporation. For 6 of the 40 transactions tested, we noted transactions for concession fees which were charged to the School Nutrition Program from July 2021 through September 2022 and are deemed unallowable. In October 2022, the School Corporation began recording all concession activity to Fund 2180, Concessions – District. The six concession transactions in our sample total $663 which are considered known questioned costs. Procurement and Suspension and Debarment The School Corporation did not have an internal control in place to monitor the food service management company was following proper procurement standards. School Corporations that contract with a food service management company on a cost reimbursement basis should ensure they are monitoring contracts sufficiently including verifying or reviewing the following: • The School Corporation should receive contract commits to supply. • Reviewing invoices received from the food service management company compared to amounts paid by the food service management company. • Reviewing contracts for compliance with Buy American • Verifying return of discounts, rebates, or credit are properly applied to the School Corporation’s account. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. MSD of Pike Township (Pike) agrees during the audit period effective controls were not in place to review and approve meal counts tracked and submitted for reimbursement, review underlying transaction detail billed, nor monitor and review the Food Service Management Company (FSMC) followed procurement and suspension and debarment regulations. Pike has increased the Business Office oversight of the Food Service Management Company (FSMC). Pike has hired a Food Service Financial Specialist to provide more the detailed review of invoices and operations ledger and the underlying transaction details. Additionally, effective October 2022, MSD of Pike Township hired a Director of Food Service to provide oversight of the Food Service Management Company (FSMC) including but not limited to meal counts, site audits, and compliance with procurement regulations. The FSMC no longer has access to submit claims on the CNP website. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan.

FINDING 2023-001 Information on the federal program: Subject: Child Nutrition Cluster Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (Or Other Identifying Number): FY2022, FY2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Procurement and Suspension and Debarment Audit Finding: Material Weakness, Qualified Opinion Condition: There was not an effective control in place to review underlying transaction detail billed by the food service management compliance to verify compliance with Activities Allowed or Unallowed requirements. There was also not an effective control in place to monitor and review the food service management company followed procurement and suspension and debarment regulations. Context: As a result of the COVID-19 pandemic, waivers from the federal government provided free meals to all students through the Summer Food Service Program and allowed meals to be consumed off-site. Due to the changing regulations, the USDA and IDOE required School Corporations to implement an Integrity Plan for any schools providing Grab and Go Meals which includes inquiring of any adult requesting meals without children present as to how many children under the age of 18 would be served. Prior to March 2020, the School Corporation was using a point-of-sale system to record meals served. Starting in March 2020, the School Corporation was authorized by IDOE to utilize a clicker to track meals served. During the summer months of 2021, the School Corporation was also authorized by IDOE to provide meal pickup service on Wednesdays from 3 – 6 p.m. for 5 days’ worth of meal for both breakfast and lunch, resulting in 10 meals being served per child under the age of 18 each week. In June 2021, the Indiana Department of Education performed an unannounced meal site observation and a second, announced meal site review noting several program compliance and administrative issues. In July 2021, the IDOE performed a targeted review of the Summer Food Service Program for the period of March 2020 through May 2021 noting the following program compliance issues. • Meals were distributed without ensuring they were going to children ages 18 and younger as required by SFSP regulations. • Meals were taken off site to be distributed/dropped off at non—approved locations. • Meals were distributed and claimed on days when no meal service was approved, • Meals were distributed outside of approved meal service times. • Some meals were not distributed in household size quantities to the parent or guardian but distributed in bulk to large groups and knowingly transported in unsafe and unsanitary ways. • Meal count records were incomplete, unsigned, or missing required information. • Meal production was not adjusted when attendance fluctuations were noted. • Different menu items were ordered for and distributed to a specific group of individuals that was not the same as the planned menu. • Menu planning did not consider food inventory on hand and MSD of Pike Township’s access to USDA Foods (commodities) to reduce overall food costs. • Unauthorized donation, distribution, and disposal of foods purchased with federal funds was made without MSD Pike administration knowledge or approval. The review also noted a lack of administrative oversight of the food service management company contract including the following issues: • Food service management company representatives were making decisions regarding child nutrition program operations without consulting MSD of Pike Township administration. This practice was ongoing and occurred over several administrations. • Potential unallowable expenditures were noted in a review of monthly itemized invoices presented to MSD of Pike Township for recent payment. Items for personal consumption of food service management employees such as coffee, energy drinks, donuts, lunches, and even unauthorized travel expenses were presented but are considered unallowable expenditures from the food service account. As a result of the IDOE review, a total of $1,299,365 was disallowed from the Summer Food Service Program. The School Corporation and IDOE agreed to a repayment plan to repay the disallowed costs identified. The School Corporation completed the repayment to IDOE in December 2021. Activities Allowed or Unallowed, Allowable Costs/Cost Principles During the testing of activities allowed or unallowed and allowed costs/cost principles, we selected 6 monthly invoices from the food service management company during the audit period. We noted there was not an internal control in place by School Corporation personnel to obtain and view the underlying support of transactions charged by the food service management company to verify the transaction was for a business purpose. The School Corporation did not obtain and review source documents, such as invoices or proof of payment for vendor transactions or a schedule of employees, assigned locations, salaries, and hours to be worked for payroll transactions submitted by the food service management company for reimbursement. We also selected a sample of 40 vendor transactions charged to Fund 0800 to test which were not related to the food service management company and incurred directly by the School Corporation. For 6 of the 40 transactions tested, we noted transactions for concession fees which were charged to the School Nutrition Program from July 2021 through September 2022 and are deemed unallowable. In October 2022, the School Corporation began recording all concession activity to Fund 2180, Concessions – District. The six concession transactions in our sample total $663 which are considered known questioned costs. Procurement and Suspension and Debarment The School Corporation did not have an internal control in place to monitor the food service management company was following proper procurement standards. School Corporations that contract with a food service management company on a cost reimbursement basis should ensure they are monitoring contracts sufficiently including verifying or reviewing the following: • The School Corporation should receive contract commits to supply. • Reviewing invoices received from the food service management company compared to amounts paid by the food service management company. • Reviewing contracts for compliance with Buy American • Verifying return of discounts, rebates, or credit are properly applied to the School Corporation’s account. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. MSD of Pike Township (Pike) agrees during the audit period effective controls were not in place to review and approve meal counts tracked and submitted for reimbursement, review underlying transaction detail billed, nor monitor and review the Food Service Management Company (FSMC) followed procurement and suspension and debarment regulations. Pike has increased the Business Office oversight of the Food Service Management Company (FSMC). Pike has hired a Food Service Financial Specialist to provide more the detailed review of invoices and operations ledger and the underlying transaction details. Additionally, effective October 2022, MSD of Pike Township hired a Director of Food Service to provide oversight of the Food Service Management Company (FSMC) including but not limited to meal counts, site audits, and compliance with procurement regulations. The FSMC no longer has access to submit claims on the CNP website. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan.

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

Planned Corrective Actions: The Community Youth Advance Interim Executive Director will make updates to the Employee Handbook and create a Standard Operating Procedures manual that outlines key responsibilities with regard to record keeping and reporting that will ensure continuity and stability during times of leadership and staff transition. This will be reviewed with staff and our accounting firm to ensure it is comprehensive and addresses the organization’s needs and the recommendations of this audit. The Board of Directors will then review and give final approval of these documents. Name of the contact Person responsible for corrective action: Danielle Middlebrooks, Interim Executive Director, Community Youth Advance Board of Directors (Cassius Priestly, Chair) and Goldin Group CPAs Planned completion date for corrective action plan: The Standard Operating Procedures Manual and the Updated Community Youth Advance Employee Handbook will be completed and approved by June 30, 2024, to take effect July 1, 2024.

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the timely filing before transmitting a copy of the report to the City of Atlanta’s Grants Accounting area. Anticipated Completion Date: Fiscal year 2024

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 2021. Payroll expenditures that were incurred or obligated before March 3, 2021, will be removed from the CSLFRF claims. 3. Anticipated implementation date: June 28, 2024

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for two of the testing selections. An additional selection contained a keying error. Responsible Individuals: Amy Spieker, Director Community Health and Analysis, and Erika Novick, Operations Manager Corrective Action Plan: The Program Director and Operations Manager will ensure all invoices are properly submitted and approved prior to including the expenses in the reimbursement requests. Program Director/Director of Community Health and Analysis will review draws/invoices to ensure amounts on supporting documents agree to the amounts submitted in the reimbursement requests. Finance will also revise Corporate Card Policy by June 30, 2024, to include expense reports being submitted in a timely manner. Finance will review open expense reports with card holder and their supervisor monthly. Anticipated Completion Date: April 1, 2024

Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the guidelines that were used to award students monies from this fund. During the audit, it was noted that SBCC incorrectly awarded undocumented students with monies from the Coronavirus State and Local Fiscal Recovery Funds. SBCC was not aware at the time of awarding these monies that a second guidance memo had been issued by the Community Colleges of California Chancellor’s Office (CCCCO) on Friday, January 21,2022 (Attachment B). The updated memo clearly stated that undocumented students were no longer eligible for these funds. SBCC had not updated its protocols to match the second memo due to staffing issues within th e financial aid office. Specifically, the manager of the Financial Aid Office was out on disability leave from January 26 through September 28, 2022. However, no funds were awarded during this absence. Within the new guidance, a new process stated how to corrects awards given to candidates originally eligible (undocumented students) under the first memo, but no longer eligible under the second memo. Per the second memo, any incorrectly awarded funds under the first policy were to be replaced with other funds that undocumented students are eligible to receive. Corrective Action To correct the incorrect awarding of funds to ineligible candidates, SBCC cancelled the awards to now ineligible recipients of Early Action Fund (EMASS/SRFR) and replace d them with awards from AB19 monies, which were rolled over from 22-23. SBCC also used monies from remaining HEERF/CARES funds, which allowed for awards to undocumented students. In total, SBCC corrected 16 awards totaling $48,000. SBCC’s records now reflect that no undocumented students received Coronavirus State and Local Fiscal Recovery Funds. Going forward, SBCC is now awarding under the correct guidelines. No further awards have been made to undocumented students. The fund is winding down and will be spent in full by the end of the 23-24 fiscal year.

This error was the result of inadvertent oversight. Initially, this resource allowed indirect costs and the validation tables from CDE allowed the account component combination. Information was subsequently changed by CDE to issue guidance to charge the indirect cost for the learning loss component to the ESSER III Fund. CDE's website was updated on October 16, 2023, with this guidance well after the year end close was complete. Staff will implement additional processes to ensure valid application of indirect cost charges to grant programs.

A/B. Allowable Costs and Cost Principles/Activities Allowed or Unallowed Administrative Cost Grants for Indian Schools FFAL #15.046 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified four expenditures where payroll was not paid in accordance with employment letter. Corrective Action Plan: Anticipated Completion Date: The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. June 30, 2024

A/B. Allowable Costs and Cost Principles/ Activities Allowed or Unallowed Indian School Equalization FFAL #15.042 Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: During the course of the engagement, Eide Bailly identified five expenditures Corrective Action Plan: Anticipated Completion Date: where payroll was not paid in accordance with employment letter. The School will review internal controls surrounding allowable costs and activities to ensure they are adequate to identify unallowable expenditures. June 30, 2024

2023-004 FINDING: INADEQUATE CONTROLS OVER PAYROLL EXPENDITURES AND NONCOMPLIANCE WITH ALLOWABLE COST & COST PRINCIPLES REQUIREMENTS APPLICABLE TO THE HEAD START CLUSTER Corrective Action Plan: The University has updated its process to collect time and effort information on a semi-annual basis rather than quarterly, which relieves some burden from staff, but still complies with federal regulations. By collecting time and effort information on a semi-annual basis, staff will have more time to reconcile time and effort against actual payroll expenditures. The University has also redesigned the time and effort collection form to show the 100% distribution of work. Further, the University now has a full-time financial research administrator who will help ensure that payroll related adjustments are done timely. The financial research administrator will work with the Early Head Start program management to ensure that the related payroll reports are reviewed and reconciled timely, in accordance with existing University procedures. Responsible University Personnel: Erin Soto, Executive Director of Family Development Center; FeMia Norwood, Director of Office of Sponsored Programs and Research; Jessica Braddy, Financial Research Administrator. Anticipated completion date: Already implemented.

Internal Controls over Compliance Requirements of Federal Awards Review process -- Recommendation We recommend that another level of review of the quarterly reporting be added to the review process. The person responsible for this additional review should be familiar with the grant budget and the underlying supporting documentation that should be used to correctly calculate allowable salary and benefit costs. In the event that mistakes happen, the Organization should advise the federal agency on a timely basis and appropriately amend the reports. Corrective Action Plan -- The following procedures have been implemented: The Chief Executive Officer is reviewing quarterly Federal Awards reports before issuance, and comparing to supporting documentation.

Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As part of the ongoing plan to improve its financial operations, EmployIndy Financial Operations, Grants & Contracts, and Program Management staff will work with WIOA subrecipients to update processes and provide any necessary training for documenting personnel costs that are charged to WIOA funding/cluster. WIOA subrecipients requesting reimbursements for personnel costs will be required to include staff timecards with documentation that shows the specific number of hours of work time charged to each program in the WIOA cluster. EmployIndy staff reviewing monthly invoices or accrued expenditure reports will be retrained on how to properly review subrecipient expenditures and supporting documentation prior to approval. Further, EmployIndy Financial and Program monitors will specifically review subrecipient time charging and invoicing activity to ensure that personnel costs are not allocated proportionately but based upon actual time worked within each program/cluster. Finally, Financial Operations, Grants & Contracts, and Program Leadership teams will receive further training on Uniform Administrative Requirements for Federal Awards to ensure there is greater understanding of documentation requirements necessary to support federal expenditures. Responsible Party and Timeline for Completion: Corrective Activity Responsible Party Timeline for Completion Develop training for subrecipient and contractor staff time charging and documentation requirements. Associate Director of Grants & Contracts, Controller 1st Quarter of Calendar Year 2024 Develop and provide updated training to EmployIndy Leadership on documentation requirements needed to approve subrecipient or contractor accrued expenditure reports or invoices that contain personnel costs Controller 1st Quarter of Calendar Year 2024 Deliver training to subrecipient and contractor staff time charging, submission, and documentation requirements Vice President of WorkOne, Vice President of Career Connected Learning, Vice President of Community Career Services 2nd Quarter of Calendar Year 2024 Update subrecipient monitoring process to review staff time charging and documentation requirements Associate Director of Grants & Contracts, Associate Director of Performance and Technical Assistance Completed in January 2024 Hold staff and subrecipients accountable for following processes Executive Vice President of Finance and Operations, EmployIndy Leadership Ongoing Complete training on Uniform Administrative Requirements for Federal Awards Financial Operations, Grants & Contracts, and Program Leadership Teams 1st Quarter of Calendar Year 2024

Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As a part of this plan, EmployIndy’s Financial Operations Team, led by the Controller, has already begun to update the expenditure approval process. This process requires that supporting documentation be retained within the financial management system. Additionally, the review and approval process consists of multiple review and approval steps by program management and financial operations staff with specific focus on retention of supporting documentation and clear connections between expenditures being allocated to WIOA and other funding clusters and documentation supporting such allocations. All EmployIndy staff will be retrained on the updated expenditure submission, review, approval, and documentation processes. Additionally, EmployIndy’s Financial Operations, Grants & Contracts, and Program Management teams will provide guidance and training to EmployIndy’s subrecipients and contractors covering the proper process for submitting supporting documentation with invoices or accrued expenditure reports. These documentation requirements will ensure that supporting information directly and clearly ties back to invoices and/or accrued expense reports. EmployIndy’s Executive Vice President for Finance and Operations will work with other members of the Executive Team and other senior leaders to hold all staff accountable for following this process. Responsible Party and Timeline for Completion: Corrective Activity Responsible Party Timeline for Completion Develop training for the timely submission and proper submission, review, and approval of accrued expenditure reports and invoices, and appropriate documentation requirements Controller and Associate Director of Grants & Contracts 1st Quarter of Calendar Year 2024 Train internal EmployIndy staff and external subrecipient and contractor staff on properly submitting, reviewing, and approving accrued expenditure reports and invoices, and including proper documentation supporting expenditures Controller, Associate Director of Grants & Contracts, and EmployIndy Program Leadership By 2nd Quarter of Calendar Year 2024 Hold Financial Operations, Program Leadership, and subrecipient and contractor staff accountable for following established processes Executive Vice President of Finance and Operations Ongoing

Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As part of the improvement to financial operations, EmployIndy will provide updated training to all staff covering the proper process for submitting, reviewing, approving, and retaining supporting documents for expenditures. The existing procedure includes a multi-step review and approval process for all expenditures, including those in the WIOA and other federal funding clusters. Additionally, EmployIndy’s Financial Operations, Grants & Contracts, and Program Management teams will provide guidance and training to EmployIndy’s subrecipients and contractors covering the proper process for submitting supporting documentation with invoices or accrued expenditure reports. These documentation requirements will ensure that supporting information directly and clearly ties back to invoices and/or accrued expense reports. Responsible Party and Timeline for Completion: Corrective Activity Responsible Party Timeline for Completion Develop training for the timely submission and proper submission, review, and approval of accrued expenditure reports and invoices, and appropriate documentation requirements Controller and Associate Director of Grants & Contracts 1st Quarter of Calendar Year 2024 Train internal EmployIndy staff and external subrecipient and contractor staff on properly submitting, reviewing, and approving accrued expenditure reports and invoices, and including proper documentation supporting expenditures Controller, Associate Director of Grants & Contracts, and EmployIndy Program Leadership By 2nd Quarter of Calendar Year 2024 Hold Financial Operations, Program Leadership, and subrecipient and contractor staff accountable for following established processes Executive Vice President for Finance and Operations Ongoing

DSHA has implemented the process of requiring the reduction of applicable credits to be applied to all future payment batches and be utilized to fund assistance. This as a result, will eliminate the funds being held by the vendor and remove the need to report as a federal expenditure. The responsibility for implementing this corrective action lies with the following DSHA staff: HAF Program Manager, Director of Housing Finance, Financial Accounting & Reporting Section Manager, and the Director of Financial Management. They will oversee the necessary adjustments to the process and ensure that future payment batches adhere to the revised guidelines. Responsible Official: Brian Rossello, Director of Housing Finance Completion Date: December 2023

DSHA has contracted with a third-party vendor that will work in tandem with an Internal DSHA ERA Staff person to submit UST reports. DSHA will work to update its policies related to UST reports to include capturing uploaded reports, documents, and dates that information is submitted, saving information to internal files as some information submitted to the UST Portal is not accessible for review after the reporting period has ended and report submission has been approved by UST. Responsible Official: Devon Manning, Director of Policy & Planning

DSHA recognizes that there were cases where cases were paid more than allowable under UST Program Guidelines. In future direct assistance programs, DSHA will update policies and procedures to add an internal DSHA staff review of any case that is approved for payment to ensure that program recipients are not approved for payments extending the UST’s current eighteen (18) months of assistance. DSHA will incorporate measures that regulate how direct payments are coded within its accounting department to ensure that all outgoing payments are made from the associated ERA account. Responsible Official: Devon Manning, Director of Policy and Planning. Completion Date: July 2023

Department: Health and Human Services Title: Internal control over Medicaid drug rebates needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: As a part of the quarterly drug rebate invoicing cycle, the pharmacy unit drug rebate team will review and approve the pre-invoicing variances prior to the generation of invoices. On a quarterly basis, the QA team will review a sample of medical claim drug lines to calculate the drug utilization and compare that to PRIMS and confirm that the invoice is calculated correctly. Completion Date: May 31, 2024 and June 15, 2024 respectively Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093

Department: Health and Human Services Title: Internal control over Medicaid cost of care deductions needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department’s State Adjustment Supervisor and Provider Relations Manager will work with OFI to request the COC manual change report be sent to the State Adjustment Unit. The State Adjustment Unit will QA the claims report received by the vendor and compare it to the OFI report to assure accurate reporting of cost of care changes for affected members. Completion Date: April 30, 2024 Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093

Department: Health and Human Services Administrative and Financial Services Title: Internal control over Medicare Part B premium payments needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Office for Family Independence (OFI) will ensure the monthly report from the data team captures all discrepancies based on the CMS monthly reporting for Medicare Part B. OFI will revise and implement standard operating procedures, including oversight procedures, ensuring monthly documentation of completed reconciliations. Completion Date: May 1, 2024 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481