Corrective Action Plans

Criteria or specific requirement: 2 CFR 200.403(b) states that costs must "Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items". Per the Federal award (contract 2018-51300-28430, PTEIN C0535A-A), there was no specific allowability for “Fees”, and the budget indicated $0 allocated to “Fees”. 2 CFR 200.303(a) requires non federal entities receiving Federal awards to "Establish and maintain internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." 2 CFR 200.430(i)(1) states that "Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed." Condition: (10.307) During testing of general disbursements, it was noted that the Organization did not retain documentary evidence of review and approval of disbursements for 4 out of 17 samples tested. In addition, for 1 sample, the Organization charged unallowable costs (bank fees) to the major program. During testing of payroll, it was noted that inadequate time and effort documentation was retained for 2 out of 26 samples tested, resulting in wages being charged erroneously between programs. (10.311) During testing of general disbursements, it was noted that the Organization did not retain documentary evidence of review and approval of disbursements for 5 out of 14 samples tested. During testing of payroll, it was noted that inadequate time and effort documentation was retained for 2 out of 21 samples tested, resulting in wages being charged erroneously between programs. During testing of indirect costs, it was noted that direct costs used to calculate the applied indirect cost rate were not supported by underlying documentation of costs incurred. Questioned costs: None Context: (10.307) For testing of general disbursements, a sample of 17 was made from a population of 113 disbursement transactions. Of the 17 sampled, 4 did not include documentary evidence of review and approval of the disbursement. In addition, 1 sample was found to be out of compliance with the provisions for 2 CFR 200.403(b). For testing of payroll, a sample of 26 was made from a population of 168 unique employee paychecks. Of the 26 sampled, 2 had inadequate documentation of time and effort spent on the major program, resulting in an overbilling in one sample and an underbilling in the second sample. (10.311) For testing of general disbursements, a sample of 14 was made from a population of 90 disbursement transactions. Of the 14 sampled, 5 did not include documentary evidence of review and approval of the disbursement. For testing of payroll, a sample of 21 was made from a population of 139 unique employee paychecks. Of the 21 sampled, 2 had inadequate documentation of time and effort spent on the major program, resulting in an overbilling in one sample and an underbilling in the second sample. For testing of indirect costs, a sample of 6 was made from a population of 21 monthly reimbursement invoices. Of the 6 sampled, 3 did not include sufficient documentation to support the direct costs used to apply the indirect cost rate. Cause: The Organization does not have adequate controls around the documentation of the supervisor review and approval process. Supervisory review and approvals are currently being communicated verbally. In addition, inadequate documentation is retained to document the time and effort of employee time spent on grants and the total direct costs that should be considered when applying the indirect cost rate. Effect: Without adequate records retained, the Organization is at risk of noncompliance with Federal programs and grant regulations, which could result in penalties or repayment obligations. Without adequate documentation and controls in place to ensure costs are reasonable and intended for the program charged, the Organization could incorrectly charge expenditures to the Federal program, report fraudulent expenditures, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: No Recommendation: CLA recommends for the Organization to evaluate its current policies and procedures to implement an additional layer of review, and to formally document such review and approval procedures for all transactions affecting federal funds (i.e. approval of general expenditures, approval of timesheets, approval of indirect cost allocations). In addition, the Organization should emphasize the importance of detailed reviewed timesheets, including a second level review by the Finance Manager to ensure the accuracy and documentation of time and effort billed to each Federal program. Views of responsible officials: Management agrees with the finding. Action Taken in Response to Finding: In response to these findings, OSA has reviewed its formal review and approval procedures to ensure that documentation of review and approval occurs with payroll time cards and wage reporting to grants. In response to this review, OSA has implemented the following: ● Adherence to a current and accurate Financial Management Policy Manual. The manual documents OSA’s policy and procedures regarding this finding: ○ Monthly close/reconciliation reviewed by Executive Director and Board of Directors. ○ Review and approval of all allowable federal expenditures including payroll wage reporting to federal programs, and invoices by OSA Executive Director or federal program Director. ○ Archiving a digital copy of review and approvals for every invoice submitted, including review and approval for all supporting documentation including approved timesheets. Name(s)of the Contact Person Responsible for Corrective Action: Laurajean Lewis, Executive Director, at laurajean@seedalliance.org Planned Completion Date for Corrective Action Plan: 06/01/2024

Lack of Documentation Views of Responsible Officials and Planned Corrective Actions: Our 2021 findings were not reported unti mid-year 2022. On June 30, 2022, Inspiration implemented a Document Retention and Destruction Policy that is still currently activee and followed.

The district no longer exists due to consolidation. The proper process will be practiced in the new district for the allocation of Title 1 funds by the Director of Federal Programs. Anticipated completion date: 6/30/23

The district no longer exists due to consolidation. Cost principles compliance will be practiced in the new district by the appropriate staff. Anticipated completion date: 6/30/23

The organization implemented an accounts payable policy to govern disbursement activity. The previous process included informal documentation via email, which has been replaced with a more formal documentation process. The organization reviewed all prior disbursement procedures, and to mitigate any impact, it established a formalized approval policy that is reflective of the current practice.

The organization implemented an accounts payable policy to govern disbursement activity. The previous process included informal documentation via email, which has been replaced with a more formal documentation process. The organization reviewed all prior disbursement procedures, and to mitigate any impact, it established a formalized approval policy that is reflective of the current practice.

Item 2022-002 – Allowable Costs Federal Program – Healthy Start Initiative Assistance Listing Number – 93.926 Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) Assistance Listing Number – 64.033 Material Weakness Condition: The Council allocates payroll costs to grants primarily based on initial budgets. The Council did not have internal controls established to verify that the employee's actual work performed did not alter from the initial budgeting, which may require and adjustment to the costs charged to the grants. Corrective Action: Both the Healthy Start Program and Supportive Services for Veterans Families allocate payroll costs for administrative personnel to recover costs. Each staff member's time is logged in the payroll system, Paycom but is not broken down by direct time spent on each grant. This was identified during a recent Department of Veteran's Affairs audit of Supportive Services for Veterans Families for fiscal 2021. The corrective action plan for that finding was to create an individual paper timesheet for administrative personnel to identify hours directly worked on each grant for each pay period. This was not enacted until fiscal 2023. The time sheets will be logged along with the allocation per pay period. The Director of Veterans Programs is responsible for the corrective action. The Healthy Start Program transitioned to another local non-profit October 31, 2023. The Council will no longer have direct control over their corrective action plan.

Federal Award Findings and Questioned Costs: Finding 2022-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: As the Borough is currently behind on its audit’s we are aware that this will continue to be an issue until we are caught up. Completion Date: June 30, 2025

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Allowable Activities and Allowable Costs – Payroll Disbursements • Material Weakness in Internal Control over Compliance Criteria or specific requirement: Per 2 CFR 200.303, non-Federal entities must “establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statues regulations, and the terms and conditions of the Federal award.” Condition: Payroll allocation review is performed annually by ED, which is not timely enough to accurately reflect employee's time worked. Additionally, the allocation performed had logical errors, including one employee’s time missing from the allocation calculation, and using an inappropriate allocation basis. Questioned costs: None Context: All employees included in selection deemed to work positions that are allowable to the program, however the client allocation process unreliable for all sections tested (25). Cause: Allocations to program based on one employee's memory (ED) for full-year organizational operations. Allocations not reviewed for accuracy by other individual. Effect: Currently, all assigned work activities employees engage in are theoretically allowable under the program, however if an employee were to work projects that are not allowable under the Federal award, reimbursement requests could be made for unallowable costs. Repeat Finding: No Recommendation: 1) Have employees enter time by period and ensure time codes reflect type of activities worked that tie to Federal program allocations. 2) Have ED review employee timesheets each pay period. 3) Review allocations by program each pay period. 4) Have a second individual (contract accountant) review allocations to ensure accuracy and completeness. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: DEC employees enter their time by period and code activities to the corresponding programs. Program Directors, then the ED reviews all employees time sheets and allocations each pay period. DEC’s contract accountant reviews monthly. Name(s) of the contact person(s) responsible for corrective action: Kimberly Meck, Executive Director Planned completion date for corrective action plan: Already implemented.

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Allowable Activities and Allowable Costs – General Disbursements • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: Per 2 CFR 200.303, non-Federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statues regulations, and the terms and conditions of the Federal award. Condition: Documentation not maintained to support one cash disbursement. Questioned costs: None Context: 1/40 of the general disbursements tested lacked indication of approval. Deemed to be an isolated incident as the vendor in question provides physical receipts to DEC, which is an unusual and infrequent method. Limited transactions with said vendor. Cause: Vendor purchases are in-person and physical receipt is obtained. This is unusual for common vendors used and leads to more opportunity for documentation loss. Effect: Reimbursement requests could be made for unallowed expenditures. Repeat Finding: No Recommendation: Review document retention process to ensure all costs that are charged to a federal program are adequately reviewed and documentation of that process is maintained. If documentation is not available, costs should not be charged to the Federal program. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: This was an isolated incident and DEC now takes steps to digitally record physical receipts with a photograph as soon as possible. Name(s) of the contact person(s) responsible for corrective action: Kimberly Meck, Executive Director Planned completion date for corrective action plan: Already implemented.

All invoices and documentation related to expenditure of federal funds are now scanned and attached to the accounting entry recording the payable. With regards to the Client Acknowledgement of Receipt of Direct Assistance Forms, we have taken steps to ensure that the documentation is signed at the time assistance is given and continue to work with the refugees as to the importance of having the proper paperwork on file.

The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2022-003, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.

Federal Program Name/Assistance Listing Title: Federal Transit Cluster Federal Assistance Listing Number: 20.507 State Program Name: State Urbanized Area Formula Program, State Formula Grants For Rural Areas Contact Person: Ted Ross, Acting Executive Director Anticipated Completion Date: 1/1/2025 Planned Corrective Action: The Transit District has changed most of the personnel in Finance and Administration, which improved expertise and performance. The Transit District is also working on a new comprehensive Finance and Administration policy which will include all new controls implemented. The new policy will contain a purchase policy (which has already begun implementation), training expectations, grant use policies (including late fees policy), and payroll. The Transit District has better documented rationale for expense allocation for grants and continues to improve on this through improved expense tracking and assignment to programs for grants.

Finding Number: 2022-009 Planned Corrective Action: Monthly financial statements are now completed to ensure evidence for each entity. The staff in finance is working on more timely audits. Anticipated Completion Date: September 2024 Responsible Contact Person: Sherrie Boudinot

Finding Number: 2022-007 Planned Corrective Action: The previous director processed payroll using one program (one time). The Finance Director & Accounting Assistant always allocate between properties at the approved amounts. The Director/Finance Director will review all payroll. Anticipated Completion Date: January 1, 2023 Responsible Contact Person: Sherrie Boudinot

Finding Number: 2022-006 Planned Corrective Action: The Executive Director no longer performs any accounting duties. An accounting firm was hired to bring everything up to date and an Accounting Assistant was hired. A new Fiscal Procedures Manual has been approved by the board. Only one Housing Assistance Payment bank account is now used; fraudulent checks were written out of the “general account” that checks are not normally written from, this account has been closed. Anticipated Completion Date: January 1, 2023 Responsible Contact Person: Sherrie Boudinot

Fremont County was assessed a Federal Awards Finding for the 2022 Audit year by Certified Public Accountants, Logan and Associates, LLC, for Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.512(a) and 200.510(b) . The regulation requires the County to determine the amount of Federal awards expenditures during the year and to properly report these expenditures in the schedule of expenditures of federal awards. After the assessment Fremont County has identified areas of improvement including internal controls. Staff members will implement monthly controls to be in compliance with the Federal Award requirement moving forward with the grant administrator. Staff members will also be encouraged to take annual Federal Award courses provided by Colorado Government Finance Officers Association or other similar entities. Fremont County will continue to enhance and streamline training for new and existing personnel, in the finance department, and implement new preventive controls. Fremont County believes these steps will improve timely and accurate submission for the Federal Awards.

Fremont County was assessed a Federal Awards Finding for the 2022 Audit year by Certified Public Accountants, Logan and Associates, LLC, for Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.505 and Appendix II to 200. This regulation requires the County to determine that contractors, individuals, businesses receiving Federal funds have not been suspended or debarred from receiving Federal funds. After the assessment Fremont County has identified an area of improvement including internal controls. Staff members have implemented and utilized the Federal Debarred Website, www.SAM.gov, to be in compliance with the Federal Award requirement moving forward with the grant administrator. Staff members will also be encouraged to take annual Federal Award courses provided by Colorado Government Finance Officers Association or other similar entities. Fremont County will continue to enhance and streamline training for new and existing personnel, in the finance department, and implement new preventive controls. Fremont County believes these steps will resolve the procurement, suspension and debarment for all Federal Awards.

Even though the Academy transferred $683,606 of ESSER funds to LKAYA based on the intergovernmental agreement that was in place during that time, the Academy itself did incur ESSER eligible costs that could have been applied against these ESSER dollars if they had remained within the Academy. The costs incurred involved improvements to technology, maintaining and increasing additional staff, curriculum materials, instructional supplies, and staff training to name a few.

For employees who are paid in full or in part with federal and other funds, management will increase the frequency of the time and effort reporting to quarterly intervals. Specifically, employees will document their time and effort based on funding sources for each payroll period; and at the end each quarter, management will review and compare the actual time and effort percentages with the current ADP Labor Distribution Report for reasonableness. The Management review report will be used as a basis to effect changes to the labor distribution report using the employee status change forms. The time and effort documentation will be available for audit. The implementation of the Corrective Action Plan did not commence until FY23 because the auditor’s field work for fiscal year 2021 ended after the close of fiscal year 2022.

CORRECTIVE ACTION PLAN Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No.: 21.027 Federal Agency: Department of the Treasury ? Pass-through from the State of California Award No.: WWID 4SSO10370 & CA 1910156 Award Year: Fiscal year 2021-2022 Category of Finding: Activities Allowed or Unallowed, Allowable Costs Name responsible for correction action plan: Emily Armstrong, Revenue Services Manager The corrective action planned: Payments applied to the 93 water bills and 81 wastewater bills will be reversed on the customer?s accounts. A notice will be issued to customers via mail and email (where possible) of the discrepancy. The funds will be returned to the State pursuant to their outlined procedures. Moving forward, the City will ensure that there is a multi-layered approval process to review the eligibility period of any State funding to identify the correct eligible applicants prior to disbursement. For future funding related to water and/or waster bills, the list of eligible applicants will be compiled by an analyst within the department and will be reviewed by the Revenue Services Manager and Assistant Finance Director prior to disbursement. Anticipated completion date: March 24, 2023

Views of Responsible Official(s) and Planned Corrective Actions: City staff will seek outside assistance to ensure that all outstanding minutes are completed and up to date. Ongoing, City staff will complete minutes so they are available for approval at the following meeting. All outstanding minutes will be completed by March 31, 2023.

Reference Number: 2022-001 Name of Contact Person: Tracy Largent Corrective Action: Staff inquired with the State Water Resources Control Board and with our auditors regarding if a single audit would be necessary for the funds received through the Water Arrearages Program. A definitive answer was not available. In the future the District will include all funds that could possibly be considered federal, regardless of confirmation. Proposed Completion Date: 5/12/2023

The Metcalfe County Fiscal Court contracted with an outside entity to manage the CSLFRF disbursements and reporting requirements. We entrusted that we were in compliance for all federal program expenditures where these funds were concerned. Prepared by: County Treasurer Page Edwards Date Prepared: March 6, 2023 Person Responsible for Corrective Action Plan: Judge/Executive Larry Wilson Anticipated Completion Date: July 1, 2023

The City of Cocoa Beach, Florida respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Carr Riggs & Ingram, LLC 215 Baytree Drive Melbourne, FL 32940 Examination Period: Fiscal Year October 1, 2021- September 30, 2022 The finding from the examination of the City of Cocoa Beach (the "City"), Florida's compliance with the requirements specified in Part IV "Requirements for an Alternative Compliance Examination Engagement for Recipients That Would Otherwise be Required to Undergo a Single Audit or a Program-Specific Audit as a Result of Receiving Coronavirus State and Local Fiscal Recovery Funds" of the CSLFRF section of the 2022 0MB Compliance Supplement is discussed below. PAYROLL COSTS Finding: The testing performed as part of the examination engagement identified $12,261 of payroll expenditures that were not allowable costs. Management's Response: Acknowledges the audit finding and corrective action has been taken. The Authority has implemented an additional accounting personnel to assist with internal controls and separation of duties. Thus, this position allows the ability for review of information prepared by others in sufficient detail to detect and correct an error. Journal entries will have consistent evidence of review and approval by someone who is both knowledgeable of accounting and independent of the preparer. Implementation Timeline: March 31, 2023 Responsible Party: Patrisha Draycott, Chief Financial Officer