Corrective Action Plans

Finding number: 2023-002; Finding: During our testing, we noted that internal controls were not properly designed over activities allowed or unallowed, allowable costs/cost principles and period of performance to identify program expenditures from other expenditures in the cost center. Additionally, we noted controls were not operating as designed to ensure payroll expenses charged to the program were properly approved. In our sample of 20 payroll expenditures, two had no evidence of timesheet approval. Correction actions taken or planned: Additional review and approval of allowable expenditures will be done by another individual outside of the preparer. Any payroll related dollars charged to the grant will require sign off by the manager prior to charging the expense to the grant. Anticipated completion Date: February 2024; UW Health employees responsible for Corrective Action Plan: Heather Brahm, Director of Finance & Controller, and Jamie Soyk, Program Director of Financial Reporting

Finding number: 2023-001; Finding: UW Health did not maintain effective internal controls over allowable costs, cost principles and reporting for the PRF program for Periods 4 and 5. In addition, during our testing we noted errors in the amount of revenue reported in the portal. This resulted in an overstatement of actual 2020 revenues of $10,000 and an understatement of actual 2021 revenues of $1,000,002 on the Period 4 and Period 5 portal submissions, respectively, for the University of Wisconsin Medical Foundation, Inc. (UWMF). Correction actions taken or planned: A systematic approach will be utilized to identify compliance reporting requirements. A secondary review of Provider Relief Fund reporting, if applicable in the future, will be documented and approved prior to final submission. Anticipated completion Date: December 2023; UW Health employees responsible for Corrective Action Plan: Heather Brahm, Director of Finance & Controller, and Jamie Soyk, Program Director of Financial Reporting

SIGNIFICANT DEFICIENCY 2023-001 Eligibility and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Condition Four providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center, Inc. is aware of the oversight and will continue to strive to improve its review process. Action Taken: As of November 1, 2023, CACFP staff verify that the tally marks from the paper claims match the total provided. Those tally marks are then entered into My Food Program, and the total is again verified to match the paper claim. Manual claim adjustments will be saved and filed with supporting documentation, if applicable.

In order to ensure proper compliance with federal award distribution, the CFO or Controller will review for proper support and documentation before any federal funds are released. Furthermore, the CFO and Controller will review the sample of 60 expenditures the auditors reviewed for the fiscal year 2023 audit, and immediately develop procedures to strengthen internal controls surrounding the disbursement of federal funds.

Background: One repeat finding from the 2022 fiscal year audit was identified on the Schedule of Expenditures and Federal Awards during 2023 fiscal year end audit conducted by Aldrich CPAs + Advisors LLP (Aldrich). For fiscal year 2022, Aldrich performed an audit on the major program Disaster Grants – Public Assistance (Presidentially Declared Disasters) for the monies received from the Department of Homeland Security passed through the Oregon Office of Emergency Management awarded to the City for the February 2021 Ice Storm. Management recognizes the importance of adequate procedures and internal control oversight and has rectified this finding. Management’s response and corrective plan of action for the finding follows. Finding 2023-001: 21.027 Coronavirus State and Local Fiscal Recovery Funds Criteria: 2 CFR Part 200.302(b)(7) requires the financial management system to include written procedures for determining the allowability of costs. Condition: City of Oregon City has not developed written procedures for determining the allowability of costs. Cause: Administration did not have written procedures for determining the allowability of costs. Effect: Unallowable costs could be charged to the program. Questioned Costs: None   Perspective: Written procedures for determining the allowability of costs is integral to the proper design of internal controls. However, the results of audit procedures did not detect any costs which are not allowable charged to the program. Recommendations: Management should develop written procedures as required by 2 CFR Part 200.302(b)(7). Responsible Official: Matt Zook, Finance Director Views of Responsible Officials: Management understands the requirement for written procedures for determining the allowability of costs. A formal policy and procedure was approved and adopted August 22, 2023. The opportunity to identify this finding arose due to new management staff and a new audit firm engage with the June 30, 2022 audit, and we appreciate the opportunity to improve compliance.

The College has made the recommended review and adjustments. In addition, the College has created a report to cross check potential over and under award situation to use in addition to heightened reviews of student awards to determine that aid was properly provided and any necessary adjustments will be made, if identified. The College continues to develop its staff and is comfortable with their abilities to perform such procedures with future awards.

Corrective Action: The District has communicated with all departments that pre-filled forms should not be utilized when documenting salaries and wages charged to federal awards. Additionally, the District has reviewed all employees with recurring federal time and effort requirements to ensure the proper forms are completed. Monitoring will occur at the beginning of each semester to ensure all required time and effort documentation has been completed and collected. Responsible Officials: Kevin Caskey, CPA - Chef Financial Officer - (843) 680-6013 Anticipated Completion: Immediately

Corrective Action: The District has implemented additional internal controls and monitoring around claiming and reconciling federal funds. Additional Controls are listed below: 1. A reconciliation of all federal funds will be done prior to the state claiming deadline of August 15th. 2. A spreadsheet has been developed that will be maintained by the CFO for any and all grants that are processed through the state GAPS system. This document will allow the district to better monitor timeliness and accuracy of claims. It will detect and prevent any variance in federal budgeting within GAPS or variances between expenditures and related claims. 3. Each federal program will be required to submit a claim packet each quarter regardless of the existence of expenditures. If there are no expenditures related to a grant in a particular quarter. This documentation will serve as a notification that there should be no claim for the quarter and it will be noted on the spreadsheet mentioned in internal control #1. 4. Each federal program office will be required to submit, along with their normal claim packet, a year-to-date report in addition to the normal quarterly report. This addition will detect any claims that may have been missed earlier in the year. In addition to these controls, additional training has been provided to each affected federal program and every federal program is now required to have quarterly pre-claim meetings with the Chief Financial Officer to ensure adequate and accurate communication and to ensure expenditures and claims are progressing timely. Responsible Officials: Kevin Caskey, CPA - Chef Financial Officer - (843) 680-6013 Anticipated Completion: Immediately

NATCHITOCHES PARISH HOUSING AUTHORITY 525 4th St. Natchitoches, LA 71457 Phone No. (318) 357-0553 Fax No. (318) 352-2086 HOUSING AUTHORITY OF NATCHITOCHES PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2023 Corrective Action Plan Finding: Finding 2023-001-Administrative Equity Deficit, and Related Large Interfund Payable Condition: At June 30, 2023, the Housing Choice Voucher (HCV) Fund owes the General Fund $68,877. Corrective Action Planned: I am Rhonda Kay, Executive Director and Designated Person to answer this finding. We continually monitor our expenses. However, we will carefully review them again, as the auditor recommends. Person responsible for corrective action: Rhonda Kay, Executive Director Telephone: (318) 357-0553 Housing Authority of Natchitoches Parish Fax: (318) 352-2086 525 4th St Natchitoches, LA 71457 Anticipated Completion Date: June 30, 2024

Elementary and Secondary School Emergency Relief – Assistance Listing No. 84.425D, 84.425U Recommendation: We recommend the District review its processes related to general disbursements for grants and implement a control where someone other than the Director of Business Services is reviewing disbursements coded to grant project codes to help ensure compliance with grant requirements. For payroll transactions, we recommend implementing a control where someone other than the Director of Business Services is reviewing who is coded to the grant on a routine basis and that the payroll allocation to the grant is appropriate and supported by time and effort documentation. We also recommend that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PARs are on file for all federal grant funded employees since FY 2017-18, this is an ongoing process. The Director of Pupil Services and the Superintendent assist with the review of coding of employees. Name(s) of the contact person(s) responsible for corrective action: Pamela Tesch, Director of Business Services Planned completion date for corrective action plan: Ongoing.

Finding 2023-004 Federal Agency Name: U.S. Department of the Treasury U.S. Department of Education Program Name: Passed through the Nevada Department of Agriculture COVID‐19: Education Stabilization Fund Passed through the Nevada Department of Education COVID‐19: Coronavirus State and Local Fiscal Recovery Fund CFDA #21.027 #84.425 Finding Summary: Amounts were reported incorrectly on the SEFA. The District did not have adequate internal controls to ensure all federal expenditures were reported with the correct assistance listing number. Prior to correction, the total federal expenditures for the Education Stabalization Fund were overstated by $19,366,000 and the total federal expenditures for the Coronavirus State and Local Fiscal Recovery Fund were understated by $19,366,000. Responsible Individuals: Jason Goudie, Chief Financial Officer Corrective Action Plan: The following controls were developed to ensure that Clark County School District reports correct assistance listing numbers on the SEFA. Anticipated Completion Date: September 30, 2024

The Hingham Public Schools’ general weekly payroll is approved on a weekly basis by Management. In the case of our summer programs a similar control has been put in place by Management to ensure all payroll records are approved before processing.

Hingham Public Schools has circulated training guides and templates to grant writers on the requirement to have time and effort reporting completed in a timely manner for staff assigned to specific grants. Grant accounting associates have also been provided with the training material to ensure that there is an additional review of time and effort reports as part of the grant accounting, review and finalization process.

Finding 2023-005– Student Financial Assistance Cluster Internal Control over Compliance Condition City Colleges did not have sufficient documentation that internal controls were in place and operating effectively relative to the following areas: • Allowable Activities: For each of the seven campuses, City Colleges did not have sufficient supporting evidence that review controls were performed over the transfer, carryforward, carryback, and administrative cost calculations in the Fiscal Operations Report and Application to Participate (FISAP) for award year July 1, 2021 through June 30, 2022 submitted during fiscal year 2023. • Reporting: For each of the seven campuses, City Colleges did not have sufficient supporting evidence that secondary review controls were performed over FISAP data for award year July 1, 2021 through June 30, 2022 submitted during fiscal year 2023. Cause City Colleges did not formally document the additional reviews and approvals over the department’s review of the FISAP. Corrective Action Taken or Planned Financial Aid will develop and document a review/approval process that will detail accurate reporting, secondary reviews, and review/approval of FISAP submissions and completions. Contact Person: Tiffany Morrison, Associate Vice Chancellor, Financial Aid Anticipated Completion Date: December 31, 2023

Corrective Action Plan: The District will initiate the development of an equipment tracking system that adheres to federal requirements. Training sessions will be conducted for relevant staff to ensure proper understanding and compliance with the new tracking procedures.

Plan: Job duties will be documented for each position and a policy will be implemented to ensure all time sheets detail the duties performed. Anticipated Completion: June 30, 2023 Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

Plan: Job duties will be documented for each position and a policy will be implemented to ensure all time sheets detail the duties performed. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

Finding Number 2023-005 — Significant Deficiency in Internal Control/Non-Compliance — Appropriate Expense Period of Covid 19-ESSER II 23b — Credit Recovery Condition: During expense testing of ESSER funds, a journal entry that reclassed the cost of Edmentum, program licenses for Plato courses, had expensed the entire annual license fee. The period for eligible expenditures did not begin until October 1, 2022. This journal entry expensed the full cost of the invoice, $11,914.50, and the district did not prorate the costs to include only those expenses from October 1, 2022 through June 30, 2023. The District did not adhere to the proper period for expenditures. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop a summary of all federal grants. This summary will detail the fiscal year it is associated with but more importantly, it will provide the proper period of eligible expenditures for each federal funding source. This summary may be used and readily available at the time approvals are granted for expenditures. If an expense does not fall within the eligible time period, the expense can be rejected by the approver. This summary will be shared with all administrators and staff. In addition, the process for reclass journal entries will also include a pause to check that each invoice associated with a federal grant, is falling within the proper period of expenditures. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

Finding Number 2023-004 — Significant Deficiency in Internal Control/Non-Compliance — Covid 19-ESSER II - Approved Expenditures Condition: During expense testing of ESSER funds, a final invoice for a sound system project in Shepherd Middle School was not detailed in the approved grant application. The expenditure was for $4,010 but the total cost of the project was $20,050. The bulk of the project cost, $16,040, was expended during 2021-2022. The sound system was not an allowable cost based on not being in the original grant application. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop an approval process that requires the Director of Business Services to review approved grant application prior to approving any federal grant expenditure. The Director of Federal Programs and the Director of Business Services will meet monthly to review federal grants, expenditures in the near future and discuss/review proper assignment of expenses to the specific grants and general ledger function codes. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

Responsible Party: Melodie Colwell Finding 2023-004 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management considers the expenditures reported to be in compliance with program regulations. Management agrees with the finding that additional supporting documentation should be retained. Going forward, for subsequent reporting periods related to the Provider Relief Fund and American Rescue Plan Rural Distribution management will implement controls to ensure all underlying support related to expenses is documented and retained. Estimated completion and implementation date for the above-mentioned corrective action plan is March 31, 2024.

Responsible Party: Melodie Colwell Finding 2023-003 The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that were reimbursed through other funding sources and reported expenditures that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management agrees with the finding that expenses should be reimbursed by only one source. Management believes that while certain expenses were reported that were reimbursed by other funding sources they have additional allowable expenditures that could have been reported. Going forward, for subsequent reporting periods related to the Provider Relief Fund and American Rescue Plan Rural Distribution management will allocate expenditures as required, and will ensure expenses are reimbursed in accordance with current guidance. Estimated completion and implementation date for the above-mentioned corrective action plan is March 31, 2024.

Federal Agency Name: U.S. Department of Treasury Program Name and FALN #: FALN # 21.023 COVID-19 Emergency Rental Assistance Program (ERA) Finding Summary: One homebuyer payment was allocated to ERA instead of the Homeownership Assistance Fund (HAF). Homebuyers are not eligible for assistance under ERA. Responsible Individuals: Chas Olson - Executive Director and Bridgette Loesch, SD Cares Housing Assistance Program Manager Corrective Action Plan: We have made the adjustment to the correct program once we were made aware of the issue by the auditors. We will carefully review the program sheets prior to submitting to accounting to ensure they are allocated to the correct program. Anticipated Completion Date: September 30, 2023

We have implemented procedures to strengthen controls over allowable costs associated with federal grants whereby any non-standard expenses require a secondary review of allowability prior to being charged to a federal grant.

November XX, 2023 Office of the Secretary of State Audits Division 255 Capitol St. NE, Suite #500 Salem, OR 97310 Plan of Action for Wheeler County, Oregon Wheeler County, Oregon respectfully submits the following corrective action plan in response to deficiencies reported in our audit of fiscal year ended June 30, 2023. The audit was completed by the independent auditing firm Solutions, CPAs PC, John Day, Oregon. The deficiencies are discussed below with the Action Plan listed for each. 1. Material Weakness – Financial Statement Preparation Criteria: The financial statements are the responsibility of the county’s management, including the prevention or detection of material misstatements in the presentation and disclosure of the financial statements. Non-attest services performed by the auditor in the preparation of the financial statements cannot be considered compensating controls. Condition: The county engages their auditors to provide non-attest services for the preparation of its financial statements. Although common for municipalities the size of the county, this condition represents a control deficiency over the financial reporting process that is required to be reported under professional standards as long as management makes all financial reporting decisions and accepts responsibility for the content of the financial statements. However, those activities performed by the auditor are not a substitute for, or extension of, internal controls over the preparation of the financial statements in accordance with generally accepted accounting principles (GAAP). Cause: The county’s accounting personnel do not possess the advanced training that would provide the expertise necessary to prepare the financial statements and related notes in accordance with GAAP, and therefore may not be able to prevent or detect a material misstatement in the preparation and disclosure of the financial statements. Misstatements in financial statements may include not only misstated financial amounts, but also the omission of disclosures required by GAAP. Effect: Material misstatement in the preparation and disclosure of the financial statements in accordance with GAAP may not be prevented or detected. Misstatements in financial statements include not only misstated dollar amounts, but also the omission of disclosures required under GAAP. Recommendations: We understand that it may not be practical to acquire or allocate the internal resources to perform all the controls necessary over financial reporting. However, management (including the County Court) should mitigate this deficiency by keeping informed about the county’s internal controls, performing supervisory reviews, studying the financial statements and related footnote disclosures, and understanding its responsibility for the financial statements as a whole. Action Plan: We understand the importance of risk management and the need to address risks in an informed, cost-beneficial way. As a result of our cost-benefit analysis we have determined the value of incurring the additional expense of hiring a staff person or another firm to prepare our financial statements does not justify the cost. We accept the auditor’s recommendations and will attempt to implement in a timely manner. 2. Material Weakness – Preparation of the Schedule of Expenditures of Federal Awards Criteria: The schedule of expenditures of federal awards (SEFA) is the responsibility of the county’s management, including the prevention or detection of material misstatements in the presentation and disclosures of SEFA. Services performed in reconciling the SEFA to the trial balance during the annual compliance audit cannot be considered compensating controls of the county. Condition: During our reconciliation of the SEFA to the financial statements, and testing of controls, we noted material omissions from program expenditures reported. Additionally, identification of funds passed-thru to subrecipients were omitted from the county drafted SEFA. Cause: The county’s system of controls over the SEFA is lacking effective controls over completeness. Effect: Material misstatement in the preparation and disclosure of the financial statements in accordance with GAAP may not be prevented or detected. Misstatements in financial statements include not only misstated dollar amounts, but also the omission of required disclosures. Recommendations: We recommend the county develop further control procedures over drafting the SEFA to address completeness. We recommend the county develop a system of tracking federal awards and related compliance requirements to assist in accumulating information to prepare the SEFA. This deficiency is related specifically to the preparation of the SEFA and does not reflect on controls over compliance or transactional controls. Action Plan: We understand the importance of risk management and the need to address risks in an informed, cost-beneficial way. We have addressed this finding with plans to develop controls over preparing the SEFA. Specifically, we intend to track compliance requirements for all grants in a database to address internal control issues over completeness. We also intend to implement review and approval controls over the county drafted SEFA. 3. Significant Deficiency – Internal Control over Compliance with Federal Program Requirements Criteria or specific requirement (including statutory, regulatory, or other citation): The Secure Rural Schools and Community Self-Determination Act of 2000 requires a county receiving funds under the Forest Service Schools and Roads Cluster to perform an allocation of funds between Title I, II, and II under based on county court certified allocations. In the current year, that allocation included a federal sequestration of funds that was also required to be allocated to Title I and Title III, which resulted in noncompliance with the requirements related to earmarking and with special tests and provisions. Annual certification of funds spent under Title III is also required. In the current year, that certification included funds that were included in previous certifications, which resulted in noncompliance with the requirements related to reporting. Condition and context: During our review of the allocation of 2023 funds received, we noted an error in the allocation performed by the county. Title I had an overallocation of funds by $2,203, and Title III was under allocated by the same $2,203. The reconciliation of the amounts included in the 2022 annual certification for Title III funding identified an over certification of $11,303 that had already been included in the 2021 annual certification. Questioned Costs: Actual questioned costs totaled $2,203 and consisted of amounts passed through to local schools and expended in the road department on otherwise compliant uses. Cause: There is a lack of internal control over earmarking, reporting, and special tests and provisions over allocation of Forest Service Schools and Roads funding and the annual certification. The county lacks review and approval controls over the allocation of funds and the annual certification. Effect: The effect is noncompliance with earmarking, reporting, and special tests and provisions requirements. Recommendations: It is recommended that the county implement review procedures over the annual receipt to verify amounts allocated are complete and accurate prior to posting to the general ledger. A recalculation of both the certification and a detailed review of amounts used in the annual reporting is recommended. Action Plan: The county understands and concurs with this finding. It is the intention of the county to implement a review process to be completed prior to making formal allocation and reporting of Forest Service Schools and Roads Cluster.

Views of responsible officials and planned corrective actions: • Asher CHC agrees to the Auditors recommendations above in addition the CPA firm that oversees our accounting department will review monthly draws. • Prior to submitting a draw request for federal funds, a Profit and Loss by Class should be exported from the QuickBooks file. The total federal draw should match the total expenditures on the report for the applicable time frame. This report should be kept with the payroll reports and invoices for the draw. • Prior to submitting the Federal Financial Report, the same Profit and Loss by Class should be exported for the grant period referenced in the report. The report from QuickBooks should be reconciled to the FFR prior to submission. • As part of the monthly financial review, the CEO should review the Profit and Loss by Class from QuickBooks to verify the federal grant classes do not show a profit or a loss, unless there are timing variances. The grants are reimbursement grants, so the net income should be zero, assuming the allocation of transactions across the classes is accurate