Corrective Action Plans

Federal Procurement Requirements for Higher Education Stabilization Fund Planned Corrective Action: A policy addressing procurement standards has been created and will be implemented for future expenditures Person Responsible for Corrective Action Plan: Cindy L Weaver, Interim CFO/Director of Finance Anticipated Date of Completion: July 25, 2023

Name of Contact Person: Doug Hale, Chief Financial Officer Corrective Action Plan: Management will implement controls to ensure that any expenditures paid from Education Stabilization funds are supported by proper documentation with proper administrative approvals. Proposed Completion Date: Immediately

The Authority is in the process of working with Illinois Department of Revenue to obtain an agreement for fiscal year 2023. Unless extraneous circumstances prevent the Authority from obtaining an agreement in a timely manner, the Authority will ensure intergovernmental agreements exist before commencing new program administration. The Authority will implement new policies and procedures to strengthen control.

Management will establish written policies and procedures to ensure compliance with Uniform Guidance. Additionally, management will establish control to ensure timely reporting of federal awards as well as the monitoring of vendors for suspension and debarment. Contact Person: Mayor Leroy Sullivan and Sandra Williams. Anticipated Completion Date: Monthly basis.

2022-004 ? Documentation and Internal Controls over Journal Entries Auditor Description of Condition and Effect. Evidence of an independent review was not documented for eight out of the eight journal entries selected for testing. The District is at increased risk of unallowable costs being charged to federal programs without being detected by its internal controls. Auditor Recommendation. We recommend the District follow its internal control policies and procedures that require independent review of all journal entries. Responsible Person: Sharon Ramirez, Chief Financial Officer Corrective Action. Management concurs with the finding. Anticipated Completion Date: June 30, 2023

Finding 2022-001: Recommendation: The School District should develop and complete a spend-down plan to ensure it reduces its Food Service Fund net cash resources below the maximum allowable amount. Action Taken: As of September 14, 2022, the School District has received items ordered prior to the fiscal year ended June 30, 2022 and will also develop and implement a spend-down plan to reduce the Food Service Fund net cash resources below the maximum allowable amount. Responsible Person and Anticipated Completion Date: The Superintendent will ensure the spend-down plan has been accomplished by June 30, 2023. If the Michigan Department of Education has questions regarding this plan, please call Paul Shoup at (231) 757-3733.

Major Federal Program: 14.231 ? Emergency Services Grant Program Compliance Requirements: Allowable Activities and Allowable Costs and Cost Principles Response: We have implemented new controls where a finance staff member prepares the request for reimbursement, including the payroll allocations charged to the grant, and the CFO will then review/ approve the request for reimbursement including the payroll allocations. Date of Completion: June 30, 2023 Person Responsible to Ensure Completion: Cindy Alley, CFO

Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: CLA recommends the County to work with department to provide training over understanding the grant agreement. As well as further reviewing the programs that received COVID funding when compiling the SEFA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor-Controller?s Office is working with departments to improve SEFA reporting and has recommended individuals who work with grants to attend annual cost principles training. Name(s) of the contact person(s) responsible for corrective action: Aimee Espinoza, Auditor-Controller and Tarrah Shockley, Division Chief. Planned completion date for corrective action plan: June 30, 2023

IU Health designed and implemented internal controls over the allowability of expenses and amounts submitted in the HRSA and ARP reports. These internal controls were precise enough to ensure that the submissions were compliant with HRSA reporting guidance. In fact, IU Health reached out directly to HRSA to confirm the appropriateness of its election. IU Health remained consistent in utilizing the annual budget as a basis for lost revenue past 2020. As inferred from the annual budget approval date threshold of March 27, 2020, our 2021 and 2022 budgets were prepared using prepandemic years as a baseline expectation. IU Health also conversed directly with HRSA wherein a representative confirmed our use of option 2 as appropriate for Period 3 and beyond, because, according to the representative, the intention of the written regulation did not literally mean budget approval for years past 2020 to have occurred prior to March 27, 2020. As our annual budgets were already naturally materially in line with our long-range plan that was approved in December of 2019, it seemed we were adhering to the spirit of the guidelines set forth. For future periods, IU Health will elect option 3 for lost revenue. Contact Person(s) Responsible for Corrective Action: David Burton Anticipated Completion Date: Effective for Period 5 deadline of September 30, 2023

Finding 2022-001: Allowable costs - material weakness in internal controls over compliance and compliance finding- timesheet and GL mismatch. CCGD will perform an audit of the existing setup of its HRIS-PayCom system to determine what is causing the mismatch between timesheets and payroll GL. If required, CCGD will re-implement PayCom with the required setup or change vendors to assure that all internal control requirements are addressed. This action will be followed by a quarterly audit of timesheets and payroll GL to ensure that there are no more mismatches. Additionally, management will perform a time study audit on a quarterly basis to ensure that individual performances comply.

Views of Responsible Officials and Planned Corrective Actions: The School Board will reconcile ESSER expenditures to RDA when submitting reimbursement requests. Additionally, the $626,729 of unearned funds was withheld from a future reimbursement request at the advice of the Virginia Department of Education.

FINDING 2022-009 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over Activities Allowed or Unallowed & Allowable Costs/Cost Principles. After this review, we will implement a system to ensure that all costs are allowable for the program. Additional steps will be completed to ensure that Time and Effort documents are completed and maintained for audit. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

FINDING 2022-008 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Activities Allowed or Unallowed and the Allowable Costs/Cost Principles. After this review, we will implement a system to ensure that all costs are allowable for the program. Additional steps will be completed to ensure that the Time and Effort documents are completed and maintained for audit. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

FINDING 2022-007 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Activities Allowed or Unallowed & Allowable Costs/Cost Principles. After this review, we will implement a system to ensure that all costs are allowable for the program. Additional steps will be completed to ensure that the Time and Effort documents are completed and maintained for audit. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

Finding 2022-002, Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles; Temporary Assistance for Needy Families Cluster (TANF), Assistance Listing Number 93.558, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Social Services. John H. Chafee Foster Care Program for Successful Transition to Adulthood (Chafee Foster Care), Assistance Listing Number 93.674, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Social Service. Recommendation: The County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. Corrective Action Plan: Every effort is made to ensure that Daysheet entries match with time claimed, the different deadline submissions for each, sometimes mean that one must be approved before the other is entered in its entirety. In these instances, we may not have been able to compare the timesheet with the full scope of Daysheet entries prior to the timesheet submission being due. Employees track time by service code in 5-minute increments. The department section will review Daysheet entry timeline expectations with social workers and ensure entries are reviewed against timesheet entries before submitting for final approval; follow up with social workers regarding any discrepancies noted and closely monitor all future transactions. Proposed Completion Date: The Corrective Action will be immediately implemented in response to the auditors? recommendations. Contact Person: Patricia Pritchett, Department Budget Manager

Management?s Response Management agrees with the findings and has developed the plan below to improve our controls Plan 1. Added additional staff to the Treasury COVID-19 Relief Hub (Richard Wong, Accountant II) 2. Filed March 2022 Annual SLFRF Compliance Report with the Treasury in January 2023 3. Added the Finance Team group email also to ensure various staff would receive reminder emails on reporting so that we can stay current on filing the report for compliance. Anticipated Date of Completion ? report submission completed. Name of Contact Person ? Janet Liang, Richard Wong and finlist@cupertino.org

Finding 2022-001 Financial Statements/Activities Allowed Corrective Action: CMU agrees with the finding and has implemented procedures to correct it. CMU has paid back the funds and has accrued for the amount in the financial statements. The unallowable expenditure of $12,831, were accrued and paid back to the granting agency by CMU in September 2022. Responsible Official _________________________________ Mark Verano, Interim Executive Director CMU 1100 South Cameron St, Harrisburg PA 17104 717-441-7033 mverano@cmupa.org

Tacoma Arts Live Response to Single Audit Findings: Tacoma Arts Live management acknowledges that a union worker?s pay was not calculated in accordance with the union contract guaranteeing a 4-hour minimum on the March 20, 2020 payroll. This resulted an underpayment of $97.68. This payroll occurred during the first week of a global pandemic that caused quarantine and all workers to move from working in the office to working in a remote environment. The underpayment was immediately paid upon notification of the mistake. We have received no complaints from the employee. On the March 20th, 2020 payroll, an employee received a disbursement from a tip pool derived from multiple events in the amount of $61.00. This compensation was not removed from the SVOG tracking spreadsheet. Therefore, it was erroneously allocated to payroll costs for the SVOG award. Overall, qualified SVOG spending by Tacoma Arts Live exceeded that which was submitted as proof of spending for our award. Management believes that such over-allocating would allow any small errors in our reports. We regret these two errors and have corrected accounting procedures to control for such items in the future, as noted below. Tacoma Arts Live Corrective Action Plan for Single Audit Finding: Management has implemented an additional internal review process of all over-hire payroll reports. Additionally, management will not balance minor errors by including an excess of legitimate costs when reporting on federal awards.

"See Corrective Action Plan for chart/table"

"See Corrective Action Plan for chart/table"

Corrective Action Plan: ODM has either completed or begun corrective action on all of the following recommendations. CDJFS Caseworker Case Processing Weaknesses AOS cited caseworker reliance as an eligibility process weakness. While Medicaid eligibility systems have been updated to bring efficiencies in the Medicaid renewal and enrollment processes, human intervention is integral to ensure cases are processed accurately and appropriately. The dependence on caseworker knowledge and judgement is ongoing and is not perceived as a weakness, but an expectation for a state supervised county administered program. The federal regulation at 42 CFR ?431.10(c) limits the state?s ability to delegate authority to make eligibility determinations to only a government agency which maintains personnel standards on a merit basis. CMS provided additional information in its response to Q32 in the COVID-19 Public Health Emergency Unwinding Frequently Asked Questions for State Medicaid and CHIP Agencies document dated October 17, 2022, indicating that the merit-based personnel standards apply to all eligibility determination functions that require discretion, whereas contractors may be used to support the administrative functions of the eligibility determination process that do not require discretion. This guidance to states supports ODM?s established process that caseworkers are expected to exercise their own judgement with regard to the eligibility determination. Further, it would not be an effective use of federal or state funds to build an eligibility system in such a way that every possible exception scenario can be addressed by system rules and functionality. There are simply too many permutations of household scenarios and eligibility outcomes to make that a feasible option. As a result, caseworker knowledge, judgement, and discretion are integral to the eligibility determination process. AOS cited caseworker training as an eligibility process weakness. ODM, in collaboration with ODJFS, will continue to conduct a variety of trainings throughout the year as described below. While not yet mandatory, all trainings are offered to all 88 CDJFS agencies and are open to caseworkers and supervisors. In addition, high priority trainings are offered live on various days and times and are made available online to view at any time. At this time, we do not yet have the technology available to assign learning plans to county caseworkers and ensure completion, however ODM continues to consider its options for mandating training for county employees, and the advantages and disadvantages of that approach. ? New Worker Training - In SFY2022, the new worker training program underwent a total overhaul to update materials, improve interactivity, and close information gaps between programs. New worker training sessions are scheduled quarterly in 2023 and are offered to all new workers across the state. A new worker training began on February 27, 2023. ? Regularly Scheduled Webinars - ODM hosts monthly webinars and other targeted trainings throughout the year with all 88 counties. The monthly webinars include policy updates, training material, and general guidance or instruction on recent changes and issues. During SFY2022, ODM provided training updates on over 30 policy or procedural topics. Targeted trainings are scheduled to continue throughout 2023. Recordings for presentations are made available to access online at any time. ODM and ODJFS also host Operational System Release Webinars to review implemented system enhancements and fixes. ? On-Demand Inquiry Assistance - Technical Assistance and System support are provided via email for counties to submit questions and receive ODM guidance on both policy and procedures, as well as how to process within the Ohio Benefits system. During the return to routine eligibility operations period, county ?Ambassadors? have access to a Return to Routine Operations Team channel with real-time Q&A support, as well as training materials and desk aids. ? Future Training Plan - Moving forward, training will be a critical success factor for closing the knowledge gap(s) identified during various audits. ODM County Technical Assistance (TA) will identify the training topics, develop curriculum and training delivery methods for the identified training areas. To ensure successful and timely delivery, ODM TA will develop a 24-36 month training schedule of development, review, and delivery milestones to monitor progress. Calendar year 2023 training will focus on returning to routine case processing outside of the PHE, including revisiting conditions of eligibility, electronic verification processing, and proper discontinuance processes. ODM conducted six live sessions in February 2023, addressing returning to routine eligibility operations and will conduct a variety of trainings in April and May on eligibility basics, considering how many case workers have not determined eligibility outside of the public health emergency continuous eligibility restrictions. Recordings of these sessions are available on the County Resources page and will be converted to the Ohio Benefits Program website. The ODM Medicaid Eligibility Quality Control (MEQC) Unit continually monitors Medicaid case processing accuracy. The MEQC Unit reviews CDJFS eligibility determinations, verifies accuracy of recipient information in Ohio Benefits, verifies information is being maintained to support the eligibility decision, and evaluates timeliness of applications. All MEQC error and technical deficiency findings are shared with the CDJFS agencies for review, appeal, and correction if warranted. The federally mandated MEQC Pilot review is currently underway and is expected to be completed in March 2023, at which time regular case evaluations will begin. ODM promptly notifies the CDJFS agencies of errors, and the root cause analysis and corrective action plans are requested. The communication between MEQC and our ODM partners, ensures potential vulnerabilities in the eligibility determination process are being addressed promptly. In addition to the offered trainings and MEQC monitoring efforts, ODM has made significant improvements to the ex parte renewal process during SFY22, to increase the number of Medicaid renewals that occur in the system without county caseworker intervention. These ex parte updates are expected to greatly assist the CDJFS agencies and decrease the burden of processing cases, while also improving accuracy. The MEQC unit has been reviewing a sample of ex parte cases each month to ensure system modifications were effective. System improvements, CDJFS training, and monitoring will be ongoing as the Medicaid program continues to change over time. System Weaknesses Ohio Benefits generates alerts to notify CDJFS caseworkers of actions to be taken on a Medicaid or CHIP case. These alerts may include potential dates of death, notifications that individuals have moved to another state, and information about changes in income. Alerts are an important feature of the Ohio Benefits system. ODM has worked with ODJFS and DAS to reduce the volume of alerts generated in an attempt to improve the usability of the information for CDJFS caseworkers. ODJFS monitors IEVS alert completion. ODM has implemented automation using bots to help work and clear certain alerts. In 2021, multiple small releases, or `sprints? were implemented as part of the plan to reduce the volume of alerts being generated. Alert reduction efforts reduced overall ~29 million backlog alerts and drove a ~22 million annual reduction in new arrival of alerts. ODM, ODJFS and DAS remain committed to improving the alert functionality. The table below shows the impact in each of the sprints during SFY22 and the beginning of SFY23. Sprint Deployment Interface Projected Backlog Reduction Actual Backlog Reduction Projected Arrival Reduction-Monthly Actual Arrival Reduction Per Month Cumulative yearly Arrival Reduction 3 7.8.21 UCB SDX/SSI 936K 936K 399K 451K 4.7M 4 7.8.21 110K 115K 1.3M R3.8 8.14.21 Healthchek, Verification, LTC, DODD, DRC Incarceration, SVES Prisoner, AVS, Buy-IN 300K 736K 66K 63K 792K 5 9.17.22 SSP Document Upload, Companion EDBC 8.3M 9M 90K 100K 1.2M 6 4.15.23 IRS TBD TBD 33K TBD TBD ODM has plans for additional improvements in 2023 to reduce the volume of alerts generated. A sprint is scheduled in April 2023, after monitoring the impact of the initial five sprints. ODM continues to work with DAS and ODJFS on correcting defects and implementing enhancements to the existing alerts. In release R4.3 (August 2022), eight defects impacting alerts were corrected and in release R4.3.1 (September 2022), two alert enhancements were implemented, along with one additional defect fix. This weakness will continue to be remediated through future system modifications. ODM will continue to work collaboratively with DAS to update Ohio Benefits to bring efficiencies in effort to improve Medicaid eligibility determination outcomes. Several releases are scheduled into 2023 to improve system functionality. ODM will continue to evaluate enhancements to assist DAS in determining if the desired outcome was achieved.

August 7, 2023 IMPACT WASHINGTON Schedule of Findings and Questioned Costs For the Year Ended December 31, 2022 Finding Number 2022-001 Corrective Action Plan: Contact Person(s): Eddie Roldan Impact Washington?s will follow the next steps: Task: Anticipated completion date: Configure a report that includes parallel detail that allows to match GL and Project coding. Add the report scrutiny to Month End Close check list. Done Revamp Finance Force (FF) Expense Report entry screens ? make it more user friendly. August 30, 2023 Sponsor staff annual best practice refresher trainings centered on IW?s accounting policies & procedures December 31, 2023 Reconfigure FF system, add and populate missing filtering fields to allow group reporting, eliminate manual filtering. December 31, 2023 Impact Washington considers the above steps sufficient and adequate to close the gaps in the coding of transactions that may have permitted unallowable costs to post to grants for YE2022. These steps will remedy the lapse in effectiveness experienced by Impact Washington?s internal controls over allowable costs.

Finding 2022-003 Federal Agency Name: Department of Justice Program Name: Crime Victim Assistance FFAL #16.575 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Our testing over payroll expenditures charged to federal program identified nine instances in which percentage of VOCA hours worked per employee timesheet differed from the percentage of VOCA hours charged to the federal program. Responsible Individuals: Becky Simmons, President and CEO, Donna Nugteren, Director of Finance, Rachel Schartz, Director of Grants Management Corrective Action Plan: State payroll is submitted monthly in the grant drawdown process. The state reviews all payroll and processes for calculating hours. They have provided Call to Freedom with their calculator to assist in the recording of employees who are partially covered under the state grant. All state drawdowns are reviewed by the state prior to payment. The new grant begins 07.01.23. Call to Freedom has obtained the requirements from the state in their Grantee Guidelines document. The Director of Grants Management is a new addition to Call to Freedom and will assist in the review of the process. Call to Freedom will verify accuracy of hours recorded. The percentages are determined by the number of hours each employee records in the grant for the monthly drawdown. Call to Freedom will audit monthly and submit to the state for their review and approval. Anticipated Completion Date: July 2023

Views of Responsible Officials: Management acknowledges the need for closer monitoring of staff labor billing rates and tighter internal control procedures surrounding calculating and recording time allocations in our accounting system. Management also notes that after a thorough internal review of 2022 payroll allocations we determined that the scope of total misallocations was isolated in program impact and minimal in financial scale and that audit sampling overrepresented the extent of the issues by capturing some of the very few instances of misallocation. To eliminate misallocation of time worked and/or salary rates, the following actions will be implemented: Monthly program time allocation calculations prepared by the Finance and Operations Officer will be reviewed and approved by the Director of Finance prior to entry into the accounting system to confirm correct rate application and time allocation. Payroll allocation rates will be monitored and updated as needed quarterly for review and approval by the Chief of Operations.

Corrective Action Plan For the year ended June 30, 2022 Finding 2022-001: Types of Services and Costs Allowed or Disallowed (Significant Deficiency) Summary: During the fiscal year ended June 30, 2022, certain payroll transactions were processed and paid without documented supervisor approval of employee timecards. View of Responsible Officials and Planned Corrective Action: Catholic Charities has implemented the following control in fiscal year 2023 to address the deficiency: ? Preventative: Payroll allocations are entered into the payroll system and adjusted based on time spent on the given programs. ? Supervisors will go into the payroll system before payroll is processed and electronically approve the timecards of their staff. This approval signifies that hours worked on the specified programs are correct and appropriate as presented. ? The Accounting Clerk will not process payroll until all timecards show supervisor approval ? Digital documents will be kept as evidence of review. Name of Contact Person(s) Responsible for the Plan: Debra Bodner-Beurer, Vice President of Finance dbodner@ccfc-ct.org (203) 416-1478 Proposed Completion Date: Completed December 13, 2022