Corrective Action Plans

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

The Neighborhood House will conduct an internal review of all payroll and payroll allocations to make adjustments and corrections to program allocations. The payroll report will be reviewed annually for revisions. Staff will discuss a procedure to ensure that payroll and benefits are accurately allocated.

The Neighborhood House is undergoing an internal review of all payroll and payroll allocations. Adjustments and corrections to program allocations will be made accordingly. The payroll report will be reviewed annually for revisions.

2023-002 -#84.425D COVID-19 Elementary and Secondary School Emergency Relief Fund II Federal Grantor: U.S. Department of Education Pass-through Award Number: 2022-131309-DPI-ESSERFll-163 Pass-through Entity: Wisconsin Department of Public Instruction Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborer must be paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL). Nonfederal entities shall include in their contracts subject to wage rate requirements a provision that the contractor or subcontractor complies with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the District weekly payrolls and a statement of compliance (certified payrolls). Condition: There was one Education Stabilization Fund construction project performed by a subcontractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $34,828. There was not a prevailing wage clause in the contract and certified payrolls were not received. Cause: The District was not aware that wage rate requirements applied to the construction project until after it was completed. Effect: A reimbursement request was made for expenditures that did not comply with wage rate requirements. Questioned Costs: $34,828. Recommendation: Establish controls to comply with wage rate requirements related to the Education Stabilization Fund. Consider determining if the contractor performing the project in 2022-2023 paid prevailing wage rates for costs reimbursed by the grant. Otherwise, the District should replace the cost with other allowable costs. Response: The District replaced the cost with other allowable costs. Contact Person: Doreen Treuden Anticipated Completion: November 27, 2023

Finding #2023-001 – Allowable Costs relating to Time and Effort and Internal Controls Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – First Quarter of 2024 Information on the Major Federal Program: U.S. Department of Health and Human Services Name of Program: Substance Abuse and Mental Health Services Assistance Listing Number: 93.243 Grant Award Number: 1H79TI085239-01/6H79SM080760-03M001/1H79TI084237-01/ 1H79SM080760-01 Grant Award Period: September 30, 2022 to September 29, 2027, November 30, 2018 to November 29, 2023, September 30, 2021 to September 29, 2026/November 30, 2018 to November 29, 2023 U.S. Department of Veterans Affairs Name of Program: Veterans Supportive Housing Per Diem Program Assistance Listing Number: 64.024 Grant Award Number: VOAQ754-1291-558-PD-21, VOAQ754-2080-558-CM-22, VOAQ754-2286-565-CM-22 Grant Award Period: October 1, 2022 to September 30, 2023 Corrective Action Plan: Effective immediately, the Organization will strictly enforce its policy for employees to properly complete their timesheets and for supervisors to properly review and approve employees’ timesheets. To do this, the Organization will conduct a training for all employees and supervisors about how to properly complete and review timesheets. To ensure compliance with the policy, the Organization will conduct random checks of timesheets every pay period to verify that supervisory approval is performed. Appropriate disciplinary action will be implemented for non-compliance.

The Director of Fiscal Services will communicate with the California Depratment of Education on all unclear unallowable indirect cost prior to year-end closing. Moving forward the district will continue to use the Standardized Account Code Resource Code Query tables to identify allowable and Indirect cost programs. Additionally, the district will continue to utilize the approved indirect cost rates established by the California Department of Education.

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Hospital claimed reimbursement for health-related lost revenue during the COVID-19 pandemic. Condition: The Hospital claimed reimbursement for health-related lost revenue based on a comparison of actual monthly revenue for the months of March, April, and May 2020 to the same corresponding months of 2019. Within the calculation, the Hospital excluded certain other operating revenue from the 2020 monthly totals which were included in the 2019 monthly totals. As a result, the compilation of revenue used between the periods was not consistently applied resulting in a higher lost revenue calculation than prescribed by the applicable guidance. Views of Responsible Officials: Management agrees with the finding. Planned Completion Date: April 30, 2024. Person Responsible: Cyrstal Wyatt, CFO.

Management agrees with the findings presented by the auditors. Management has taken the following actions already to ensure that there is proper review and approval. The Organization went through a payroll system transition in FY23. During the implementation phase of the new payroll system, the organization encountered a significant learning curve. As we progress into FY24, we will utilize our payroll system to document the approval process for staff working on federal grants. We offer two options for this documentation: either via timesheets or written confirmation of hours worked on federal grants for recordkeeping.Management will continue to conduct staff training and education regarding the importance of time tracking when allocating time to federal grants. To ensure strong internal controls, management is committed to conducting periodic internal reviews as part of our compliance checks.

2023-002 - Expenditure Controls - Significant Deficiency The District agrees that while significant progress has been made in this area, there is still work to do regarding the pre-authorization of purchases. The Business Manager has held meetings with each building and department individually to communicate proper procedures. She has also issued All Staff emails outlining these procedures and referencing board policy supporting these practices. Proper procurement procedure instructions are also available via video through a link on the Business Office Department page of the District website for reference. We recognize that proper training is imperative to compliance in all departments and the Business Office will continue to provide training throughout the year, with an emphasis in departments with new staff.

Management agrees with the finding. The Medical Center’s secondary review control will ensure allowable expenses are being claimed.

Corrective Action: The Executive Director of Finance and Coordinator of Testing and Accountability & State/Federal Programs will do additional training on Title I plans and how to claim money.  We will monitor the claims quarterly to track spending for each quarter to make sure we are meeting the percentages that are required by the state department. The Coordinator of Testing and Accountability & State/Federals will meet monthly with the Grants Accountant to monitor Title I.

The Institute has implemented procedures to ensure all documents to support the salaries and wages charged to federal programs are prepared in accordance with the SCDE requirements.

The District will require those personnel that are subject to federal award requirements to complete a personnel activity report (PAR) or semi-annual certification. The person responsible for the corrective action is Irene Byrne, the CFO. The anticipated completion date of the corrective action plan is immediate. The plan for monitoring adherence is for the CFO to monitor federal employees and review the completed documents for all employees.

This finding is caused by Human error in transcribing amounts from the general ledger to the proper Activities and Objects on the Final Expenditure Report. The completion date for the corrective action plan is immediate. The person responsible for the corrective action is Tina Mills, the Business Manager. The plan for monitoring adherence is the business manager will double check reports before submitting them to the State of Michigan.

West Central NE Development District will need to collect reports from various offices (County Clerk & County Treasurer) to verify all expenditures and disbursements match and perform their own calculations.

Views of Responsible Officials: As part of our investigation, we determined staff involved in the embezzlement colluded to circumvent Alight’s systems of internal controls at the directions of an Alight manager. In addition to taking the immediate actions listed above, including terminating the employment of staff involved, we also took the following actions:  We filed a police report, and are pursuing legal actions against the key actors involved in the malfeasance.  Alight’s executive leaders conducted policy, procedures and fraud notification training with the Thai staff including how to report suspected incidence of fraud.  Executive leaders and Thai leaders traveled to field offices to review operations and provide staff the opportunity to report issues. We believe these actions reinforce management’s zero tolerance to fraud and offer staff the knowledge and opportunity to report potential issues going forward.

Epidaurus dba Amity Foundation respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: BeachFleischman PLLC 1985 E. River Road, Suite 201 Tucson, AZ 85718 Audit Period: Year ending June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings - Major Federal Award Programs Audit 2023-001 Procurement Recommendation: We recommend the Organization implement changes to their procurement policies so they contain all the requirements of 2 CFR Part 200. Auditee response: Management is working on improving the documentation of their procurement policies, and will ensure any updated policies are in line with the requirements of 2 CFR Part 200. Management expects to have the policies updated by the end of December 2023. If you have any questions regarding this plan, please call Gloria Meridew, at 520-622-6489 or gmeridew@amityfdn.org.

Upon learning of the possibility of frauduelent activity, the University began an internal audit review and all activity on the grant was stopped. Throughout the process, the University coordinated with the Ohio Department of Development. The internal audit procedures led to the determination that $209,101 was incorrectly reported by the program advisor and was not detected by the program director. These funds were returned to the Ohio Department of Development on October 11, 2023. The program has been termianted and program income returned. The individuals involved with this program are no longer employees of the University. The University is in the process of seeking reimbursement from the former employee. An internal controls questionnaire was prepared and reviewed for the other Small Business Development Center (SBDC) program noting no areas of concern. The FY24 internal audit plan will include additional review of the remaining SBDC program as well as review of controls within the department which previously managed the program noted in the finding. In addition, training related to roles and responsibilities for supervisors/approvers will be provided in FY24 to emphasize the guidance provided in the grants manual. Contact person responsible for the corrective action: Mark Polatajko, Senior Vice President for Finance and Administration.

ACTIVITIES ALLOWED OR UNALLOWED AND ALLOWABLE COSTS/COST PRINCIPLES Federal agency: U.S. Department of Education Federal program title: Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U, 84.425W Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): Not applicable Award Period: July 1, 2022 - June 30, 2023 Type of Finding: • Significant Deficiency in internal control over compliance CORRECTIVE ACTION PLAN (CAP): Recommendation: We recommend the District Board approve the wage rate of all employees via contracts or separate, individual approval. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will ensure employees’ wage rates and salaries are approved by the District’s Board. Official Responsible for Ensuring CAP: Heather Hipp, Business Manager. Planned Completion Date for CAP: June 30, 2024.

Client Response: The Finance Director has already met with many of the various program leaders within the District to ensure they understand and grasp the concept of indirect cost calculations. They have also shared with them the excluded expenditure listing again to re-emphasize the need to accurately budget for indirect cost. The District has also looked into the potential to reduce its reliance on indirect cost and increase its direct spending from grants. For the finding above, the Finance Director will serve as the primary contact person for district compliance effort. The District has an estimated completion date of November 2023 as the District has already corrected the finding and resolved any noncompliance, if any, moving forward related to the above listed finding.

Management will work with various departments to review current policies and procedures related to federal grant awards. We will focus on the related controls necessary to avoid transactions paid in advance that extend passed the expenditure period. Grant procedures will include review, approval and consideration during the grant planning process.

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER (INCLUDING COVID-19 FUNDING) – FEDERAL ALN 84.027 AND 84.173 2023-002 Internal Control Over Compliance and Material Noncompliance With Federal Allowable Costs Requirements Finding Summary 2 CFR § 200.405 specifies a cost is allocable to a particular federal award if the goods or services involved are chargeable or assignable to that federal award in accordance with relative benefits received. This standard is met if: the cost is incurred specifically for the award, the cost can be distributed in proportions that may be approximated using reasonable methods, and if the cost is necessary to the overall operation of the District and is assignable in part to the federal award in accordance with the principles in 2 CFR 200 Subpart E – Cost Principles. During our audit, we noted that the District did not have adequate internal controls in place to ensure all salary costs charged to the federal special education cluster program met the standard for an allowable or allocable cost as defined by the U.S. Office of Management and Budget’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) allowable costs standards, which resulted in a reportable instance of noncompliance. Corrective Action Plan Actions Planned – The District’s Finance Director, along with special education staff, will review all salaries and benefits being charged to the special education cluster in fiscal 2024 to ensure that adequate time and effort documentation will be maintained for all salaries charged to the program so only allowable costs are being claimed for federal reimbursement. The District will also review its policies and procedures relating to allowable costs for its federal programs to ensure compliance with the Uniform Guidance in the future. Official Responsible – Brady Hoffman, Finance Director. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – Brady Hoffman, Finance Director, will monitor implementation of the corrective action plan to ensure compliance with the Uniform Guidance in the future.

Antelope County will complete the annual expenditure report as required by ARPA Funding.