Corrective Action Plans

RE: Finding 2022-003, Document Policies and Procedures over Federal Grants. To whom is may concern, The Town of Wayland Town Managers Office has prepared the documentation for procedures over Federal Grants. The Town of Wayland is now in compliance with this requirement. Sincerely, Brian Keveny Finance Director Town of Wayland, Ma.

RE: Finding 2022-002, Maintain Employees' Time and Effort Records To whom it may concern: Time and Effort Records have been maintained as of the start of the 2022-2023 fiscal year. The District is now in compliance and will be going forward. Tom Lafleur Director of Finance and Operations

The District Federal Programs Coordinator will: 1. Attend professional development activities provided by our Federal Programs Consultant, Dr. Cheryl Sattler with Ethica, LLC. These activities include monthly technical calls, annual Title 1 Bootcamp, and Spring Coordinator's Workshop. 2. Seek help and advice from Dr. Sattler as needed. 3. Attend FASFEPA Conferences, twice per year, to learn about updates and changes to federal laws regarding Title 1 funds. 4. Review the budget entered into the district's accounting system to ensure there are no discrepancies.

Audit Finding Reference: 2022-003 Improve Controls and Documentation over Payroll Process Planned Corrective Action: The Portland Public School District's payroll operations have been under strain since its conversion to a new software system (Munis) in January 2019. Certain modules and functionalities were not set up completely or correctly prior to launch, which necessitated workarounds, time-consuming manual processing, and error correction. These challenges were compounded by staff turnover, staffing shortages, and the heightened pressures across the district caused by the pandemic. As a result certain systems, processes, procedures, and documentation protocols have weakened over this time. PPS is aware of this and has been working toward a permanent solution to the root cause of the payroll challenges. In collaboration with outside consultants, PPS has entered into an agreement to transition to ADP as a third-party payroll provider for the district, with expected implementation in fall 2023. PPS has retained a project manager for the transition, whose focus will not only be the technical software transition but also ensuring that sound policies, procedures, and controls are in place alongside system capabilities that meet the needs of the district. Additionally, PPS intends to invest in additional HR staff in order to implement new workflow that ensures appropriate segregation of duties, review, and documentation of employee pay information. Name of Contact Person: Terry Young Ed.D Executive Director of Operations Portland Public Schools 353 Cumberland Avenue Portland, ME 04101 Direct: (207) 842-5333 Anticipated Completion Date: 11/1/2023

Finding 2022-004 Improve Time and Effort Documentation Planned Corrective Action: The Housing and Economic Development Department will establish a process to document time and effort certifications for salaried employees, and ensure that compliance is monitored on an ongoing basis by the HCD Division Director. Anticipated Completion Date: May 1, 2023 Contact Person: Mary Davis, Interim Department Director, Housing and Economic Development and Division Director, Housing and Community Development

2022-004 ? Allowable Costs/Cost Principles Auditee?s Response and Planned Corrective Action JCHA will implement and follow a procurement policy that details documentation of authorized purchases made by the Authority. Planned Implementation Date of Corrective Action: On or by June 30, 2023. Person Responsible for Corrective Action: Executive Director with the assistance of Bedrock Housing Consultants.

Finding Number: 2022-004 Condition: Although the City has processes in place to cover these areas, the City lacks formal written policies covering these areas. Planned Corrective Action: The City has adopted a number of financial policies that address this finding on 04/17/23. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 04/17/23

Finding Number: 2022-002 Condition: We examined $1,746,599 of federal funds reimbursed to the City from the State Revolving Fund award during the year. Management informed us and we verified that $134,102 of reimbursements were for ineligible construction costs as these amounts were bid alternates that were not allowed uses of the federal award. Further, management informed us and we verified that $17,253 of federal reimbursements were received for a duplicate construction invoice. Further, as a result of reviewing the ineligible costs, management found that in fiscal year 2021, ALN 66.458 included $5,768 in ineligible expenditures, and the overall total expenditures was understated by $184,073. In addition, ALN 14.228 had expenditures of $229,554 that were understated in fiscal year 2021, and ALN 10.760 had expenditures totaling $81,228 that were understated in fiscal year 2021. Planned Corrective Action: The City adopted an allowable cost policy on 04/17/23. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 04/17/23

Finding 2022-009 Federal Listing Number 16.560 ? Allowable Costs Corrective Action Plan Management will include the procedures to provide support and documentation of expenditures related to federal grants and contracts with the internal control procedures. Anticipated Completion Date November 30, 2023 Name of Contact Person Responsible for Corrective Action Angelo DeSantis, YPTC

Finding 2022-008 Federal Listing Number 16.560 ? Allowable Costs; Period of Performance Corrective Action Plan Management will recognize revenue for cost reimbursable grants and contracts as the expenses are incurred. The sub-recipients will be paid as the expenses are incurred/invoiced. In 2023, WizeHive, a project management application, has been implemented to track grant and contract spending and invoicing. Accounting and Operations. Management will document the internal control procedures used to manage federal awards to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. The internal control procedures will include the monitoring of Subrecipients. Anticipated Completion Date November 30, 2023 Name of Contact Person Responsible for Corrective Action Angelo DeSantis, YPTC

Finding 2022-007 Federal Listing Number 16.560 ? Allowable Costs Corrective Action Plan Management agrees the equipment purchased should be capitalized and not charged for supplies. However, the grant allows the purchase of equipment without prior approval. The equipment purchased was a Sciex Workstation and a Pipettor Dilutor. Based on the guidelines published by the Office of Justice Programs prior approval is not required if the purchase is not 10% greater than the original award amount. (Archived Office of Justice Programs: Financial Guide - Part III - Chapter 5: Adjustments to Awards (ojp.gov)). The purchase of the Sciex Workstation and the Pipettor Dilutor was made based on this guideline. The classification of equipment, computers and supplies will be included in the documentation of internal controls. Anticipated Completion Date November 30, 2023 Name of Contact Person Responsible for Corrective Action Angelo DeSantis, YPTC

Corrective action the auditee plans to take in response to the finding: We applied for set aside funding from HUD for this issue as an unforeseen circumstance and awarded $25,000. Although insufficient in amount, we added a part-time admin assistant and a full-time second HQS inspector. Both positions continue in our 2023 budget. Anticipated date to complete the corrective action: The corrective action was completed in the first quarter of 2023, and PCHA is in full compliance as of the second quarter of 2023.

FINDINGS - FEDERAL AWARD PROGRAM AUDITS U.S. DEPARTMENT OF EDUCATION Finding: 2022-001: IDEA - Part B, Section 611 (84.027) & IDEA - Part B, Section 619 (84.173) Recommendation; We recommend that the District have proper internal controls in place to ensure that the employees working in the grants are certifying their actual percent of time and effort that is being spent working in the federal award program. Monthly certifications should be completed if less than 100% of time is being worked in the federal award program or semiannually if 100% of time is being spent. Corrective Action Plan: The District will implement a system of internal controls to ensure that all certifications are completed in accordance with the percentage of time worked (ie. Monthly or semiannually) and that they are completed timely. Additionally, the District will ensure that time being charged to the grant agrees to actual time spent working in the grant for each employee. Anticipate,/ Completion Date: Currently in process with a final expected date of October 31,2022.

Finding 2022-003 United States Department of Health and Human Services Pass-through from North Carolina Department of Health and Human Services Program Name: Block Grants for Prevention and Treatment of Substance Abuse Federal Assistance Listing Number - 93.959 Significant Deficiency in Internal Control over Compliance and Nonmaterial Noncompliance - Allowable Activities/Costs Responsible Individuals: Thom Elmore, Executive Director Finding Summary: Our audit procedures noted multiple instances in which costs were included in the grant reimbursement reports that were unallowed per the terms of the grant agreement and relevant federal and state compliance guidance. These findings included the inclusion of sales tax expenses that could be legally recouped by means of refunds, inadequate documentation supporting the current pay rate for an employee whose wages were included in the award reimbursement requests, and reported indirect costs that exceeded the maximum allowable indirect cost rate per the terms of the award. The total questioned costs related to these findings were not material to program compliance. Corrective Action Plan: The Organization has developed appropriate controls over the review and approval of allowable costs; however, the Organization will review and strengthen these control activities by providing a more thorough examination of expenditure supporting documentation by an individual that is not responsible for preparing the federal award reimbursement requests. Additionally, we will review and strengthen our internal control activities over personnel pay rate changes by requiring independent verification that all pay rate changes implemented are supported by current documentation in the respective employees' personnel file. Anticipated Completion Date: Ongoing.

U.S. Department of Education 2022-002 21st Century Community Learning Centers ? Assistance Listing No. 84.287C Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to review amounts charged to the grant prior to submitting for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new Chief Financial Officer was hired in March 2022 with appropriate expertise to evaluate financial reporting processes and controls. Additional controls over the preparation of financial statements to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP have been implemented.. Name(s) of the contact person(s) responsible for corrective action: Jerri Kautsky Planned completion date for corrective action plan: completed as of date of audit report, December 8, 2022. If the U.S. Department of Education has questions regarding this plan, please call Jerri Kautsky, CFO, at 239-255-7223.

Finding 2022-002 The Center?s use of spreadsheets for labor allocations did not provide a documented system of internal control that could be used to test changes to allocation made during the year. Corrective Actions Taken or Planned: Management concurs with this finding. On March 1, 2023, Carole Robertson Center for Learning transitioned tracking of labor costs to our human resource information system, Paycor. This has been a work-in-progress which began in the fall of 2021. The result has been accomplished with diligence, attention to detail, efficiency and accuracy during a period a significant growth. Each pay period, Paycor produces a Job Costing Report that supports the reimbursement process for labor costs. Further, the content of the Job Costing Report seamlessly exports these costs to the general ledger for each pay period. A formal approval process will be established to connect the flow of documentation from budgeting, to actual costs incurred, to the reimbursement from funders so that verification of each element (grant budget development, payroll, cost allocations, general ledger entries, and reimbursement requests) will match/reconcile without requiring recalculation. The contact person is Peg Heslinga, Chief Financial Officer. SAGE Intacct accounting software will be implemented with a planned go-live date of July 1, 2023. The contact person is Peg Heslinga, Chief Financial Officer. Our Accounting Policies and Procedures will be reviewed by November 1, 2023, and revised to reflect accounting policies that have been modified since the previous version was approved in September 2022. Going forward, these policies will be reviewed annually for needed revisions. The contact person is Peg Heslinga, Chief Financial Officer. The Controller, the Director of Accounting, the Director of Contracts Management, and the Contracts Manager will attend Uniform Guidance training, and all positions within the Finance Department will be reviewed to determine additional training and education needs. Implementation is planned for completion by September 30, 2023. The contact person is Peg Heslinga, Chief Financial Officer.

Finding 2022-002: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics Federal Financial Assistance Listing/CFDA Number: 93.697 Finding Summary: The Medical Center?s listing of expenses claimed under the Testing and Mitigation for Rural Health Clinics program as an allowable cost had more expenses than funds received. Some of these excess funds related to a different period and would have been reported on the Schedule in a different year. This should have been caught with an effective secondary review of expenses. Responsible Individuals: Nathan Pickel, Chief Financial Officer Corrective Action Plan: Management agrees with the finding. Controls will be put into place for a more thorough review of the expense detail to ensure expenditures being claimed pertain to the year in which they were incurred. For the current year, the expense detail was ran by accounting date as opposed to service date. Anticipated Completion Date: June 30, 2023

SIGNIFICANT DEFICIENCY Finding 2022 ? 001 Activities Allowed, Allowable Costs Name of contact person: Kirby Nickerson, CFO Corrective Action Plan: Management plans to review the segregation of duties in order to provide reasonable assurance that transactions are handled appropriately. This will include a process review of expenditure approval prior to payment and approval of the Personal Action Forms used to make payroll changes. If changes are needed to the process to provide the reasonable assurance that transactions are handled appropriately, management will collaboratively work with the operations team to revise the procedures as necessary. Lastly, training for managers and supervisors will be provided on the procedures to ensure the proper implementation of the updated process. Proposed Completion Date: Management will implement the above plan by the end of April 2023.

U. S. Department of Housing and Urban Development (Pass-through from Virginia Office of Community Planning and Development) Assistance Listing #14.267 Finding: 2022-003 Known Questioned Costs for a Federal Program Not Audited as a Major Program Criteria: In accordance with 2 CFR 200.516(a)(4) known questioned costs that are greater than $25,000 for a program that is not audited as a major program must be reported as an audit finding in the federal awards section of the schedule of findings and questioned costs. In September 2022, the U. S. Department of Housing and Urban Development, identified $1,463 of unallowed expenditures and a deficit of $27,464 in the required cash match under the Continuum of Care program for the year ended December 31, 2021, as a result of monitoring. Rapid Rehousing Requirements: Criteria: 24 CFR 578.51; 24 CFR 578.57 Condition: The Federal awarding agency has determined, in accordance with 24 CFR 578.51; 24 CFR 578.57; $1,463 of allowable HMIS expenses were not documented and that in accordance with 2 CFR 200.1; 2 CFR 200.103(a)(11); 2 CFR 200.306; 24 CFR 578.73 the grantee failed to match $27,464 on its Continuum of Care rapid rehousing project. Corrective Action Plan: The CFO will ensure that the HMIS expenses are being captured in financial documents be setting up a new account code in the financial software. Staff members that have HMIS hours will also record those hours separately on their timesheets each pay period. NRCA will be submitting copies of timesheets which record data entry by line item as further documentation of the HMIS expenses submitted in answers to the monitoring report. While NRCA respects the position of the Department of HUD, NRCA also believes management followed the grant agreement as submitted. NRCA sees resolution to this matter with the Department of HUD and is currently seeking counsel to ensure this resolution in an acceptable and appropriate manner. Persons Responsible: Michelle Cox, Chief Financial Officer and Krystal Thompson, Chief Executive Officer Timing for Implementation: Immediate

Finding 2022-003 Federal Transit Cluster - SEFA Management?s or Department?s Response: Management agrees. Views of Responsible Officials and Corrective Action: SCRRA will document the process to review the SEFA from prior year. Compare the SEFA to the final Single Audit Report to ensure the ending balances tie back to the Single Audit Report, before starting the current year?s SEFA. Name of Responsible Person: Thelma Bloes Implementation Date: June 30, 2023

Twin Oaks will allocate costs in the accounting system in accordance with the established cost allocation plan. This will be reviewed on an annual basis or as needed.

Finding 2022-001 - Allowable Costs/Activities, Period of Availability and Reporting; Material Weakness Responsible Person: Toneq? McCullough, Director of Transportation Action: During fiscal year 2022, the City?s Department of Transportation recognized a need for additional controls in reviewing and approving contractor invoices prior to submission to the Finance Department for payment. While additional controls were implemented during the year for non-payroll expenditures, developing a similar procedure for payroll invoices was inadvertently overlooked. As of September 2022, the City updated the process by which payroll invoices are approved and paid and the invoices are now approved by the Director of Transportation. The City?s Department of Transportation will begin reviewing and approving the non-financial information in the Annual Operating Statistics Report as of November 2022. Anticipated Completion Date: November 2022

Finding 2022-002 Condition A sample of 40 items were selected for testing. During our testing, we noted one item selected for testing did not contain support of authorization. This was not a statistically valid sample Corrective Action Plan Corrective Action Planned: The Company agrees with the finding and will implement procedures to ensure all invoices approved via email will be stored in our document management and workflow software. Name(s) of Contact Person(s) Responsible for Corrective Action: Daniel Murray, CEO and Timothy McQuaid, CFO Anticipated Completion Date: completed

FINDING 2022-007: ESSER PAYROLL The School Corporation did not have a documented internal control over payroll claims in place relating to the Allowable Activities and Allowable Costs compliance requirements. Corrective Action Plan: Central Office staff will verify and sign reports for FY2023.

Respectfully, the school corporation does not agree with several of the findings in regards to segregation of duties and purchases. First, the SBOA auditors' told the school corporation during the 2019 audit that operating the school lunch program through the extracurricular account was not legal. The school corporation was informed that this account must be transferred to Central Office and a Corrective Action Plan must be in place. This directive was incorrect and pointed out in the official response from November 5, 2019 under IC 20-26-5-4(a)(l l). Second, segregation of duties, oversight, and approval of functions existed in 2019 and are presently occurring daily, weekly, and monthly within the cafeteria program under the corporation accounts and supervision of Central Office. Cafeteria workers record and submit timesheets of duties performed during each payroll period. The Cafeteria Director verifies and signs timesheets to be submitted to the Treasurer and Deputy Treasurer for review and payment from the Cafeteria account. A payroll docket report is sent to the Superintendent prior to payment from the bank. Prior to the 2019 audit, the High School Treasurer spent approximately two hours per day counting cash received each day from school lunches purchased. She also receipted those funds it into the software system, made deposits to the bank, paid invoices for food expenses, and processed part of payroll. Tasks conducted by the High School Treasurer were segregated by a timesheet and supervised by the High School Principal. All those tasks were shifted to Central Office in 2020 and are now segregated to the Treasurer and Deputy Treasurer. The Treasurer documents hours spent on Cafeteria accounts on a timesheet for review and signature by the Superintendent. Financial reports of expenditures and revenues are provided for review and oversight to the Superintendent and School Board at monthly board meetings. Third, RSSC has a small Central Office consisting of a Superintendent, Treasurer, Deputy Treasurer, and Secretary. It has no Assistant Superintendents, Human Resources Director, or Business Manager. Each person in Central Office wears multiple hats and performs multiple duties each day. It was noted in the Audit Report filed from July 1, 2008 to June 30, 2010 that " ...Randolph Southern School Corporation is unable, due to financial limitations, to employ additional personnel to segregate duties in our receipts and cash and investment balances. This statement would apply to all of our internal controls. " The circumstances for RSSC have not changed in the audit periods from July 1, 2010 through June 30, 2022. Corrective Action Plan: The School Board had chosen not to add additional staffing due to costs. RSSC is still unable to segregate duties for financial transactions and reporting. Fourth, the Cafeteria Program only has one full-time staff member, the Cafeteria Director. Eight part-time cafeteria workers prepare and feed up to 300 students each day. This food service program is one of the best run programs in the State oflndiana. It has not had one food preparation or sanitation violation from IDOE or Department of Health in the last 12 years. Fifth, the Cafeteria Program is economically efficient and fiscally responsible. The account carries at least a 3-month cash balance at all times. This success is a direct result of oversight by the combination of the Superintendent, Treasurer, and Cafeteria Director. RSSC adopted board policy 6114 Cost Principles-Spending Federal Funds on May 9, 2016. RSSC has had an Indirect Cost Rate in place since 2013. The adopted policy allows the school corporation to apply Indirect Costs to all federal funds including the Cafeteria account. On December 5, 2019, email communications between the Dr. Donnie Bowsman, Superintendent and Tina Herzog, IDOE Assistant Director of Operations and Food Distributions clearly state the school corporation can apply the Indirect Cost Rate to the Cafeteria account. The email communication clearly states that the high cash balance was a result of not applying the Indirect Cost Rate to the Cafeteria account (See Exhibit 1 Emails). The Indirect Rate was approved by the IDOE Office of School Finance and existed prior to the audit years being referenced in the finding. Technically, the prospective portion (going forward for the next school year) as referenced on pages 24-25 of USDA Indirect Cost Guidance Manual pertains to the 2013 Fiscal Year. Moreover, the fact was reiterated by the IDOE School Nutrition Office with email communications on December 5, 2019, not 2021 or 2022 as referenced in the finding. RSSC has not charged or recouped the Cafeteria Account the Indirect Cost rate for many years and has subsidized this account which should be independent and self-sufficient. The School Corporation did not apply the Indirect Cost Rate in 2020 or 2021 because we were not sure how many students would be eating and how fiscally sound the account would be due to students not attending school because of COVID. Corrective Action Plan: The Indirect Cost Rate will be applied and collected in the future prior to June 30 of each current fiscal year. It should also be noted that in 2021, RSSC purchased a new cafeteria dishwasher utilizing ESSER II funds. This unit was 20+ years old and needed to be replaced in order to continue feeding children and to run the food service program. This expense could have been and should have been a direct cost of $58,189 to the Cafeteria account. However, due to the unknown circumstances of COVID, the RSSC could not take a chance. The ESSER II grant is still open and we are now questioning whether this expense could be charged directly to the Cafeteria account. Those ESSER II fund could be utilized for staffing to support student learning loss and remediation. Sixth, COVID caused this financial account to increase exponentially from 2020 to 2021. ESSER funds were provided by the federal government to provide free lunches to every child which paid the food operations expenses for two school years. Student participation of eating school lunches increased during these time periods. Additionally, staff members were receiving hazard pay incentives on top of their regular hourly rate. Further, the School Corporation and Cafeteria Program took on the enormous task of feeding children over the summers of 2020 and 2021 when COVID cases were at its peak. The cafeteria personnel fed 5286 and 5740 students respectfully during those summers. The number of meals served during the summer almost equaled the total amount of meals served during the entire school year for each respective academic year. These additional meals created additional unexpected revenues for the fiscal year. The school corporation did not charge mileage for satellite lunches being delivered or indirect costs.