Corrective Action Plans

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

Corrective action planned: Cash flow requirements to fund daily operations will be reviewed more thoroughly so that awarded funds are expended consistent with the terms of their respective agreements. Projects presently on quarterly cost reimbursement schedules will be changed to monthly cost reimbursement requests. Contact person responsible for corrective action: John D. Pepe, Controller. Anticipated or actual completion date: October 1, 2024.

2021-01: Approval for expenditures Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.

2019-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregating certain duties is not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.

Finding 2023-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the projects and related expenses submitted to FEMA for reimbursement. Current Status: In progress. Resolution: Management will develop and implement additional internal controls to ensure documentation is retained to evidence the operating effectiveness of the internal controls. These internal controls will ensure expenses included in FEMA grant applications are reported completely and accurately. The additional internal controls will include a reconciliation of application expense detail to final paid invoices along with a notation that each expense is allowed to be included in the FEMA submission. The reconciliation will be reviewed and approved by the Cottage Health Director of Finance prior to final FEMA submission and evidence of the review will be retained. Contact Person: Lawrence Thomas, Director of Corporate Finance Anticipated Completion Date: November 29, 2024

HSD acknowledges the identified weakness and implemented an updated Accounts Payable control procedure in 2024, that includes an additional standard monthly report and review process to ensure that reimbursements are processed with the required 30-day period.

For the Hill Housing Facility - FINDING 2023-001: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 - SURPLUS CASH NOT DEPOSITED INTO RESIDUAL RECEIPTS ACCOUNT - Recommendation: The Project should deposit surplus cash as of December 31, 2021 into a residual receipts account as soon as possible. Action Taken: The Project agrees with the finding. Management will deposit $14,079 in a residual receipts account as soon as possible.

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Medical Assistance Program / State Health Insurance Assistance Program / Medicare Enrollment Assistance Program – Assistance Listing No. 93.778 / 93.324 / 93.071 Recommendation: We recommend that there is an appropriate reviewer of each grant claim. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The amounts reported were accurate and in compliance. The department will continue to train employees in respective positions to ensure responsibilities align with program requirements. Immediately upon discovery of the omission of the review step, management reiterated to department financial staff the importance of the review process. Name(s) of the contact person(s) responsible for corrective action: Kim Merrill, Finance Manager Planned completion date for corrective action plan: December 31, 2024

Contact Person - Pattie Solberg, Auditor; Corrective Action Plan - The City should follow their procedures for signing off on all requests for reimbursement reports before submitting the federal reimbursement. Completion Date - December 1, 2024.

Contact Person - Pattie Solberg, Auditor; Corrective Action Plan - The City should contact the Contractor to determine if the amount that was overpaid will be refunded or adjusted on the next "Pay Estimate." The City will also need to contact the Grantor to determine if the reimbursed dollars should be returned or adjusted on the next draw. To mitigate the risk of overpayment in the future, the City should reconcile construction payments to the "Pay Estimates." Completion Date - December 1, 2024

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standardized process for review and approval of drawdowns before request for reimbursement by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

Management Response The Garden did not draw more on awards than had been incurred over the course of the contract. Adjustments in the general ledger were made in subsequent periods to tie out requested reclasses from program staff. Corrective Action Plan: Education and reverification of the processes documenting the flow of information from the general ledge to the federal award billings has been provided to accounting personnel involved in federal award accounting and billing. Contact person(s) responsible for the corrective action: Jaime Kuczkowski, CPA Jaime@balancefm.com, Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org Anticipated Completion Date: Education will be complete by August 31, 2024.

Name of auditee: Town of Plattsburgh Housing Development Fund Company, Inc. TIN: 014-EE068 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2023 CAP prepared by: David Kimmel President Two Plus Four Property Management Co,. Inc. (315) 437-2178 Current Finding on the Schedule of Findings and Questioned Costs and Recommendations Finding 2023-002 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. (b) Action taken: Management will deposit the surplus cash in the amount of $11,218 into the residual receipts account during August 2024.

Staff will indicate on grant drawdown approval forms the date that the draw was taken to avoid duplication.

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full - range of controls relating to reporting, including federal program reporting. MARR will take such steps as necessary to ensure that reports are timely and accurately prepared, reviewed, and approved prior to filing. All controls, including review and approval will be documented in such documentation to be maintained. MARR will retain a CPA consultant to implement and adopt formal written policies relating to grants management ordered by Uniform Guidance.

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR’s protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting process be accurate. Further, controls over grant billings will be established to ensure expenditures represent actual costs incurred. All control activities, including independent review, should be documented and evidence of review and approval will be maintained.

Planned Corrective Action: MARR will retain a CPA consultant to establish formal written policy documenting significant accounting procedures including but not limited to the independent review of the grant period of performance when recording transactions and preparing grant reimbursement requests. Evidence of the review to be documented and maintained according to the procedures to be implemented.

FINDING 2023-003 Finding Subject: Internal Controls over COVID-19 – Coronavirus State and Local Fiscal Recovery Funds: Lead Reduction Grant Summary of Finding: The County submitted one invoice for reimbursement to the State during the audit period. The County had not established a proper system of internal control over reporting as one employee in the County Health Department prepared and submitted the invoice with no evidence of an oversight, review, or approval process to ensure that the report was accurate. Contact Person Responsible for Corrective Action: Paula Kern-Edwards Contact Phone Number and Email Address: 812-275-3234 pedwards@lawrencecounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This grant period has ended. The County will review all future grant awards for similar requirements and comply with any oversight, review or approval requirements. Anticipated Completion Date: Completed

Residual Receipts in the amount of $12,257 was not incurred in the fiscal year of 2023. This surplus cash was incurred in prior years. Excess residual receipts have not been remitted for two reasons 1) funds are needed for improvements which we are pursuing to 3 bids for as required and 2) HUD has not notified management of the method to remit.

o As of June 30, 2024, LifeWire has implemented a new software package called VELA in which direct services staff enter their actual time worked to contracts, which is then reviewed and approved by their supervisors and reported to Finance staff for payroll processing. By December 31, 2024, the Finance staff will ensure all 2024 actual hours worked toward contracts have been reviewed and approved by all direct services staff whose time is billed and approved by their supervisors. o Name of Responsible Individual: Jeannette Biffle, Controller

o LifeWire’s Senior Accountants, Controller and Co-EDs carefully review all costs charged to contracts to ensure they fall within the appropriate contract period. As of September 9, 2024, all 2024 contract charges are captured in the correct periods. o If the staff of LifeWire has any question about the permissibility of a given charge, we will reach out to the contract manager, obtain clarification and/or permission in writing, and ensure that documentation is filed and maintained appropriately. If we are unable to obtain this permission, we will find another funding source for the charge or find alternate methods of supporting survivors’ needs. o Name of Responsible Individual: Jeannette Biffle, Controller

Finding 2023‐002 Condition We selected three monthly submissions of GEARS and SPARC reports across multiple programs received by the Wisconsin Department of Human Services and the Wisconsin Department of Children and Families. One of the three GEARS and SPARC reports tested was not reviewed by an independent person before submission for reimbursement. Our sample was not statistically valid. Corrective Action Plan Corrective Action Planned: In September 2023, a review process was established and implemented starting with the August Claim to ensure that required reports are reviewed by someone other than the preparer of the reports prior to submission. Name(s) of Contact Person(s) Responsible for Corrective Action: Reports prepared by Kozue Bush, Finance Manager, will be reviewed by Chad Lillethun, FMS Division Administrator prior to submission. Anticipated Completion Date: Review process was implemented with the August 2023 claim.

Condition: Controls in place were not adequate to ensure the Authority complied with all requirements under 2 CFR. Planned Corrective Action: The Authority will work to establish a written procedure to follow requirements in 2 CFR 200.305. Contact person responsible for corrective action: Shedreka Miller Anticipated Completion Date: 12/31/2024

Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reports be reviewed by a supervisory-level person who is not the preparer of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have established a mandatory review process where all reimbursement requests and performance reports must be reviewed and approved by a designated supervisory-level staff member who did not prepare the report before submission to the granter. We have communicated the importance of this review process in ensuring compliance, completeness and accuracy. We will monitor the process to prevent recurrence. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: August 7, 202

Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reimbursement requests be reviewed by a supervisory-level person who is not the preparer of the requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have established a mandatory review process where all reimbursement requests must be thoroughly reviewed by a designated finance staff member who did not prepare the request. A final approver (i.e. supervisor or director) will authorize the reimbursement request before submission to the grantor. We have communicated the importance of this review process to our team to ensure compliance, completeness and accuracy. We will monitor the process to prevent recurrence. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: August 7, 2024