Corrective Action Plans

Views of responsible officials and planned corrective action: Areas of Focus will be in the documentation of polices and procedures to provide clear expectations of internal control documentation used to complete the drawdowns from the Department of Education and for a process of record retention. Our objective would be to formalized the policies and procedures be updated in the Financial Aid policy manual with shared access between the Financial Aid office who approves the aid, the Business Office who ultimately pulls down from the Department of Education, and with the Cashier who distributes any refunds. We have put in place an electronic folder with restricted access to provide confidentiality and provide documentation of the shared communication between offices. The POISE system already generates a listing of students. That workflow will be amended to retain that documentation to be available. Measurable targets will be to do this weekly or as batches are prepared for draw-down. This documentation will be found in the shared electronic folder, which has already been implemented. The transfer of student records into the financial system is being done weekly and documentation is retained of students for which transactions occur.

Planned Corrective Action Plan: The District has hired a new business manager as well as engaged a third party accountant with considerable experience. The individuals will work together to process financial transactions and record resulting financial information going forward. Controls have been implemented to ensure that source documentation is retained to support all t ransactions. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Rocio Humphreys, Business Manager

Finding 2023-003: Lack of Review Procedures of Cash Management for Grants Finding: NCBHS management stated that cash reimbursement requests were reviewed prior to submission to the grantor, but there was no verifiable evidence that the reviews took place. Corrective Actions Taken or Planned: The issue related to the monthly reimbursement requests for the DMH grants not being reviewed and approved by the CEO before they are sent to the State of Illinois. All reimbursement requests for both the State of Illinois and federal grants will be reviewed and approved by the CEO before they are sent to the appropriate parties for payment. Name of person responsible for corrective action: Diane Garland, CFO/VP of Finance Anticipated completion date: March 1, 2024

Corrective Action Plan The one student found with a disbursement reported late to COD was the result of a correction which was posted past the deadline. This was the result of staff turnover in the Financial Aid Office and the use of temporary employees as we began the job search for permanent replacements. Going forward, training will be provided to all new employees including temporary employees. Timeline for Implementation of Corrective Action Plan The College plans to implement the corrective action plan by April 1, 2024. Contact Person James Ryan, Ph.D. Vice President of Enrollment Management

Education Stabilization Fund – Higher Education Emergency Relief Fund –Student Portion, and Minority Serving Institutions – Assistance Listing No. 84.425E, 84.425L Recommendation: We recommend that the University review the current assignment of duties for individuals and incorporate review processes for individuals where appropriate. Action taken in response to finding: The Finance department implemented an approval process for drawdown. The Controller will obtain drawdown approval from the VP of Finance and CFO. Name(s) of the contact person(s) responsible for corrective action: Shalini Patel, Controller Planned completion date for a corrective action plan: June 30, 2023

Planned Corrective Action: Implement accounting system to track federal awards; Reconcile general ledger to award amounts and to reimbursement requests.The organization purchased and is currently implementing a new accounting system which utilizes fund accounting and separate general ledger accounts for each award. Processes and procedures will be implemented to reconcile award amounts and reimbursement requests to each award within the general ledger. Additional supporting schedules will also continue to be maintained to reconcile to the general ledger.

FINDING NO. 2022-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Auditor Recommendation: Management should deposit $4,400 into the residual receipts account to refund the unapproved withdrawal. S3800-150: Action Taken: Management agrees with the finding, and has taken corrective actions which include communication with the Project Accountant and Regional Manager and will transfer $4,400 from the operating account to the residual receipts account.

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan. Recommendation (2023-300): Eligibility for the Children’s Health Insurance Program We recommend the Wisconsin Department of Health Services work with the federal government to resolve these improper payments, including the determination of the total amount of improper payments, and return these amounts to the federal government, as appropriate. Wisconsin Department of Health Services Planned Corrective Action: The Division of Medicaid Services (DMS) acknowledges that we maintained eligibility under the Children’s Health Insurance Program (CHIP) for individuals who had turned age 19, including SCHIP participants. It was our overarching policy to not terminate health care coverage upon certain changes in circumstances for Medicaid participants during the federal public health emergency (PHE). To comply with this policy, DHS made system changes at the beginning of the pandemic to maintain eligibility for all participants. After CMS provided additional information specific to SCHIP, DHS considered whether to make the necessary system changes to terminate SCHIP participants who turned 19 during the public health emergency. Because of the system limitation and DHS’s overarching goals to maintain continuous coverage, amongst other reasons, DHS decided to temporarily keep all CHIP participants enrolled until the public health emergency ended. DMS leaders met with CMS leaders on May 11, 2022, to discuss this compliance issue and related systems limitations. During that meeting, CMS indicated that they understood the system and communication challenges of having a single program that combines Medicaid and CHIP. CMS also acknowledged that the federal public health emergency was likely to end at any time, so making the required system changes would not be prudent. CMS said they would follow up with Wisconsin if they determined that further state action was needed, but they did not communicate to us after the meeting that they felt the compliance issue needed to be addressed. This confirmed the Medicaid Director’s decision to not pursue costly systems changes to support a change that might only be needed for a short period of time. After the PHE ended, DHS took proactive steps to identify aged-out CHIP participants and ensure that their eligibility was redetermined in the first two months of unwinding. In contrast to the rest of the CHIP and Medicaid population, whose renewals were distributed over a 12-month period from June 2023 through May 2024, these members’ renewals were accelerated to June and July 2023, so that their CHIP coverage would end as soon as possible after the end of the PHE. While we agree conceptually with the finding, the questioned costs identified do not consider that many (if not most) of the ineligible members would have been eligible for Medicaid as childless adults upon aging out of the CHIP program. We will discuss this likelihood with CMS and if necessary, use data available in our CARES eligibility system to assess how many of these members did retain eligibility as childless adults or in other categories of Medicaid after completing renewals in June and July. Anticipated Completion Date: March 31, 2024 Person responsible for corrective action: Jori Mundy, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services jori.mundy@dhs.wisconsin.gov. Rebuttal from the Wisconsin Legislative Audit Bureau - As stated in the finding, and as acknoledged by DHS, DHS maintained continous eligibility for SCHIP participants who were over age 19. This eligibility requirement continue through the public health emergency. Since CHIP and MEDICAID are separate programs, consideration of whether these participants could have been eligible for the Medicaid program would not have been part of our audit. Payments to providers for these participants were funded by SCHIP and not the medicaid program.

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-301: Social Services Block Grant – Subrecipient Contracts. This is the department’s Corrective Action Plan.  Recommendation (2023-301): Social Services Block Grant – Subrecipient Contracts We recommend the Wisconsin Department of Health Services update its procedures for contract development to ensure information provided in its subrecipient contracts identifies the Social Services Block Grant as the federal funding source for the basic county allocation of the community aids program related to the transferred Temporary Assistance for Needy Families funds. Wisconsin Department of Health Services Planned Corrective Action: DHS will change the Assistance Listing Number (ALN) for Temporary Assistance for Needy Families funds transferred to the Social Services Block Grant (SSBG) to the SSBG’s ALN, 93.667, for future Basic County Allocation contracts. Anticipated Completion Date: July 31, 2024 Person responsible for corrective action: Rebecca Mogensen, Section Chief Managerial Accounting, Bureau of Fiscal Services, Division of Enterprise Services rebeccaj.mogensen@dhs.wisconsin.gov

Planned Corrective Action: The DCF Bureau of Finance will update current subrecipient contracts containing Social Services Block Grant (SSBG) funds to include information required under 2 CFR section 200.332. The bureau will incorporate the SSBG fund source into existing procedures which identify the federal assistance listing numbers for subrecipient contracts. Anticipated Completion Date: The bureau will complete this work by June 30, 2024. Person responsible for corrective action: Rachelle Armstrong, Director Bureau of Finance Rachelle.Armstrong@wisconsin.gov

The Director of Nutrition Services, hired August 2023, has been trained on the verification process and procedures along with timeline compliance requirements.

Management concurs with the auditor's findings and recommendations. The management agent is making several organizational changes to help track and monitor compliance with contracts and agreements.

Contact Person Rhonda LaBatte, Comptroller Corrective Action Plan Management recognizes the deficiency and plans to change the process for how the College calculates the drawdown. This will eliminate an extra manual calculation step removing the potential for human error. Planned Completion Date for CAP Immediately

Finding: 2023-001 Condition: The Organization drew down the FY 2023 Bridge Access Program grant funds in full upon receipt of the award in the amount of $19,507 in advance of incurring federal expenses. The Organization identified allowable expenses which were incurred prior to receipt of the grant award and during 2024, management worked with HRSA to submit and obtain approval for a budget revision, enabling the Organization to apply the funds to the pre-award costs. lndividual(s) Responsible for Corrective Action: Kim Harrison, Chief Financial Officer Planned Corrective Action: 1. For any grant award, the person developing the budget, most often the CFO, will refer to the Grant Allocation file and ensure that any salaries charged to the grant are not covered by another grant for that same time period. 2. The CFO will review the budget with the Controller and Senior Accountant together and ensure the expenses to be charged to the grant and the time period for the grant is clear. 3. Prior to any HRSA drawdown, the CFO will request a list of expenses charged to the grant in question to ensure the money has been expended. 4. The CFO will share the drawdown data with the Controller. Anticipated Completion Date: Some of this is already occurring but the entirety of this will go into effect immediately.

This error occurred during a time of transition from one outsourced accounting firm and accounting system to another. The new outsourced accounting systems were not fully in place or automated at the time of the reporting error and there was no internal review process. The outsourced accounting firm is now fully transitioned, all systems are fully integrated with the accounting software, and the accounting team provides the program managers and organization managers with the reports needed to prepare drawdown requests. Cure HHT has developed and fully implemented a corrective action plan. The organization has communicated with the cognizant agency and all expenses eligible for submission for payment through grant funding will be submitted to and paid from the overdrawn funds. Once these funds are depleted, the organization will resume monthly draw submissions for all eligible expenses. The organization will reconcile all eligible expenses prior to requesting grant funds to avoid future duplicate and/or incorrect requests for grant funds. In addition, pending proper internal approvals of all submitted expenses, grant funds received will be dispersed within 3-7 business days from the date received.

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: A written federal policy has been prepared and is in the process of final acceptance by the Board of Selectmen. Anticipated Completion Date: June 2024 Contact: Austin Cyganiewicz, Town Administrator

Finding 2023-002: Internal Control over Compliance and Compliance with Cash Management Federal Programs ALN: 93.575, 93.596, 93.558 Criteria: In accordance with the grant agreement, and Division of Early Learning (DEL) Program Guidance 240.01, Cash Management Procedures, any advance that cannot be expended or offset by September 18, must be returned to DEL by September 30 of the following year. Condition: The Coalition did not timely remit the unexpended advance related to the 2022-2023 fiscal year in compliance with the grant agreement and DEL Program Guidance. Cause: Lack of effective controls surrounding cash management and review of controls to ensure compliance with grant and DEL Program Guidance. Effect: The Coalition did not timely remit the unexpended advance related to the 2022-2023 fiscal year to DEL until January 8, 2024. Recommendation: We recommend the Coalition implement procedures to ensure that all advances are reconciled on a monthly basis and remitted to DEL in accordance with the grant agreement and DEL guidance. Corrective Action Plan: ELC Management will make sure that measures are in place to ensure all advances are reconciled monthly and paid timely back to DEL. Responsible Party: Felicia Milton, CFO Anticipated Completion Date: March 2024

Federal Agency Name: Department of Education Pass-through Entity: State of Iowa Department of Education Federal Financial Assistance Listing #84.287 Program Name: Twenty-First Century Community Learning Centers Program Cash Management Material Weakness in Internal Control over Compliance Finding Summary: No support could be provided for the third quarter draw requests to substantiate a secondary level of review was completed prior to submission of the draws. Documentation to support the review of draw requests prior to submission was not retained during the transition period in the Finance Director role. Corrective Action Plan: SHIP had a one-month period of transition in 2023 in which there was no one in the Finance Director role. The Executive Director took over those duties and also contracted for higher level review and approval from a third-party accounting firm during the transitional period. All draws were reviewed, approved and even supported by the Executive Director and the contractors. SHIP did provide current auditors with the time tracking from the contracted accounting firm that they did review the 3rd quarter report, the report was just not officially signed off on. Staff requesting the draw forgot to get one approval signature for quarter three, all others were signed. Moving forward, SHIP will re-train staff to ensure all draws are signed off on. Responsible Individuals: Mindy Baylor - SHIP Finance Director Anticipated Completion Date: September 2023

FINDING 2023-003 Finding Subject: Title I Grants to Local Educational Agencies – Internal Controls Summary of Finding: The School Corporation did not have a properly developed internal control process over payroll transactions to ensure expenditures were allowed and in conformance with the cost principles. The Program Administrator reviewed a report attached to program reimbursement requests which showed the total amount paid from each fund and account; however, a detailed payroll report was not reviewed which would have identified the employee and related payroll benefits being paid from the grant fund. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 37 The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Superintendent will start to review the detailed payroll report posted to the Title I funds to match to the reimbursement request. Anticipated Completion Date: April 1, 2024

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

Recommendation: Request reimbursement of loans throughout the project.

Title V Grant Cash Management Planned Corrective Action: The University will implement and follow a formal process for making drawdowns when or after expenditures have been incurred and require that supporting documentation be retained to support compliance with cash management requirements. Person Responsible for Corrective Action Plan: Jim Pierce, Controller Anticipated Date of Completion: June 30th, 2024

Assistance Listings number and program name: 97.067 Homeland Security Grant Program Contact Person(s): Augustin Huerta Jr., Commander Anticipated completion date: April 30, 2024 Due to unexpected staff turnover, including the retirement of the office manager responsible for submitting Homeland Security Grant Program quarterly reports, the Sheriff’s Office ultimately relied on staff that was not properly trained nor have sufficient time to prepare the reports. The Sheriff’s Office has since improved the understanding of grant administration and submission process. The Sheriff's Office is working collaboratively to ensure accurate and timely submission of required documents to the grantor. Subsequent to June 30, 2023, the Sheriff's Office implemented calendar reminders of deadlines, statistic and financial reports are generated one week in advance of the due date, and quarterly reports are completed by the 13th day of each month. The Sheriff's Office will work with County finance staff to develop and implement written policies and procedures.

COLGATE UNIVERSITY. Corrective Action Plan – Finding 2023-001. Responsible Official – Kyle Dombrowski, Director of Tax and Financial Reporting. We will perform and document a review of reimbursement submissions before they are processed to ensure that reimbursement requests are not in excess of funds disbursed for the period. After the error in the Federal Direct Loan reimbursement for November 2022 was identified, we implemented a new requirement that the Director of Tax and Financial Reporting or the AVP/Controller must review the reimbursement request calculated by the Assistant Controller/Director of Grant Accounting before it can be processed. As of June 30, 2023, this review was fully implemented. Anticipated Completion Date: 3/27/2024.

2023-003 Cash Management / Period of Performance – Control Deficiency View of Responsible Officials Management appreciates the opportunity to respond to the findings of the audit. The Hawaii State Public Library System (HSPLS) makes every attempt to meet all federal laws and guidelines for funding that is received. Many factors outside our control directly impacted the timely payment of vendors as noted in the audit. Specifically: 1) Federal budget uncertainty; delay in receiving federal funding. For the past several years, Congress has not been able to pass a comprehensive federal budget, and instead has funded the Grants to States fund via continuing resolutions making it difficult to plan out expenditures with any certainty. In addition to lacking the certainty of when and/or if funding will be available, the Grants to States funds have not been released to states in a timely manner, including during the audit period. Instead of at the beginning of the federal fiscal year around October 1st, funding has been received months later, leaving States with a lot less time to procure, process and receive purchases. This means we do not have access to the funding for the full grant cycle and directly impacts if/when we are able to procure goods and services. 2) Supply chain and shipping issues. The State of Hawaii procurement requirements do not allow us to pay for goods and services until we receive the products or the services are rendered satisfactorily. HSPLS continues to face significant supply chain and shipping issues which affects the timely payment of vendors. As an island state in the middle of the Pacific Ocean, there are often delays in receiving an entire shipment on time in full, even post-pandemic. For large products or orders, sometimes the order and/or related parts are not shipped together further delaying completion of the order by the vendor and issuance of the invoice. In many instances, vendors do not send their invoices in a timely manner, preventing HSPLS from dispersing funds in a timely manner. 3) Federal agency guidance. We would also like to note that in the past, we have contacted our funding federal agency and let them know that we have had challenges with supply chain and shipping issues. We were advised that it was understood, and that as long as we had encumbered the funds by September 30, that we would be able to use the funding that was allotted to us even if the invoice is received after the close of the federal fiscal year. Corrective Action Plan We will do our best to continue to monitor and minimize any untimely disbursements of federal funds. Contact Person: Stacy A. Aldrich State Librarian Hawaii State Public Library System Anticipated Completion Date: Ongoing