Corrective Action Plans

Condition: During our testing of reimbursements, we noted that the District reported incorrect meal counts on their submitted reimbursement claim forms for the months of October 2022 and May 2023. We tested 2 months of reimbursement claims submitted by the District based on daily attendance records for breakfast and lunch. Of the 4 meal counts tested (2 months of breakfast and 2 months of lunch), we identified three variances where the count claimed for reimbursement did not agree to the underlying records per the school district. Plan: The District will ensure that supporting counts for each months claims are retained and properly reconciled to reimbursement requests. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Corrective Action to be Taken for Finding 2023-002 - Report Deadline Tracking o Catholic Charities will create a shared calendar for use by the Caseworkers, Program Director, Operations Director, and Fiscal Manager to document all deadlines of required reports and staff responsible for completing the reports. o This calendar will be monitored and updated by all staff with new arrival dates, quarterly report deadlines, close of case report dates, billing dates, Match Grant enrollment dates, 180-day budget deadlines, and 240-day budget deadlines. - Trainings o The Program Director will contact the staff of United States Council of Catholic Bishops, here after referred to as USCCB, when an individual begins employment and request a login and password into the USCCB resource website, MRS Connect, which has all USCCB trainings recorded and saved for staff to review. o Within 30 days of an employee’s start date the individual will participate in all approved USCCB training on reporting requirements. - Case File Review o Within the first week of arrival, the Program Director will review a case file. o Thereafter, a weekly case file review to monitor that case files have required documentation in accordance with the federal guidelines will be completed.

Corrective Action to be Taken for Finding 2023-001 - Food Purchases o The practice of purchasing food will be to have the Caseworker for each case take the family shopping to Giant Foods, where there is a Catholic Charities account. The Caseworker should shop with the family and then after the purchase is completed the clients signs the required RF-35 documentation and the receipt is then given to the Program Director to pay within the accounting software. A copy of the signed RF-35 and receipt will be made available for the client case file and for the Fiscal department for billing purposes. o If the option of shopping at Giant Foods is not available due to dietary restrictions or culture requirements, gift cards to these specific grocery stores will be made using a Catholic Charities credit card. The gift card will be given to the family for them to sign the appropriate RF-35. The Caseworker will then take the family shopping to ensure clients spend funds on federally approved food items. A copy of the receipt for the gift card purchases and the signed RF-35 as well will be made available for the client case file and for the Fiscal department for billing purposes. - Rent Payments o The practice will be to have a lease from the Landlord to issue a check for security deposit and rent. On the day of move in, the lease will be signed by the client, the RF-35 will be signed, and then the check will be released to the Landlord. Once the lease is signed, a copy of the lease and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. o The practice when a client is going to be living with their US-tie is that a letter of agreement between the case’s primary applicant and the US-tie will be established explaining the amount the client is responsible for paying for rent and utilities. That agreement will then be signed by the client, the US-tie, and will be witnessed by a third party (Caseworker, Program Director, Operations Director). That agreement will then be utilized as the documentation for requesting rent payments on behalf of the client along with the signed RF-35. A copy of this agreement and signed RF-35s will be made available for the client case file and for the Fiscal department for billing purposes. o The practice when two unrelated clients are going to be living together is as follows: all appropriate required documentation establishing the responsibilities between the two clients will be established. The lease and all agreements will then be signed and will be witnessed by a third party (Caseworker, Program Director, Operations Director). The lease and signed agreement will then be utilized as the documentation for requesting rent payments on behalf of the clients along with the signed RF-35s for each case. A copy of the lease, this agreement, the signed RF-35s will be made available for each of the clients’ case files and for the Fiscal department for billing purposes. o Rent payments made after the initial payment will be made in the amount of the client’s rent according to the lease and will be accompanied by a signed RF-35. A copy of each signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. - Utilities o Educate the clients to turn utility bills into the Caseworker and have the client sign a RF-35 in the amount of the utility bill. The Caseworker then gives the utility bill to the Program Director to enter the invoice into the accounting software for payment. A copy of the utility bill and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. o If the Landlord pays the utilities and seeks reimbursement, the landlord will provide a copy of an invoice for the client to turn into the Caseworker and have the client sign a RF-35 for the amount of the utility bill. The Caseworker then gives the invoice to the Program Director to enter the invoice into the accounting software for payment. A copy of the invoice and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes.

Finding #2023-002 – Residual Receipts Reserves and Tenant Security Deposits Responsible Individuals: Mary R. Duncan, CPA, CGMA, Chief Financial Officer Corrective Action Plan: The Organization has implemented practices for deposits of residual receipts reserves to be made within 60 days of year-end and proper collection of security deposits, as required by U.S. Department of Housing and Urban Development. Anticipated Completion Date: Fiscal year 2024, as a new Equipment and Facilities Operations Manager was hired.

The District agrees with the finding and will work with TDA to develop a plan to spend the excess fund balance on approved NSBLP expenditures, and maintain an appropriate amount of fund balance in the future.

Management’s Corrective Action Plan Management takes its responsibility to maintain effective internal control over the federal award that provides reasonable assurance that the agency is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award seriously and gave significant consideration to what additional controls would be effective to ensure the proper amount of indirect costs are charged to all federal grants. To prevent another occurrence, the organization will: On October 17, 2023, the agency refunded the indirect costs that were overbilled in error. By December 31, 2023 and annually thereafter, the Director of Grants Management will provide training and technical assistance to all Grant Specialists and Grant Accountants on allowable costs, including detailed training on proper determination of indirect costs for each grant. This training will also be incorporated into the onboarding process for any new grant staff. Continue its current policy that the Director of Grants Management complete a detailed review of each grant reconciliation monthly, to ensure all costs charged to the grant are reasonable and necessary for the performance of the award. This review will include appropriate tests of indirect costs including ensuring the appropriate indirect cost base is used, all items required to be excluded from the indirect cost base are excluded, and the appropriate indirect cost rate is applied to the indirect cost base. Continue its monthly analytical review to test the reasonableness of grant revenue relative to grant-funded expenditures. At least twice annually, the Controller will complete a second detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. At the end of each award cycle, the CFO will complete a third detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. Going forward, should indirect rates or methodologies change for any award, the CFO will review the grant reconciliation the first month following the effective date of the change to ensure the change has been properly implemented.

Corrective Action Plan The District will implement procedures to ensure planned capital expenditures, using Elementary and Secondary School Emergency Relief Funds, receive approval by either the U.S. Department of Education or the Texas Education Agency prior to the actual purchase. Person(s) Responsible Assistant Superintendent of Business & Finance Anticipated Completion Date Fiscal year 2023-2024

Auditor Recommendation Recommendation: We recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers and Josh Warner (management agent) will establish a review process that will include making sure all payments are recorded within the proper period. 3. Official Responsible for Insuring CAP Sara Wohlers is the official responsible for insuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP Julie Baruch (board chair) and Sara Wohlers will be monitoring this plan.

Auditor Recommendation Recommendation: We recommend that the Organization verifies all requests for reimbursements are received in a timely manner. We also recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers and Josh Warner (management agent) will establish a review process that will include making sure all payments are recorded within the proper period. It will also include ensuring all HUD/HAP funds are received in full during that period and any short falls or overages are identified within the proper period. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP John Frank (board chair) and Sara Wohlers will be monitoring this plan.

Finding 2023-004 Name of Responsible Individual: Demetrius Carmichael, AVP Finance and Controller Corrective Action: We understand the requirement of disbursing Title IV funding to eligible students and parents and the requirement to make disbursements as soon as administratively feasible, but no later than 3 business days following the receipt of funds and eliminating excess cash balance within the next 7 calendar days. In this case, the School received funds from the student from unknown sources, and the School submitted the funds to the ED on behalf of the student at the student’s request to lower outstanding educational debt. We discuss the importance of lowering education debt during our debt counseling sessions and encourage students to return funds not needed due to subsequent scholarships or family support. We have not found guidance that will support the requirement to submit funds to the ED within the 3 business days plus 7 calendar days that are earned and provided by the student to submit to the ED under the cash management ruling. Anticipated Completion Date: March 1, 2024

Finding Synopsis: The District has inadequate controls over reviewing and approving quarterly "historical expenditure reports" filed with the Illinois State Board of Education. Action Steps: The District intends to fully implement the recommendation in FY2024, as corrective action was not taken until midway through FY2023.

The Blood Bank added review and approval processes to ensure only allowable charged are included in the MTDC subject to the indirect cost rate.

1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding The Academy will adopt the referenced policies to achieve compliance with Uniform Guidance. 3. Official Responsible Samuel Yigzaw, Executive Director, is the official responsible for ensuring corrective action. 4. Planned Completion Date June 30, 2024 5. Plan to Monitor Completion The Board of Education will be monitoring this Corrective Plan.

Name of Contact Person: David Richmond, Interim Director Corrective Action/Management's Response: In response regarding the above mentioned finding for Moore County Social Services, please see the corrective action plan below: Training: • Accounting will develop and implement annual training for applicable DSS staff in conjunction with State required day sheet training. • This training will also be given to all new applicable staff in the orientation process. • DSS Accounting will maintain a record of all staff completing the training. Internal Reviews/Auditing by Unit Supervisors: • Each biweekly payroll is currently approved by supervisors prior to processing. • After each payroll the day sheets for that biweekly period will be reviewed by the supervisor to ensure proper coding and matching time to the payroll reports for each employee in their unit. • When this process is complete, they will send a report to DSS Accounting with their findings. Internal Reviews/Auditing by DSS Administration • DSS Accounting will monitor each reporting period to ensure each supervisor has submitted their bi-weekly report. • DSS Accounting will maintain files with these reports for additional follow-up as needed. • DSS Accounting and Payroll staff will work with necessary staff that have discrepancies to ensure corrections are completed. • In addition, at the end of each month (prior to submission of the 1571 State reimbursement report) DSS Accounting will spot check 3 random Services records for accuracy. Findings will be reported, and corrections completed/processed by the 15th of the month of review. Proposed Completion Date: The expected completion date to have corrective action implemented is December 15, 2023.

Nutrition Cluster – CFDA Nos. 10.553 and 10.555 Significant Deficiency: See Finding 2023-002

Nutrition Cluster – CFDA Nos. 10.553 and 10.555 Name of contact person – David Gates, Business Manager Recommendation: We recommend the Food Service Director more closely review all meal count information entered for reimbursement prior to submitting each monthly claim to ensure accuracy and consistency with supporting documentation. We recommend that the Food Service Director review all monthly claims filed in fiscal year 2023-24 available for revisions to ensure reports were accurately filed. Further, we recommend that District management periodically monitor claim submissions for accuracy. Action Taken: Management agrees with the recommendations. The Food Service Director has reviewed all monthly claims submitted in school year 2023-24 and found no errors requiring revision. Further, management will implement a plan to periodically review claim submissions for accuracy. Proposed Completion Date: January 31, 2024

A. Audit Finding No. 2023-01 Statement of Condition: The Project did not deposit 2022 surplus cash into residual receipts account within 90 days after the fiscal year end. Criteria: Pursuant to HUD Regulations, the Project is required to deposit surplus cash into a residual receipts account within 90 days after fiscal year end. Effect of Condition: This is a violation of the HUD Regulations. Cause of Condition: The procedures in place to ensure the surplus cash deposit was made timely were not consistently followed. Recommendation: No action is needed, as the required surplus cash deposit has already been made to the residual receipts account. Response: See Corrective Action Plan. B. Comment on Findings and Recommendations We concur with the auditors' finding that the project did not make the full residual receipts (surplus cash) deposit within 90 days of the March 31, 2022 fiscal year-end. C. Actions Taken or Planned The Director of Accounting and the Property Accountant will review and verify the balance of the project's surplus cash and ensure the residual receipts deposit is made within 90 days of the fiscal year-end in accordance with current regulations.

A. Audit Finding No. 2023-01 Statement of Condition: The Project did not remit residual receipts balances in excess of $250 per unit to HUD BY THE Project Rental Assistance Contract renewal date. Criteria: Pursuant to statutory language from the Consolidated and Further Continuing Appropriations Act, HUD is required to recapture residual receipt balances that are in excess of$250 per unit. The funds must be remitted to HUD upon "termination" of the Project Rental Assistance Contract. Termination is defined as expiration of the contract term, which for most PRACs falls on contract renewal date. Effect of Condition: This is a violation of the HUD Regulations. Cause of Condition: The procedures in place to ensure the excess residual receipts remittance was made timely were not consistently followed. Recommendation: No action is needed, as the required return of excess residual receipts has already been remitted to HUD. Response: See Project's Corrective Action Plan. B. Comment on Findings and Recommendations We concur with the auditors' finding that the balance in excess residual receipts was above the limit allowed by HUD and was not remitted per HUD's guidelines. C. Actions Taken or Planned The Director of Accounting and Property Accountant will review and verify the Residual Receipts balance, determine amount eligible for retainage and return the remainder to HUD in accordance with current regulations.

A. Audit Finding No. 2023-01 Statement of Condition: The Project did not remit residual receipts balances in excess of $250 per unit to HUD BY THE Project Rental Assistance Contract renewal date. Criteria: Pursuant to statutory language from the Consolidated and Further Continuing Appropriations Act, HUD is required to recapture residual receipt balances that are in excess of $250 per unit. The funds must be remitted to HUD upon "termination" of the Project Rental Assistance Contract. Termination is defined as expiration of the contract term, which for most PRACs falls on contract renewal date. Effect of Condition: This is a violation of the HUD Regulations. Cause of Condition: The procedures in place to ensure the excess residual receipts remittance was made timely were not consistently followed. Recommendation: No action is needed, as the required return of excess residual receipts has already been remitted to HUD. Response: See Project's Corrective Action Plan. B.Comment on Findings and Recommendations We concur with the auditors' finding that the balance in excess residual receipts was above the limit allowed by HUD and was not remitted per HUD's guidelines. C. Actions Taken or Planned The Director of Accounting and Property Accountant will review and verify the Residual Receipts balance, determine amount eligible for retainage and return the remainder to HUD in accordance with current regulations.

A. Audit Finding No. 2023-01 Statement of Condition: The Project did not deposit 2022 surplus cash into residual receipts account within 60 days after the fiscal year end. Criteria: Pursuant to HUD Regulations, the Project is required to deposit surplus cash into a residual receipts account within 60 days after fiscal year end. Effect of Condition: This is a violation of the HUD Regulations. Cause of Condition: The procedures in place to ensure the surplus cash deposit was made timely were not consistently followed. Recommendation: No action is needed, as the required surplus cash deposit has already been made to the residual receipts account. Response: See Corrective Action Plan. B. Comment on Findings and Recommendations We concur with the auditors' finding that the project did not make the full residual receipts (surplus cash) deposit within 90 days of the March 31, 2022 fiscal year-end. C. Actions Taken or Planned The Director of Accounting and the Property Accountant will review and verify the balance of the project's surplus cash and ensure the residual receipts deposit is made within 90 days of the fiscal year-end in accordance with current regulations.

A. Audit Finding No. 2023-01 Statement of Condition: The Project did not remit residual receipts balances in excess of $250 per unit to HUD BY THE Project Rental Assistance Contract renewal date. Criteria: Pursuant to statutory language from the Consolidated and Further Continuing Appropriations Act, HUD is required to recapture residual receipt balances that are in excess of $250 per unit. The funds must be remitted to HUD upon "termination" of the Project Rental Assistance Contract. Termination is defined as expiration of the contract term, which for most PRACs falls on contract renewal date. Effect of Condition: This is a violation of the HUD Regulations. Cause of Condition: The procedures in place to ensure the excess residual receipts remittance was made timely were not consistently followed. Recommendation: No action is needed, as the required return of excess residual receipts has already been remitted to HUD. Response: See Project's Corrective Action Plan. B. Comment on Findings and Recommendations We concur with the auditors' finding that the balance in excess residual receipts was above the limit allowed by HUD and was not remitted per HUD's guidelines. C. Actions Taken or Planned The Director of Accounting and Property Accountant will review and verify the Residual Receipts balance, determine amount eligible for retainage and return the remainder to HUD in accordance with current regulations.

Condition: The District did not review the general ledger and ISBE expenditure reports to ensure grant expenditures were posted and reported correctly; Plan: District has implemented a change in staffing and its review procedures have been augmented to correct this condition; Anticipated Date of Completion: 10/31/2023; Name of Contact Person: Ivy Fleming; Management Response: N/A.

Condition: The District did not review the general ledger and ISBE expenditure reports to ensure grant expenditures were posted and reported correctly; Plan: District has implemented a change in staffing and its review procedures have been augmented to correct this condition; Anticipated Date of Completion: 10/31/2023; Name of Contact Person: Ivy Fleming; Management Response: N/A.

Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Noncompliance Finding/Significant Deficiency; Activities Allowed or Unallowed Compliance Requirement Corrective Action Plan: The Medical Center will implement procedures to ensure that future reporting of federal expenditures are reduced by an amount that other sources have reimbursed or are obligated to reimburse using actual Medicare cost report percentages to compute the amount that has been previously reimbursed by Medicare. Anticipated Completion Date: The Medical Center intends to implement this immediately which will apply to any future reporting periods.

Finding 2023-004 Personnel Responsible for Corrective Action: Assistant Comptroller – Brian Huggins Anticipated Completion Date: December 2023 Corrective Action Plan: The University has implemented a process to reconcile all expenditures from federal funding sources prior to being drawn down. This exception was addressed subsequent to the drawdown and detective control addressed it after the fact. The revised preventive control is in place and no subsequent issues were noted.