Corrective Action Plans

The School District concurs with the findings reported in Finding 2023-004 and does not dispute the details reported under the Criteria or Specific Requirement section, Condition section, and Effect section of the report. Your findings identify charging of unallowable costs that involved federal funds received by the School District. You noted that the unallowable costs involved payment of employment compensation to an employee on multiple dates, during times and for reasons that were suspect and unauthorized. The School District also concurs with the guidance you provide in the Recommendation section of the report. Corrective actions are already being taken, and training has already begun. The School Board will adopt appropriate policies to ensure appropriate oversight over the manner in which funding is expended for employee compensation, including situations when the sources of funding involve federal awards that obligate the School District to meet specific control requirements. Currently, the School District is reviewing all uses of federal funds, starting with Title 1, the 21st Century Center Learning Center Cohort, and the Education Stabilization Fund. The following additional corrective steps will be taken by the Superintendent: 1. All change of job assignments, program assignments and/or employee compensation must be approved by the Superintendent and memorialized in writing as evidence of approval. The Human Resources Department shall cause the necessary documentation containing the Superintendent's approval to be prepared, signed, and maintained in employee payroll and personnel records, and ensure that employee compensation is paid when owed for the appropriate amount(s). 2. The Superintendent will require the employees, supervisors, and management operating or overseeing individual programs and operations to become and remain familiar with their respective program and/or operation requirements, including those that govern which costs are allowable/authorized and steps required to demonstrate compliance. 3. In light of the Findings, the Superintendent will also identify one or more key administrative staff members who will be tasked with overseeing the use of federal funds for Title I, the 21st Center Learning Center Cohort, and the Education Stabilization Fund. 4. The Superintendent will direct staff to immediately confer with general counsel and with appropriate federal or state agency points of contact when compliance steps or obligations are unknown or require clarification. 5. Individuals compensated through federal funds shall be obligated to comply with applicable rules as a condition of employment. No staff member will have lone or sole responsibility for administering or overseeing administration and/or payment of their own compensation from federal funding sources. 6. At least twice annually, the Superintendent shall direct a review of wheterher funds have been appropriately reused for costs that are authorized and allowable. Title I, the 21st Century Center Learning Center Cohort, the Education Stablization Fund, and other programs/operations where noncompliance is known or suspected will be reviewed at least four times during the following school year, or more frequently when deemed necessary by the Superintendent. Additional program or operation areas may be identified for review through random sampling. Training on the rules governing authorized and allowable costs and expenditures of federal funds shall occur by August 12, 2024, prior to the start of the 2024-2025 school term. Training will be conducted by the Superintendent (Sam Moore), CFO (DaVona Howard), general counsel (Doug Lawrence), members of the School District's business office staff and others designated by the Superintendent.

Response - Management agrees with the recommendation and will implement the necessary components of the recommendation. Accounting policies and procedures have been developed which pertain to our subrecipient reporting and monitoring and are in the process of being implemented. Also, by adding the bookkeeper in March of 2021, receipt spot checking of subrecipients on a monthly basis has been implemented to help ensure compliance.

Response - Management agrees with the recommendation and will continue to work at implementing the necessary components of the recommendation. New board members have come aboard and are working to implement changes. A finance committee has been established (independent of the CEO) and their role will be to ensure the adoption and recommendations of the CAP to ensure transparency and accountability. A bookkeeper was added March 2021 as another tier of financial control, along with CEO handing over some financial duties to the financial advisor and bookkeeper. Regular meetings are held by bookkeeper, financial advisor, and finance committee member of the Board. Please note though, that the small size of our staff, precludes the total elimination of this weakness.

CAMcare has made significant changes to the patient payment collection process. Updates were made to the Patient Payments, Refusal to Pay, Waiver/Reduction of Charges Policy, Sliding Fee Scale Policy, and Patient Payments Policy, and a Patient Payments Policy was introduced. The new EMR system allows for individual Patient Service Representatives (front desk personnel) to monitor management's adherence to collection efforts.

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all the LCTS reports submitted by each collaborative member each quarter for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following: · Increased scrutiny of claims based on claims volume. · Issued a moratorium on new provider registrations for impacted provider types · Prevented Reimbursement of Claims for Impossibly Rendered Services · Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment · Set thresholds for services to initiate a prepayment review. · Required claims to be billed for specific dates of service rather than ranges. · Flagged claims for services of the same style/overlapping codes. · Created a prepayment review process for providers utilizing suspicious billing practices. · Eliminated retroactive billing. · Credible Allegation of Fraud (“CAF”) suspensions include both provider entities and owners/ behavioral health (“BH”) practitioners. · Implemented ID.Me identity verification for AHCCCS Online. · Required providers to disclose any third-party billing relationships. · Behavioral Health Providers are now considered high-risk provider types for provider enrollment. · Per Diem codes have been set to only be able to be billed once per day. · Practitioners, including Behavioral Health Technicians, can no longer be patients at the same provider. · Worked with the Arizona Corporation Commission to flag suspicious registrations. · Ensured AHCCCS coding adhered to National Correct Coding Initiative (“NCCI”) standards and confirmed no edits had been turned off. · Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. Stop gap strategies in process include, but may not be limited to, the following: · Implementing eligibility integrity requirements for AIHP enrollment. · Linking BHP to BH companies they work for. · Link BH Providers to BH facilities they work at. · Conduct onsite quality of care reviews for patients in treatment longer than 90 days. · Require medical records to define specialized services. · Implement a new pre/post pay claims system. · Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements. AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.

Assistance listing numbers and program names: 84.425D COVID-19 - Education Stabilization Fund—Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425R COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRSSA EANS) Agency: Arizona Department of Education (ADE) Name of contact persons and titles: Michelle Udall, ADE Associate Superintendent Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: November 30, 2024 Agency’s response: Concur ESSER Reporting will be validated by at least 2 people before submitting to U.S. Department of Education. This validation will include the reconciliation of data from the LEA to ADE's report. ADE is finalizing policies and procedures for validating the data prior to submission. ADE has already begun implementing a reconciliation system to ensure accurate reporting in the EANS annual performance report. This system tracks obligations by category, expenses, and appropriate earmarking of nonpublic schools (e.g., DUNS/UEI, grades served). ADE is finalizing general policies and procedures for how this data is compiled, interpreted, and reported based on the initial implementation and corrections of the EANS program.

The following steps have been taken or will be taken to address Finding 2023-001: Shalom Health Care Center, Inc. has made some changes in how the draws are done with each payroll versus previously per month. Shalom has also hired new staff to help keep up with the grants and payrolls and entering data into the accounting system, as we had previously had turnover and were using temp services for some of the prior year. Contact Person: Michael A. Nino, Chief Financial Shalom Health Care Center, Inc. anino@shalomhealthcenter.org 317-269-7198

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

Management acknowledges that improvements were necessary in assuring that drawdowns of grant funds are in compliance with regulations. Accordingly, drawdowns of grant funds will be more aligned with bi-weekly and/or monthly expenditures as supported by an analysis of payroll and accounts payable system activity by the Chief Financial Officer prior to authorizing any drawdowns. This process revision will be implemented no later than March 31, 2025.

Finding Number: 2023-003: Allowable Costs – 1 of the 25 payroll transactions tested, the amount of time charged to the grant did not agree wo the employee’s timesheet. Planned Corrective Action: Turning Point has as an established Grant Activity Reports – Time and Effort Recording policy. We will ensure strict adherence to our policy by verifying that all hours charged to grants match employee timesheets. Staff will receive additional training on proper reporting procedures, and monthly audits will be conducted to ensure compliance moving forward. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance

Auditor’s Recommendation: The Organization document internal control over compliance procedures and document written procedures to ensure compliance with 2 CFR 200.305. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

Management will continue to attempt to contact the Project's HUD Project Coordinator in order to obtain the required approval for the withdrawal from the reserve for replacements account

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

2023-003 – ALN 14.850 – Public & Indian Housing – Activities Allowed or Unallowed Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised HUD that it is in the process of marketing and selling its affordable property portfolio. The management company has reached an agreement in principle with a buyer for the sale of a significant portion of its affordable property portfolio. The buyer has significant experience in the affordable housing industry and is well-positioned to own and manage these properties. The parties are in the process of drafting all necessary documents and will work with HUD on all necessary documentation and approvals promptly once the underlying documents are fully negotiated. The management company is confident that there will be sufficient funds at the conclusion of the collective transactions with the buyer for the (re)payment of amounts to address the Findings identified herein. The management company anticipates closings by the end of 2024.

Corrective Action Plan: The Fogarty Center ("the Center") had this finding in 2022-02 as well. The Center reported in the 2022 corrective action plan, that the Center was in contact with the State of Rhode Island representative regarding these items throughout the year; however, some of the email conversations occurred after the deadlines had passed. At the end of the contract, the State of Rhode Island did send an email stating that they understood the reasons for the delays and that the reports were accepted as submitted and are in compliance.

Finding 2023-003: Internal Control Deficiency Cash Management Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: There is no evidence of internal controls in place to ensure that requests for reimbursement are based on expenses paid for by AdviseWell. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-02 finding, to ensure drawdowns are made on expenses paid for by AdviseWell and not on unpaid obligated funds before proceeding by having a secondary review by appropriate staff. Documentation will be maintained to support those payments preceded drawdowns and secondary review has been completed. Management will ensure all duties are appropriately segregated. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

The University agrees with the finding. The University has had a significant amount of staff turnover and reorganization in FY 2023 in the financial aid office. The Interim Director of Financial Aid is collaborating with the controller’s office to make sure that the University has internal controls in place over Federal programs to assure that the Pell reporting requirements are executed in compliance with Federal statutes, regulation and terms and conditions of the federal award. The University is investing in making sure that the Financial Aid Office is staffed and create policy and procedure that assure that we improve internal controls on the Pell process.

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another two disbursements included expenses for other clubs outside the grant agreement that was charged to the grant. The last disbursement was missing supporting documentation for the costs charged to the grant. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that the Organization verify that costs submitted for reimbursement are valid and allowable expenses. Additionally, the Organization needs to properly allocate costs in accordance with the grant agreements. Corrective Action. Management concurs with the finding. The Organization will ensure valid and allowable expenses, including proper allocation of costs, are remitted through enhancement of the current review processes. Responsible Person. Stacy Holman, Chief Financial Officer. Anticipated Completion Date. December 31, 2024.

Upon discovery (during 2023) of the failure of the College to determine the amount of excess cash it had retained, and to timely return it ot the Secretary of Education, the College immediately implemented a corrective action plan that included a strengthening of procedures with corresponding internal controls, and the immediate return of any excess cash. The Correction Action Plan included Student Financial Aid training sessions for Business Office Staff responsible for Title IV cash management oversight. To further address this situation, the College engaged an independent consultant to assist in the review and revisiion of existing Business Office Title IV policies and procedures, which were immediately adopted and implemented.

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

The County Clerk & Treasurer are continually looking for effective control over SEFA funds. The county has hired a part-time employee to help in the Treasurer's office to continue these efforts, which will include a new filing system for SEFA funds.

Management recognizes the importance of record retention and filing systems. When management became aware of the misplaced records related to wage and hour reports, management undertook a detailed review of the compliance requirements in the grant agreement and examined expenditures under the federal award to ensure the entity is in compliance with laws and regulations