Corrective Action Plans

Audit Finding Reference: 2022-005 Limit Federal Cash on Hand (Significant Deficiency) Planned Corrective Action: The district is aware of this finding and will be taking steps to address this in the coming months. The City needs to decrease the cash balance in the school lunch fund so that it falls within acceptable Federal guidelines. Name of Contact Person and Completion Date Kevin McHugh, City of Lynn School Business Manager December 31, 2024

Management Response / Corrective Action: Rowan-Salisbury School hired a new payroll director in May of 2022 who identified the cause for the above noted discrepancy, noting the team was overbudgeting taxes on staff personnel payments due to employees who opt in for the ?pre-tax contributions.? When an employee enrolls in the ?pre-tax contributions,? the budgeted amount for Social Security/Medicaid is adjusted so that the rate no longer meets the 7.65% calculated amounts for all employees. As a result, the team has gone through each month?s drawdown and determined that $7,793.78 was over budgeted and we are correcting that in our February 2023 drawdown by reducing the drawdown by $7,793.78. We have also adjusted our budget calculation so that we are properly accounting for those employees who opted for ?pre-tax contributions? going forward.

1. Receive the CACFP check, and book all revenue to CACFP Budget line(5230) 2. Generate an invoice based on the IPV tool and rates laid forth in EUSD inter program agreement 3. Create JE debiting CACFP(5320) expense account and crediting NSLP(5310) expense account These steps will track funding sources and revunes by progrm in which it follows Child and Adult Care Food Program, Child Nutrition Cluster, National School Lunch Program Guidelines. Contacts: Bao Ho and Anna Scimone

Finding Reference Number: 2020-01 ? Material Weakness in Internal Control Over Financial ReportingDescription of Finding:The Town should have internal controls over financial reporting that provides reasonable assurance that the accounting records can be relied upon and used to prepare the basic financial statements and related notes in conformity with accounting principles generally accepted in the United States of America. Having effective internal controls and procedures over financial reporting will ensure that the financial information is being accurately presented and allow the governing body to make sound financial decisions on a timely basis.There were multiple rounds of revisions to the trial balances before a final trial balance was able to be provided. Significant effort was expended identifying required information and corresponding adjustments and reconciliations. The audit process was delayed while Town personnel and audit staff worked towards a complete set of financial statements. Material journal entries were required to ensure the financial statements were properly stated in accordance with Generally Accepted Accounting Principles.Some of the deficiencies in the Town?s internal control over financial reporting processes are described below:o The interfund balances between the General Fund and the other funds were not reconciled on a timely basis.o The Town and the Board of Education do not currently have formalized accounting policies and procedures manuals detailing the daily, monthly, quarterly, and year-end closing procedures.Statement of Concurrence or Nonconcurrence:The Town and Board of Education agrees with this finding.Corrective Action:The Town agrees with the finding regarding internal control over financial reporting. The Town has a new Finance Director and Treasurer and has engaged additional accounting assistance to develop policies and procedures and ensure that controls are in place to ensure that the financial records are reported accurately and timely.Name of Contact Person:Cynthia Varricchio, MBA, Director of Finance and School Business Operations, (860) 889-6098, varricchioc@prestonschools.orgProjected Completion Date: June 30, 2023

The Auditor's office with work with the Community Transportation Connection and provide training on the importance of grant reporting and tracking.We will also explain and show how using the ERP system can aid in the tracking of expenses and help to ensure better accounting for grants.The Auditor's office will implement an additional level of control for this department's grant award, reporting, and reimbursements to be reviewed by our office for accuracy.Use online state and federal agency websites to verify grant awards amounts and disbursements.

View of Responsible Officials and Planned Corrective ActionThe Organization is planning to assign responsibility of grant compliance to someone in the Organization.

Assistance Listings number and program name: 84.374 Teacher and School Leader Incentive GrantsDepartment: Maricopa County School SuperintendentContact Person(s): Matt Morales, Deputy Superintendent of Schools, Maricopa County School Superintendent?s Office.Anticipate completion date: June 30, 2023Concur: The Maricopa County School Superintendent?s Office (Superintendent's Office) acknowledges the human error that was made with the May 2022 drawdown. Once the error was identified, the Assistant Superintendent for Economic Management, along with the grant project leader and the Human Capital Management Administrator, contacted the program officer at the US Department of Education and notified them of this error. The overdraw was resolved as there were additional program costs prior to the grant?s closeout in September 2022, and all program expenditures and reimbursements were reconciled prior to closeout. The Superintendent?s Office has implemented updated procedures including the addition of one more person to the reimbursement request approval process who will ensure that program expenditures are reconciled based on the fund balance report from the financial system for the correct time frame.

Assistance Listings number and program name: 14.231 COVID-19 Emergency Solutions Grant ProgramDepartment: Maricopa County Human ServicesContact Person(s): Nicole Forbes, Finance Manager, Human Services Department.Anticipated completion date: April 1, 2023Concur: Maricopa County Human Services Department (HSD) concurs with the finding. HSD will develop and implement written policies and procedures to pay subrecipients for program expenditures they incur and request reimbursement for within the required 30 days of receiving their completed reimbursement requests. HSD will also develop a tracking system to ensure payments are released within 30 days upon receipt of a completed reimbursement request, which will document attempts to obtain a completed reimbursement request.

FINDING # 2022-024No finding in prior yearThe New Jersey Department of Labor and Workforce Development (DLWD) has a policy in place for processing tuition reimbursements that are performed by the Department?s Accounts Payable unit. The policy was reviewed by the Office of Finance & Accounting (F&A) and internal control procedures were enhanced to ensure that fiscal cutoff measures were appropriately addressed. Tuition reimbursement procedures include having the requests forwarded to the responsible Supervising Analyst in the Appropriations/Accounting unit for final review and approval to ensure the proper fiscal period is charged. The correcting transactions were completed during the Single Audit timeframe to remediate the findings by charging and reimbursing the proper fiscal year accounts. The DLWD will continue its efforts to ensure compliance and that all charges applied to Federal awards are within the specified period of performance going forward.COMPLETION DATE/CONTACT PERSON December 31, 2023Ruslana Nagorniak(609) 984-7678Ruslana.Nagorniak@dol.nj.gov

FINDING # 2022-018No finding in prior yearThe DCA staff responsible for the LIHEAP cash management function retired prior to this audit period without a proper transition of these tasks and there was also a delay in refilling the position. As recommended, the DCA has reviewed current procedures and controls regarding cash drawdown approvals and has developed a Policy Memo that details the Payment Management System (PMS) drawdown procedures going forward. For each request made, a Contract Administrator will produce a Business Object report for all transactions to be included in the drawdown and will send the report to the Program staff for review and approval that the amounts contained in the report are correct. Once the Program staff review is complete, the approved Business Object report will be forwarded with a cover email to the Division Fiscal Unit staff responsible for drawing down the funds in PMS for final processing.COMPLETION DATE/CONTACT PERSON March 27, 2023Fidel Ekhelar(609) 815-3905Fidel.Ekhelar@dca.nj.gov

2022-027. Working Capital Reserves in Excess of Federal GuidelinesState Agency: Department of Government OperationsFederal Program: VariousDivision of Purchasing and General ServicesCooperative Contract Management ? Public entities in Utah rely on the Division of Purchasing and General Services (State Purchasing) to maintain the cooperative contract program to help with public procurement in Utah. The usage of state cooperative contracts by public entities increased dramatically this past year resulting in a corresponding increase in the collection of administrative fees. State Purchasing still continues to decrease the administrative fees on state cooperative contracts as each contract expires and is rebid. This is a slow process since State Purchasing has nearly 1,200 cooperative contracts that expire only every five years. Although State Purchasing is allowed under law to collect up to a 1.0% administrative fee on each cooperative contract, currently the average administrative fee is 0.38%. State Purchasing has also requested the Utah Legislature to appropriate out a portion of the excess reserves in this fund in fiscal year 2023. The calculation for the refund of the federal portion of this transfer out will be submitted to Cost Allocation Services for review and approval when this transfer is complete.Federal and State Surplus Property - Due to the completion of the new Utah State Prison, Surplus Property anticipates relocating by the end of calendar year 2023. At that time, Federal and State Surplus will need to use their working capital reserve funds for the costs of moving to and furnishing their new location. These additional expenses should eliminate these excess reserves by December 2023.Contact Person: Windy Aphayrath (waphayrath@utah.gov), Division Director, Division of Purchasing & General ServicesAnticipated Correction Date: December 30, 2023Purchasing Cards ? The Division of Finance (State Finance) is in the process of implementing a new travel and expense reporting system for all State agencies to simplify travel approvals, travel reimbursements, and reduce the administrative burden for the purchasing card (p-card) expense reports on State agency personnel. To cover system implementation costs, State Finance elected not to distribute the rebates received from U.S. Bank related to State agency p-card spending for calendar years 2021 and 2022. Rebates were still passed through to participating entities external to the primary government. The anticipated completion date for the system is the end of calendar year 2023. State Finance will review annually the costs of the system, develop a cost allocation strategy between the Travel and P-Card programs, adjust travel rates to cover the travel program?s ongoing costs, and distribute any remaining p-card rebates to State agencies respective to their spend. This effort will reduce and/or eliminate excess federal reserves by the end of fiscal year 2024.Contact Person: Allyson Branch (abranch@utah.gov), Manager of Accounting Operations, State Division of FinanceAnticipated Correction Date: June 30, 2024Division of Risk ManagementWorkers? Compensation Fund & Property? We requested approval in the current legislative session to transfer $2,000,000 out of the Workers Compensation Fund and into the Property Fund. We will submit the calculation for the refund of the federal portion of this transfer to Cost Allocation Services for their review and approval when this transfer is completed. Additionally, in FY 2023, the premiums charged for workers compensation have been reduced 26% from $0.61 per $100 to $0.45 per $100. The property commercial insurance market and the Property Fund are experiencing enormous year-over-year premium increases. We have seen a doubling of premiums in the last five years, from $14,000,000 to $28,000,000. Additionally, the budget process requires that we project funding 1-2 years in advance before we can enact rate increases to pay the excess insurance premiums that are due each fiscal year. As such, we deem it important to maintain a retained earnings balance in the Property Fund to be able to sustain the Fund's ability to pay for increasing premiums.Contact Person: Rachel Terry (rachelgterry@utah.gov), Division Director, Division of Risk ManagementAnticipated Correction Date: June 30, 2023Division of Technology ServicesPrint Services ? DTS currently projects Print Services retained earnings will decrease by $181 thousand in fiscal year 2023. The Print Services rate was set lower than the cost to provide this service in fiscal year 2024. DTS plans to annually review and adjust rates and issue mid-year rebates, if necessary, to bring DTS Print Services into compliance with federal excess reserve guidelines by the end of fiscal year 2024.Communication Services - The fiscal year 2024 rate was set to under recover the cost of providing this service by an additional $425 thousand. Because the reductions to retained earnings were smaller than expected in fiscal year 2022 and are projected to be smaller than expected in fiscal year 2023, DTS will need an additional year to address this excess. DTS plans to annually review and adjust rates and issue mid-year rebates, if necessary, to bring DTS Communication Services into compliance with federal excess reserve guidelines by the end of fiscal year 2025.Network Services - DTS anticipates significant expenses to this product in fiscal year 2023 as DTS upgrades the aging network infrastructure and as the demand for network services continues to increase (e.g. Agencies are asking for increased bandwidth). Upgrades to the infrastructure have been more complex than originally estimated, which has delayed the majority of this expense to fiscal year 2023. DTS projects the Network Services retained earnings will decrease by nearly $1 million in fiscal year 2023. DTS plans to annually review and adjust rates and issue mid-year rebates, if necessary, to bring DTS Network Services into compliance with federal excess reserve guidelines by the end of fiscal year 2023.Mainframe Services - This product will be coming to an end by fiscal year 2024. As the product ends, DTS will issue a rebate to reduce retained earnings to the agencies using the system. DTS plans to issue a credit in fiscal year 2023 which will bring Mainframe Services into compliance.Contact Person: Dan Frei (dfrei@utah.gov), Finance Director, Division of Technology ServicesAnticipated Correction Date: June 30, 2025Division of Human Resource ManagementHuman Resources Core Services - The Division of Human Resource Management (DHRM) projects DHRM Core Services expenses to increase in fiscal year 2023 and future years. The DHRM Core Services excess reserves was the result of an error correction. In an effort to decrease these excess reserves, DHRM has not requested a rate increase for DHRM Core Services, though we do anticipate costs to increase. We will continue to annually review and adjust the DHRM Core Services rate and, if necessary, issue refunds or rebates to ensure DHRM Core Services is in compliance with federal excess reserve guidelines by the end of fiscal year 2024.Contact Person: Jake Hennessy (jakehennessy@utah.gov), Finance Director, Department of Government OperationsAnticipated Correction Date: June 30, 2024

Federal Funds Received Were Not Disbursed or Refunded Within Required TimeframeState Agency: Utah State UniversityFederal Program: Student Financial Assistance ClusterUtah State University will change its process for requesting federal funds in advance. The Controller?s Office will down less than the full amount of the estimated financial aid disbursement amounts to be issued to students, as calculated by the University?s Financial Aid Office at the first of each semester.The Controller's Office personnel will then review federal financial aid disbursements within three days of receiving the advance draw in order to return any undisbursed funds to the Department of Education within the required timeframe. Federal financial aid funds will then be drawn down on an on-going basis as additional federal financial aid funds are disbursed to students during the semester.Contact Person: Jennifer Jenkins, Manager of Sponsored Programs Accounting, 435-797-1077Completion date: October 31, 2022

Underlying Accounting Data Does Not Support Coronavirus Relief Fund Quarterly ReportsState Agency: Governor?s Office of Planning and BudgetFederal Program: Coronavirus Relief FundGOPB will continue to review its master CRF expenditure file and reconcile all reported CRF expenditures to FINET transactions. The reconciliation will account for original expenditure transactions, CRF expenditures that are booked when agencies are reimbursed for eligible transactions, and FEMA reimbursements for expenditures charged to the CRF.Contact Person: Duncan Evans, Senior Managing Director of Budget and Operations, 801-538-1592Anticipated Correction Date: April 10, 2023

September 14, 2023This is a corrective action plan in response to the audit finding on our FY2022 Single Audit (2022-001) provided to the Town of Rutland on 8/29/2023.Planned Corrective ActionDuring FY2022 and FY2023 there were significant changes to staffing in the Town Administrator and Town Accountants offices. The project to create formalized written policies and procedures that are required under the Uniform Guidance was not completed. The Town has draft policy and procedures established that will be adopted by the Board of Selectmen and will be implemented for fiscal year 2024.Contact person and Completion dateThe Town Administrators office will be facilitating the implementation of the new policy and procedures that will bring us into compliance with the Uniform Guidance for FY2024. The contact information for his office is as follows:Austin Cyganiewicz, Town Admin. ? acyganiewicz@townofrutland.org 508-886-4100 ext. 1000Tomeca Murphy, Executive Asst to TA & BOS ? tmurphy@townofrutland.org 508-886-4100 ext. 2001

Education Stabilization Fund: 2022-005 Condition: We noted during ESSER III testing the District was reimbursed for duplicated expenditures reported on the 3rd and 4th quarter reports. Recommendation: We recommend the District compare and reconcile the expenditure reports filled with the general ledger before submitting.

Corrective Action Plan: ? 2022-001. The District will implement procedures to read each Fund stipulations to ensure our Staff follows the requirements set within the Fund Documentation. From this day forward, we will certify that each guideline is followed and completed exactly as required before requesting reimbursement.

Finding 2022-006The Corporation management agreed with the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls. The below wording was added to the SEFA Preparation Memo, which is used to prepare the SEFA each year.a. Grants listed on the prior year are reviewed to determine if the grant is still active or if the grant has closed out.i. For grants that have closed the ending dates of the grant are verified, and current year activity is reviewed to ensure that all activity for that grant has been properly accounted for.Responsible Personnel include Harley McCoige, Controller and Cortney Couture, Director of Accounting.

Finding 2022-004 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Special Test and ProvisionsThe Corporation management agreed with the finding. Effective September 1, 2022, The Corporation has implemented the following changes, which we believe would address future internal control considerations.The below procedures were added to the grant checklist which is required on all grants applied for by the Corporation entities. Responsible parties are required to document all procedures and sign off on these procedures. The requirements formalize reporting and data management procedures, which include proper management approval and retention of these records. The grant checklist is additionally approved by the grant applicant and Vice President or Executive Director overseeing the grant.Determine required data requests in order to support this grant:? All data requests should list required data fields and constraints and must be reviewed and approved by management.? Detail sample review of the results must be performed to validate the accuracy and completeness of data and that report results meet the grant requirements.? Report access should be restricted to approved users or report results must be validated to approved constraints.Documentation of these procedures must be retained with management sign off and readily available upon request.Grants in excess of $187,500 require review by Finance or Internal Audit representative to verify that appropriate procedures are in place for documentation of controls on reporting and data management.Responsible Personnel beyond the specific Vice President or Executive director of the grant include Harley McCoige, Controller, Cortney Couture, Director of Accounting, and Samantha Pratt, Director of Internal audit.

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are applied to the correct period for the correct amount after the Accounting Coordinator inputs the data to ensure that Federal funds are reimbursed accurately and in the appropriate period

Vendor invoice processing is performed by the Accounting Coordinator who inputs pertinent invoice data into the accounting software for payment. The UWGC Senior Director of Finance or in her absence the UWGC Chief Financial Officer will provide a secondary level of review to verify invoices are applied to the correct period for the correct amount after the Accounting Coordinator inputs the data to ensure that Federal funds are reimbursed accurately and in the appropriate period.

To ensure the charging of indirect costs to federal programs are at the elected de minimis amount of 10% and in the correct fiscal period, the UWGC Chief Financial Officer or the UWGC Senior Director of Finance will perform a secondary review of the calculation prepared by the Finance Manager. The review will take place prior to the final completion of the report to ensure that Federal funds are reported in the correct time period as well.

Finding Number: 2022-002Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 fiscal yearwhich resulted in several vacancies, including the Director of Finance position, for a significant portion ofthe year. As a result, many of the reports that are standard practice in our organization were not beingcompleted. In addition, the filing of certain documentation to support expenditures was not being doneconsistently. The Director of Finance position was filled in the fall of 2022. As a result, documentationof allowable expenditures is being addressed for the fiscal 2023 audit.In addition to turnover, the organization transitioned to a new general ledger system with a new chartof accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certaindata pertaining to the federal programs was not being captured. Management has informed all staff ofthe requirements to track federal programs within the general ledger accounts.Anticipated Completion Date: June 30, 2023Responsible Contact Person: Erica Tkachyk, Director of Finance

Dear Mr. Waguespack,Thank you for the opportunity to respond to your office's finding related to cash management for Research & Development Cluster (R&D) programs. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the concerns identified by your staff and concurs with the finding.Recommendation:LSUHSC -S should ensure that a review and approval is performed on the final amounts requested for reimbursement and evidence is maintained. LSUHSC-S should also ensure that established controls are followed to ensure the review and approval is performed by someone other than the preparer.Response and Corrective Action Plan:LSUHSC-S' s monthly NIH drawdown process document is being updated to include the detailed efforts of the grants department accounting staff. The preparer's monthly reconciliation of federal award expenditures will continue to be reviewed by the grants manager before final drawdown and the clear evidence of this review and approval consistently noted on the documentation.LSUHSC-S will improve the drawdown schedule to be more consistent with the reconciliation process. In addition, any variances between the reconciliation and actual drawdown amount will be documented by the approver.Name of Contact(s) Responsible for Action PlanWilliam Haacker, Assistant Director of Grants AccountingCurtis Lawrence, Staff Accountant of Grants AccountingSheila Faour, Chief Financial Officer, Business and ReimbursementsAnticipated Completion Date: June 30, 2023If you have questions or need additional information, please contact me at (318) 675-5230 or via email at cindy.rives@lsuhs.edu.Attachment: LSUHSC-S Monthly NIH Drawdown Process Document at March 26, 2023 for completion by June 30, 2023 (See Corrective Action Plan for attachment)

REFERENCE: 2022-013 ? Allowable Costs/Cost PrinciplesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (93.461)Federal Grantor: U.S. Department of Health and Human ServicesFinding Part 1: CommonSpirit Health did not have controls in place to limit the claims being submitted for Testing-Related Items and Services to include items and services related to furnishing or administering the COVID-19 test or for the evaluation of such individuals to determine the need for a COVID-19 test.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. In addition, Management believes CommonSpirit followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program.Although CommonSpirit Health continues to dispute the findings (REFERENCE 2021-014), CommonSpirit Health is refunding the Questioned Cost of $10,998 related to the findings for 2021 in order to resolve this finding. The refunds will be completed by April 30, 2023. In addition, the Program stopped accepting claims for testing and treatment on March 22, 2022, and claims for vaccine administration on April 5, 2022, due to lack of sufficient funds. CommonSpirit Health has not submitted claims to the Program since the Program was discontinued. In the event that CommonSpirit Health, through its proactive compliance efforts, identifies any additional claims submitted to the Program where reimbursement may not have been appropriate, CommonSpirit Health will refund such claims.Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: Management believes the item is resolved.Finding Part 2: CommonSpirit Health did not have controls in place to ensure that claims were not submitted for reimbursement when COVID-19 was not the primary diagnosis.Corrective Action Plan: Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. With respect to this one claim where COVID-19 was incorrectly listed in the primary diagnosis position, CommonSpirit Health will refund the claim amount of $547 by April 30, 2023Person Responsible: Danielle Weber, System SVP Revenue CycleExpected Completion: April 30, 2023

REFERENCE: 2022-002 ? Special Tests and Provisions ? Borrower Data and Reconciliation (Direct Loan)Student Financial Assistance Cluster (Assistance Listing No. 84.268)Federal Grantor: U.S. Department of EducationFacility: Good Samaritan College of Nursing and Health ScienceFinding: Good Samaritan College of Nursing & Health Science did not perform the direct loan monthlyreconciliations for FY22.Corrective Action Plan: Good Samaritan implemented a formal monthly reconciliation process, includingcomparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting anyexplaining any differences, proper sign off for preparation and review and the date by Good Samaritan management.A year end reconciliation will also be performed following the same process.Person Responsible: Judy Kronenberger ? President Good Samaritan College of Nursing and Health Scienceand Financial Aid Services (FAS)Completion: June 2022