Corrective Action Plans

Finding 2022-002 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. As part of our review of the Child and Adult Care Food Program (CACFP) it was noted some of the Club’s daily food invoices were missing the site supervisor’s signature for having received the meals specified. Response: The monitor and director will review each month’s daily food invoices from all sites to ensure they are complete. Additional procedures will be put in place to ensure all daily food invoices have the appropriate receiving signatures.

Finding 2022-001 Finding: CACFP requires that non-Federal entities receiving Federal Awards establish and maintain internal control designed to reasonably ensure compliance with Federal Statutes, regulations, and the terms and conditions of the Federal award. The Club was unable to replicate exact payroll expenses that were reported to the state monthly for the program. This is due to a lack of payroll documentation retained monthly. This documentation took time to replicate during the audit. No fraud is suspected related to payroll reporting issues for the program. Response: Adjustments were made to the payroll process to retain all supporting documentation and to replicate any prior period paperwork. The Club switched to a new payroll processor which has enabled improved payroll reporting.

(B) The Department will review and revise, as necessary, its taxi claim billing requirements and rates to ensure that they are consistent. In addition, the Department will devise controls to ensure that taxi claims are paid in accordance with established requirements and rates and explore controls to ensure that only permitted providers bill as a taxi. The Department is working on reductions in the max fee and unit limits for taxi claim billing codes, which it will have completed by the end of October 2021. In addition, the Department is considering systematically pricing the code at each taxi provider?s specific Public Utilities Commission (PUC) rate. This change, if pursued, will require a system change request, which will take a year or more, which is why the Department has selected an implementation date of December 2022. If this proves infeasible, alternate controls will be implemented. HCPF has met with DORA PUC. The Department is trying to establish a process to decide if the PUC taxi rate still applies or an internal rate can be created. Because of these discussions and needed system changes the implementation date has been moved to December 2023. (D) The Department intends to define in rule the types of documentation that NEMT providers must keep on hand and make clear that they must furnish records to the Department upon request. The July 2022 date will allow for the completion of formal rulemaking. The Department further intends to develop and implement a process to perform regular risk-based provider file reviews with a focus on noncompliant providers. These reviews will ensure, at a minimum, that the providers? paid claims are supported with appropriate documentation and represent the least costly option appropriate to meet each recipient?s needs. The Department met with the RAC team on February 22, 2023 to come up with a process to perform small audits for claims from providers that are outside the Intelliride service area. New systems will be implemented which has pushed the anticipated completion date to December 2023. (E) The Department will amend its contract with its NEMT broker by adding a mandatory annual audit so that it can reconcile trip scheduling data with paid claims data. This will help ensure that the Department pays accurately, pays for NEMT services, and pays for the least costly transportation option appropriate for each recipient. The Department chose July 2022 to add the audit through its annual contract amendment and renewal processes. The contract amendment was completed and signed June 30, 2022 that included a clause for an annual audit of claims. (F) The Department will develop a data review process to reconcile interChange data on NEMT trip claims to interChange data on Medicaid medical claims. This process will entail periodic reviews of NEMT claims to see if members have corresponding medical claims on those dates. If they do not, the Department will follow up with the appropriate NEMT provider to investigate. The July 2022 implementation date reflects the potential need for system changes. This is implemented, the Department has been pulling claims data and where corresponding medical claims are not found HCPF is investigating on a case by case basis to find the cause. (G) Department staff will work with the Department?s Program Integrity (PI) staff on processes to investigate and recover, as appropriate, the overpayments and inappropriate payments that the audit identified as known or likely questioned costs, and repay the federal portion, as appropriate. The December 2022 implementation date reflects the time needed to investigate and when appropriate, recover any overpayments. This has been implemented and the federal portion has been returned to CMS. (H) The Department will develop a process to track staff time and productivity to ensure that it has sufficient staff assigned to oversee and administer NEMT. This process will include documenting time spent each week on various tasks to get a sense of where help is needed, and which tasks take up the most staff resources. Based on its findings, the Department will explore staffing options, as needed. The Department selected the July 2022 implementation date to allow for data collection through the end of State Fiscal Year 2021-22. This has been implemented. New NEMT staff was hired November 1, 2022 to act as the liaison to the counties and clients in the 55 counties outside of the Intelliride service area.

(A) The Department will enhance its internal controls and processes to ensure it complies with the federal Cash Management Improvement Act requirements for the federal Highway Planning and Construction Program (Program) by ensuring personnel responsible for preparing and reviewing the cash draw requests are adequately informed of the draw pattern for the applicable fiscal year in which the draws occur including federally-approved changes during the year. Personnel responsible for the draw will review the approved draw letter from the State Treasury with a secondary verification on the Federal Site, www.fiscal.treasury.gov/cmia/resources-treasury-state-agreements.hmtl for the specified timeframe before conducting the draw. (B) The Department will enhance its internal controls and processes to ensure it complies with federal Cash Management Improvement Act requirements for the federal Highway Planning and Construction Program (Program) by establishing and maintaining formal procedures that specify the draw request dates in relation to the program expenditures to ensure required draw patterns are met. The process to implement changes to the cash draw pattern will be added to the draw procedure by March 2023.

CDLE will continue to develop, formally document, and implement policies for completing its federal reports for the Unemployment Insurance program. These policies will require the workbooks used to prepare the reports to be protected, for the data to be substantiated, and will require supervisory review on a monthly basis prior to submitting the reports to the federal government.

The Department of Local Affairs (Department) agrees with the recommendation. The Department will strengthen its internal controls through the development of an onboarding program that will include different modules that new employees and/or contractors must work through to receive certification. These modules will include all relevant steps associated with the waiting list process.

In January 2023, the Executive Director of Financial Aid and Scholarships implemented a code of conduct that addresses and prohibits University personnel from awarding financial aid to their family members or other persons considered conflicts of interest. The Office of Financial Aid and Scholarships will draft policy by June 30, 2023, to address the segregation of duties that prohibits awarding and disbursing federal, state, or institutional funding to students by one employee.

2022-007 Significant Deficiency in Controls over Compliance and Compliance Finding: Double Reporting of Student Counts. Effective January 2022, the Business Manager now reviews all count sheets and ties the counts to the summary report used to submit claims prior to submittal for reimbursement. She did not, however, review the actual claims before submittal and discovered after-the-fact that these duplicate counts had occurred. The review procedures were immediately changed to include reviewing the actual claim submittal before the Food Manager certifies their claims.

2022-004 Material Weakness in Controls over Compliance: Activities Allowed or Unallowed We agree with the recommendations and have made improvements to our procedures. The schools were not prepared for the rapid expansion of the food program, not only at our two high schools, but our partner schools' which requested contracted breakfast/lunch food services for their students as well. This unprecedented growth coupled with supply chain issues from food wholesalers, and shortage of employees in the hiring pool, only exacerbated our issues. The audit sample showed a large error rate for one of the schools. We have gone through the entire year for the school(s) individual count sheets. In the event the Michigan Department of Education determines that the identified discrepancies warrant a repayment we have recorded an allowance in the financial statements for the year ended June 30, 2021. Staff were not properly trained in how to complete the count sheets; however, supervisors did not take the time once they saw there was a problem due to everyone trying to simply get the meals served to the children. In addition, there was a lack of oversight of the Food Service Manager by her direct supervisor. At the time of the 2021 audit, when the issue was brought to our attention, we developed new procedures. School staff performing counts have been trained in how to properly complete the count sheets. The Business Manager now reviews all count sheets and ties counts to the summary report used to submit claims prior to submittal for reimbursement. Given that training and implementation of procedures did not fully occur until January 2022, there are errors in counts prior to implementation of the procedures and repeat findings in fiscal year 2021-22. In addition, with the end of the pandemic, beginning with the 2022-23 school year, the schools were able to resume using electronic software to accurately capture the meal counts.

Finding Number: 2022-015 ? Cash Management Corrective Action Plan: A process has been put in place for the school principal to review all RFRs prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the RFR as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

Views of Responsible Officials and Planned Corrective Actions - Management recognizes the overall volume of transactions the Organization continues to grow each year and it being one of the reasons this is a repeat finding. The questioned costs were immaterial. While improvements were made during the year, the internal recordkeeping controls and protocols will continue to be reviewed with the new accounting service provider and improved measures implemented.

Proposed corrective action: The finance department has already implemented a process in which the Chief Financial Officer reviewed draws on federal funds noting no discrepancies. Going forward, the Chief Financial Officer will calculate the amount of the draw on federal funds, which will then be reviewed, approved, and documented by the Chief Executive Officer before the draw is submitted. Anticipated correction date: This has already been implemented retroactively effective January 2023. Responsible official: Gabriela Cordero, Chief Financial Officer.

Proposed corrective action: The finance department has already implemented a process in which the Chief Financial Officer reviews the documentation for expenditures allowed and unallowed under the terms of the grant agreement, and the drawdown happens only when the amount of allowed expenditures has been determined. Anticipated correction date: This has already been implemented retroactively effective January 2023. Responsible official: Gabriela Cordero, Chief Financial Officer.

Corrective Action Steps Taken - As of August 3, 2022, the school management company Distinctive Schools, has engaged with EdOps to provide additional Financial Operations Support to Plymouth Educational Center. Future Steps to be implemented ? EdOps and Distinctive Schools have begun holding monthly review meetings with various members of the Plymouth Educational Center team to provide stronger review and greater visibility into potential budget related impacts. Based on information obtained during these meetings, annual forecasts are created and if any amendments are deemed necessary during the process, they will be presented to the board of directors. Monitoring Plan ? The CFO and Manager of Financial Strategy and Budgeting will monitor monthly the budget to actual variance and present forecasted information monthly. Additionally, an amended budget will be presented to the board for approval if necessary. Date of Completion - Nov 1, 2022 People Responsible ? Elizabeth Winke, Controller & Interim CFO & Nadine Blanco, Manager of Financial Strategy and Budgeting Finding 2022-002 Corrective Action Steps Taken ? The management company, on behalf of Plymouth Educational Center, is working with the equipment vendor to rectify the shipping issue. Future Steps to be implemented ? The technology team will include receipt dates within the equipment tracking system and will follow up on any discrepancies identified from purchasing, to receipt of goods, to payment of goods. Additionally, those governed with approval of invoices will verify receipt of equipment prior to invoice approval and payment. Monitoring Plan ? Equipment inventory will be verified quarterly for new inventory purchases versus grant reimbursements to confirm all inventory has been received and is accounted for against the grant, including appropriate tagging of equipment. Date of Completion ? November 1, 2022 Person Responsible ? Roberto Vargas, Director of IT, and Karey Henderson, Managing Director of Operations PLYMOUTH

2022-003 Cash Management Management?s Response and Planned Corrective Action: Management will monitor reimbursement requests to insure that payments have been made to vendors prior to submitting the reimbursement request. Name and Title of Contact Person: Timothy Matte, Executive Director

U.S. DEPARTMENT OF AGRICULTURE SIGNIFICANT DEFICIENCY 2022-003: Child Nutrition Cluster ? CFDA No. 10.553, 10.555 and 10.559 Grant period: Year Ended June 30, 2022 Condition and Context: Per review of the Summer Food Service Program summary sheet for April, the incorrect number of breakfasts was reported. Criteria: The District is required to submit the number of breakfasts and lunches served in order to receive reimbursement for them. Cause: The number of meals entered for reimbursement on the summary sheet was incorrect. Effect: If the correct number of meals is not reported the District will not be reimbursed the correct amount. Recommendation: We recommend that the summary sheets used to compile the request for reimbursement is double checked for accuracy as to the number of meals on the daily count sheets. Grantee Response: We concur with the recommendation. In addition, someone will be reviewing all summary sheets before the request for reimbursement is submitted.

The Agency recognizes this finding and notes that this occurrence resulted from additional emergency additional funding provided by funders in a different payment structure than other grants received. Going forward with any new grants that are cost reimbursement based and where individuals are only partially allocated to the program, a staff allocation tracking will be implemented for said employees.

Finding 2022-002 (ACFR 2022-001): There were instances in which the number of meals claimed did not agree with the meal count records resulting in an over/under claim. Corrective Action Approved by the Board: Prior to submitting reimbursement claims to the NJ Department of Agriculture, the meals claimed should be verified to the meal count activity records. Method of Implementation: More care will be taken to ensure meals claimed are verified to meal count activity records. Person Responsible for Implementation: Joanne Origoni, Secretary to the Business Administrator. Completion Date of Implementation: 3/9/2023.

Corrective Action Plan 2022-001 This finding is caused by the District?s Food Service Fund?s fund balance being over the USDA?s threshold of 3 months average expenditures. The District is fully aware of this situation and has a spend down plan in place to help alleviate the excess fund balance down to a reasonable level and anticipates the completion date for the corrective action plan be before the end of the 2022-23 fiscal year. The person responsible for the corrective action is Michelle Adams, the food service director. The plan for monitoring adherence is the food service director will work to assess where the fund balance is after all of the projects from the spend down plan are completed.

Finding: 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: National Bioterrorism Hospital Preparedness Program Federal Financial Assistance Listing #93.889 Compliance Requirement: Activities Allowed and Allowable Costs, Period of Performance, Cash Management and Reporting Finding Summary: No independent secondary level of review or approval is performed relating to compliance. One employee is involved in preparing, reviewing and approving information. Additionally, Internal control procedures documented within Coalition?s Grant Management Policy have not been updated since departure of the Grant Management Director. Responsible Individuals: Greg Santa Maria, Executive Director Corrective Action Plan: The SDHCC has updated its invoicing process to include an internal review of all invoices prior to submission for reimbursement by the state. Per the new process, the executive director reviews, prepares and completes the initial invoicing process. Once complete, the invoice is forwarded to the SDHCC treasurer for final review and approval prior to final submission to SD DOH. The review process is formally documented by treasurer signature on face document prior to submission to DOH. Grant management policy is currently in revision. Anticipated Completion Date: For Invoicing Process, practice was changed to reflect final review by SDHCC treasurer on January 10, 2023, beginning with BP4 Invoice number 227. Projected Grant Management policy revision first draft to Board is Friday April 7, 2023.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2022-001 Internal Controls Over Compliance With Cash Management, Allowable Costs, Standards for Financial Management, and Procurement Finding Summary During our audit, we noted that Universal Academy?s (the Academy) written internal control policies over compliance with the U.S. Office of Management and Budget?s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) did not include adequate written controls over compliance with cash management, allowable costs, financial management standards, and procurement. Corrective Action Plan Actions Planned ? The Academy has implemented an updated version of its written policies and procedures relating to cash management, allowable costs, financial management standards, and procurement for its federal programs to ensure compliance with the Uniform Guidance effective for fiscal year 2023. Official Responsible ? The Academy?s Executive Director, Farhiya Einte. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The Academy agrees with this finding. Plan to Monitor ? The Academy?s Executive Director, Farhiya Einte, will ensure appropriate written internal controls and procedures are updated and in place for future federal grants.

FINDING 2022-003 Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Context: For all four monthly claims selected for testing, there was no formal evidence of the sponsor claim reimbursement summary being reviewed by someone independent of who prepared the sponsor claim reimbursement summary prior to submission. Additionally, we noted that for one claim in the sample of four, the meal counts were overclaimed for the month. In October 2020, the School Corporation overclaimed breakfast by 43 meals and underclaimed lunch by 11 meals. Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Description of Corrective Action Plan: Food Service Director, Brisha Dunbar will verify that the numbers she pulls from E-trition match the amounts that she is claiming for reimbursement. FSD completes a daily edit check form and compares totals to the monthly E-trition report. Once the food service director has the monthly forms completed Southwestern ECA treasurer, Amber Mitchell will review and compare totals before the numbers are submitted to the State. She will initial the totals form along with the FSD and these forms will be kept on file in the FSD?s office. Responsible Party and Timeline for Completion: Food Service Director, Brisha Dunbar and ECA Treasurer, Amber Mitchell ? these changes will be implemented effective March 2023.

Finding 2022-002: Material Weakness related to Cash Management Condition: Cash draws from WIOA Cluster and Coronavirus Relief Fund grants exceeded the amount needed to cover allowable costs. Recommendation: Management needs to work with the State of Indiana Department of Workforce Development to refund the overdrawn funds or apply the funds to allowable costs in the upcoming fiscal year. Management?s Corrective Actions: Staffing changes have occurred, and the fiscal management duties have been outsourced to a third party which has experience with Workforce Boards and related grants. The new Fiscal Agent is working with IN DWD to correct these errors.

Finding 2022-003: Noncompliance with Cash Management Condition: Cash draws from WIOA Cluster and Coronavirus Relief Fund grants exceeded the amount needed to cover allowable costs. Recommendation: Management needs to work with the State of Indiana Department of Workforce Development to refund the overdrawn funds or apply the funds to allowable costs in the upcoming fiscal year. Management?s Corrective Actions: Staffing changes have occurred, and the fiscal management duties have been outsourced to a third party which has experience with Workforce Boards and related grants. These issues are being addressed with IN DWD.

Finding Number: 2022-004 Finding: Emergency Rental Assistance Program Reporting. All Emergency Rental Assistance (ERA) grantees must submit monthly and quarterly reports. Monthly reports capture details specific to that month while quarterly reports contain several cumulative fields covering all activity from the date of the grant award through the quarter close. These reports provide financial and performance data regarding grantee administration of their ERA projects and capture program design in addition to program status data elements. Quarterly reports are intended to capture standard financial and performance data, as well as detailed information on qualifying direct and indirect expenditures pursuant to the government-wide Federal Funding Accountability and Transparency Act (FFATA) reporting requirements and in accordance with Section 15011 of the Coronavirus Aid, Relief, and Economic Security Act, as amended and interpreted in the U.S. Department of Treasury?s reporting and compliance guidance on Treasury.gov. The reports submitted by the Organization to the Sonoma County Community Development Commission inaccurately reported total expenditures to date due to a formula error. However, monthly expenditures reported and claimed for reimbursement were determined to be accurate. Planned Corrective Actions: The Finance Director will review and check for clerical errors on all claim forms prior to submission to the funder. A spreadsheet will be maintained which will track signoffs that indicate the review was performed. Anticipated Completion Date: Completed. Responsible Contact Person: David France, Director of Finance