Corrective Action Plans

Program Affected-Child Nutrition Cluster-Assistance Listing No. 10.555, 10.556, 10.559 Criteria: The Uniform Guidance requires the local program operator to submit monthly claims for reimbursement to the administering agency. All meals claimed for reimbursement must meet federal requirements and be served to eligible children. Condition: Audit sampling revealed variances between total meals claimed in monthly food service claims and the meal cotmt sheets that the District used to track meals served to students. Cause: Meal counts were not accurately reported on the claim forms in the months sampled. Effect: Excess reimbursement amounts claimed may be disallowed and, if any, the excess may need to be returned to the federal agency. Questioned Cost: Unknown. Repeat Finding: Yes. Auditor's Recommendation: We recommend the District set up a review procedure to review the claims and reconcile the claims to actual meals served. Grantee Response: The District has reviewed procedures and implemented a system to review the claims and reconcile the claims to actual meals served. This will be done by entering the actual meals served in our computer system (Skyward) on an ongoing basis at the point of service, meaning the meals are entered daily into the system as students/staff go through the food service line at their school. This is a change from the past--<luring COVID, when all meals were served free to all students. At that time, our previous food service director used a manual, "tally" method, as a result of being short staffed. Now, we have a new food service director and we are going to keep all of our meal counts up to date in Skyward, as opposed to using the manual, "tally" method from the past two years. Contact Person: District Administrator Terry Slack Anticipated Completion: December 31, 2023

The Treasurer, Town Manager and Select Board has taken the following actions to address finding 2022-007: The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. This policy was approved and implemented by the Select Board on January 23, 2024.

Recommendation:We recommend management and the board of directors should review reporting frequently to make sure that they are complying with the requirements. Management Response: We agree with the recommendation and the record retention policy that was adopted on November 14, 2022 should prevent this from happening in the future.

Recommendation: We recommend the Company should implement a timesheet protocol for all employees to complete on a weekly basis. Action Taken: We agree with the recommendation, we have hired a CPA as third-party bookkeeper; the bookkeeper has implemented a timesheet program for all time allocated to grants for each employee to follow.

Recommendation: The Company needs to retain documentation. Management Response: Management has hired a 3rd party bookkeeper who is a CPA has sent up a system for documentation retainage.

Recommendation: We recommend the Company start properly tracking hours worked by employees per grant on a weekly basis. The Company needs to start retaining audit evidence for review of independent audits and grant compliance. Action Taken: We agree with the recommendation. We have moved to a timesheet allocation on a weekly basis which is reviewed and tracked by the 3rd party bookkeeper. The 3rd party bookkeeper now requests all invoices before a check for reimbursement to be released.

Recommendation: We recommend requesting reimbursement of grant monthly – bi-monthly depending on the size of the reimbursement request. Action Taken: We agree with the recommendation, and we are making more of an effort to request reimbursement throughout the grant rather than completion.

2022-001 Financial Reporting Oversight Responsible Party: Libby Albers, Executive Director Implementation Date: 2/15/2024 1. KAWS Executive Director, will continue to log deposits and deposit documentation in an internal spreadsheet and reporting each deposit to the KAWS Accountant via email. The Conservation Easement Specialist will check the deposit spreadsheet against the monthly bank statements to ensure that all deposits are present. This extra reviewer of bank statements is independent of any of the parties handling the deposits. 2. Executive Director will request quarterly Profit and Loss and Transaction reports by Job from the outsourced accountant, and compare the data against the expense reporting platforms, payment requests, and bank statements. 3. Executive Director will discuss the issue of reallocation of expenses being changed after quarterly reports have been provided and request that the outsourced accountant locks the Quickbooks data at the end of each month’s reconciliation. Should the data need to be unlocked the outsourced accountant will notify the Executive Director. Although this still places Quickbooks control with the accountant, it will create additional steps required of the accountant.

The finding was corrected. The payer of the Concessionaire, which has access to the system, was appointed. According to internal procedure, she does not issue payments until she is sure that the account has a budget.

Finding number: 2022-047 – Cash Management Significant Deficiency in Internal Control over Compliance Finding: A reimbursement request was not reviewed and approved by an individual independent of the preparation of the request. Corrective Action Take or To Be Taken: The Division has added additional internal controls to ensure the separation between reimbursement requestors and approvers, in addition to providing adequate guidance to all new staff involved in cash management on the internal control policy. If to be taken, estimated date of completion: These procedures were implemented July 1, 2023. Agency Response Does the Agency agree With finding: Yes If No or Partial, please Explain reason(s) why: Individual Responsible for Corrective Action Plan: Name, Title: Brooke Barlow, Chief of Fiscal Phone Number: 775-684-0659 Email: bebarlow@dwss.nv.gov Reviewed and Approved: Crystal Buscay, CFO

Audit Finding: 2022-029 Homeowner Assistance Fund: 21.026 Cash Management Material Weakness in Internal Control over Compliance Summary: No monitoring of cash drawdowns by the subrecipient to ensure that the time elapsing between transfer of federal funds to the subrecipient and the disbursement for the program purpose is minimized. There was no tracking of interest earned on funds advanced by the Department of Treasury and no remittance of any interest earned greater than $500 as required. Recommendation: Implement internal controls to ensure time between disbursement of federal funds to the subrecipient and their disbursement for program purposes is minimized and ensure interest is appropriately tracked and remitted. Agency Response: The Nevada Housing Division (“Division”) disagrees with this finding as cited and feels strongly that it should be only a Significant Deficiency in Internal Control over Compliance due to the lack of tracking the interest earned on funds advanced and the late remittance (an inquiry for process has been initiated). Per the HAF Guidance that was published by the U.S. Treasury and per the FAQ that currently exists on the U.S. Treasury website, the U.S. Treasury themselves noted that the funds would be disbursed in only two payments, an initial 10% and then the remaining funds per the approved plan of the recipient. If the intent of the U.S. Treasury was per section 305(b)(1), then the Treasury would either have 1) not approved the Division’s plan, and/or (2) disbursed funds on an as needed or reimbursement basis. Corrective Action: The Division will establish an internal audit and compliance committee to enhance oversight of existing policies for assessing risk, monitoring, and sharing best practices across its business. The internal audit and compliance committee will be responsible for reviewing internal controls and policies on an annual basis, following up on any audit findings and ensuring follow-through of corrective action plans. The Division has already followed up with the Controller to understand the process to have the state, who is holding the funds, remit the interest collected both in FY22 and FY23 back to Treasury. Going forward, this will be supported by the new committee. Adoption of Corrective Action: December 2023 Division Contact and Corrective Action Plan Lead: Christine Hess, Chief Financial Officer Nevada Housing Division 775-687-2249 chess@housing.nv.gov

Management agrees that due to turnover in staff during 2022 and 2023, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 3/1/23 Staff: Don Reynolds, contracted CFO

For any construction or building improvements requiring the use of contractors in the future, management will discuss adherence to the Davis Bacon Act regarding prevailing wages with the contractors and obtain documentation from the contractors demonstrating compliance with the Act.

Agree with the finding. We will implement the segregation of duties matrix as part of SOPs. We will ensure that authorization and review of cash draws of fedral funds are done by some one other than the individual who initiates and records the transaction . We have implemented the same and Dr EIli (pi) is reviewing and approving the report before each withdrawal. The Finance Head ( Nafih) is withdrawing the fund .Anticipated Completion Date : 12/31/2022 Actual date of implementation :01/24/2023

FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that agrees to reports submitted Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Deb Martin, Director of Student Learning & Title I Contact Phone Number and Email Address: Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports and supporting documentation, which supports each report submitted, will be reviewed/approved by the program director. All supporting documentation will be retained for future audits. Anticipated Completion Date: December 8, 2024

FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowledgeable individuals for review. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Form 9 Data The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Reimbursement Requests Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023.

Finding 2022-003 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 the Club was not adhering to accrual accounting as it pertains to reporting of expenses. Response: Adjustments have been made to the process of monthly adjustments. Additional procedures will be put in place to ensure financial reporting is done correctly.

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.