Corrective Action Plans

Views of Responsible Officials: During the COVID 19 pandemic the District experienced turnover in various key positions resulting from a lapse with record keeping. Management will work to ensure that records related to claim reimbursements are retained for a period of three years. Name of Responsible Person: Jennifer LaBarre, Executive Director of Student Nutrition Services Implementation Date: Fiscal Year 2023-2024

Panthera implemented an approval workflow in Chrome River, but we will also ensure a formal written approval is issued on quarterly expenditure reports going forward.

Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: Social Services Block Grant Assistance Listing #: 93.667 Questioned Costs: None Corrective Action: We agree with the auditor?s comments and actions stated in the recommendation. The Organization is rewriting its accounting policies and procedures to ensure adherence to the proper procedures for vouchering, which will be completed in fiscal year 2024. In August 2022, the building at 4730 N. Sheridan was sold. During the move some documents were misfiled or otherwise missed place. This made it difficult to find vouchers for the audit. The new accounting system allows Alternatives to save a copy of the vouchers and necessary support within the software. The electronic filing of the backup documentation will prevent misplacement of vouchers in the future. Contact Person: Sonya Cook, Finance Director Anticipated Completion Date: December 15, 2023

2022-05 Education Stabilization Fund 84.425 Plan for Remediation: The College had to adapt to new territory and evolving guidelines and compliance requirements related to COVID 19 funding. Moving forward, compliance guidelines will be adhered to for all federal funding received by the Controller and the Vice President for Administrative Services.

Finding Reference Number: SA2022-005 - Cash Management ? Draw Down of Community Development Block Grant Funds in Advance of Expenditures Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant ? Entitlement Grant COVID-19 - Community Development Block Grants/ Entitlement Grants-CV Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-21-MC-06-0042 COVID-19 ? B-20-MW-06-0042 CDBG Daly City Pass Through #Not Available Name of Pass-through Entity: City of Daly City ? Name(s) of the contact person: Karen Chang, Finance Director ? Corrective Action Plan: The CDBG grant seldom involves a contract that has included a retention payable. Going forward, staff will double check contracts that have retention clauses and ensure the reimbursement submission does not include an unpaid retention. Staff will also check with the grantor to see if the City needs to reimburse the interest earned on the grant funds advanced. ? Anticipated Completion Date: December 31, 2023

REFERENCE # 2022-003 ELIGIBILITY FOR INDIVIDUALS ? NONCOMPLIANCE Program ADOPTION ASSISTANCE TITLE IV-E (Assistance Listing # 93.659) Identification Number(s) 18000 Finding New York State has enacted legislation which allows payments to be made for the care and maintenance of children when they are adopted. Suffolk County Department of Social Services (the ?Department?) provides a monthly adoption subsidy payment mandated by law for the care, maintenance, and/or medical needs of a child who fits the definition of handicapped or hard-to-place as defined by New York State law and regulations. Subsidy payments are available to all eligible children until the age of 21 regardless of the adoptive parent?s income. These payments are discontinued only when it is determined by a social service official that the adoptive parent(s) is no longer legally responsible for the support of the child or that the child is no longer receiving any support from the parent(s). Of the sixty (60) files selected for testing: ? Five (5) case file did not include the Home Studies narrative; and one (1) case file did not include the Criminal check form. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Questioned Costs Cannot be determined. Recommendation We recommend the Department strengthen its monitoring controls over the adoption assistance case files to ensure the timely and accurate determination of eligibility. Corrective Action Plan With regards to the Criminal check form: Corrective Action Plan: It was found that one (1) case file did not include the criminal check form. The criminal check forms for this case was conducted when the children were in Foster Care and the results were included in the Foster Home record. Foster Home records are purged after eight (8) years of the home closing and no longer available. Currently: The criminal record check is included in the Adoption Subsidy file upon adoption as well as maintained in our Adoption vendor files. With regards to the Home Study narrative: Corrective Action Plan: It was found that five (5) cases did not include the Home Study narrative. The Home Study narratives for these case files were conducted when the homes were first certified as Foster Homes and were included in the Foster Home case record. Foster Home records are purged after eight (8) years of the home closing and no longer available. Currently: The Home Study narrative is included in the Adoption Subsidy file upon adoption as well as maintained in our Adoption vendor files. Action Date Record Check ? 2018 Home Study ? 2021 Final Implementation Date Record Check ? 2039 Home Study ? 2042 Name And Phone # Of Person Responsible For Implementation Carleen Newlands, Division Administrator 631-854-9626

REFERENCE # 2022-004 ELIGIBILITY FOR INDIVIDUALS ? NONCOMPLIANCE Program LOW-INCOME HOME ENERGY ASSISTANCE (ALN # 93.568) Identification Number(s) 21-LCM-15, 21-LCM-23, 22-LCM-06, and 23-LCM-01 Finding The New York State Office of Temporary and Disability Assistance is responsible for Low-Income Energy assistance programs that provide assistance and support to eligible families and individuals. The Home Energy Assistance Program (HEAP) helps eligible New Yorkers heat and cool their homes. An eligibility family may receive one regular HEAP benefit per program year and could also be eligible for emergency HEAP benefits if you are in danger of running out of fuel or having utility service shut off. Of the sixty (60) files selected for testing: ? One (1) case file did not include the required documentation to support eligibility for HEAP. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Questioned Costs Cannot be determined. Recommendation We recommend the Department strengthen its monitoring controls over the Low-Income Home Energy case files to ensure the timely and accurate determination of eligibility. Corrective Action Plan Staff will be reminded of the importance of scanning all applications and required documentation into the Imaging and Enterprise Document Repository to ensure that a complete and accurate case file is kept electronically for all cases. Action Date 9/20/2023 Final Implementation Date 2024 Name And Phone # Of Person Responsible For Implementation Loreta Keller 631-854-9920

REFERENCE # 2022-005 Other- Basis of Accounting ? Material Weakness Program EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ALN # 93.323) Identification Number(s) 6831-01 Finding The Suffolk County Department of Health Services (the ?Department?) receives Epidemiology and Laboratory Capacity for Infectious Diseases funds from Health Research, Inc. (the ?Agency?). The Department reports to the Agency on an accrual basis, as required by the Agency. The County?s Schedule of Expenditures of Federal Awards is presented on the accrual basis of accounting. The Department provides all supporting documents to the Agency for reimbursement. Of the sixty (60) files selected for testing: ? We noted that the Department submitted four (4) allowable invoices in the amount of $549,538, which were incurred and dated in the prior year. The Department recorded the expenditures and revenue in the 2022 financial statements. These invoices were also added to the Schedule of Expenditures of Federal Awards in calendar year ended December 31, 2022. Questioned Costs Cannot be determined. Recommendation We recommend the Department report program expenditures on the Schedule of Expenditures of Federal Awards on the same basis as the County. Corrective Action Plan During year end processing, the Suffolk County Department of Health Services, when entering vouchers into the financial system, will ensure items to be accrued will contain the letter ?A? as a prefix to the voucher number. The department will also check to ensure all items that should be accrued, are in fact accrued prior to year end closing. In addition, the department will confirm the date entered in the financial system, reflects the proper year in which the expense and associated revenue should be recorded. When preparing the annual Schedule of Expenses of Federal Awards (?SEFA?). The department will reconcile expense reports with the expenses reported on the annual SEFA. Action Date September 20, 2023 Final Implementation Date December 31, 2023 Name And Phone # Of Person Responsible For Implementation Susan Hodosky 631-854-0182

Individual Responsible for Corrective Action Plan: Whitney Holliday, Director of Club Financial Services Corrective Action: Previous Process: The previous process was created prior to the current admin becoming the dedicated Financial Services leader on the Boys & Girls Clubs in TN/TN Alliance admin team. All changes took place over the 2022/2023 grant cycles. Current Process: The previous process was overhauled to our current process in Q1 of 2022. Training and updates to the process were performed with 20 organizations throughout the year. We also implemented better direct communication with admin/staff 1:1s and a quarterly financial update call to continue training and best practice sharing. Process Update: A process update will be implemented beginning with July 2023 reimbursement requests/submissions to funders. These updates will be shared with individual Clubs with an expectation of full implementation by the end of Q3 2023. The admin will enhance its policies and procedures over sub-recipient monitoring to ensure accurate invoicing. -All reimbursement requests due from the Clubs by the 15th of each month o Previous Process: ? Requests were either loaded in the shared drive or emailed directly to the admin. Requests were consistently late and admin would communicate with each Club to see if they submitted something but it was missed. o Current Process: ? Calendar reminders are disbursed to all financial contacts with the deadlines clearly defined ? All submissions must be made in the shared drive. No email reimbursement requests are allowed. ? Admin no longer reached out to Clubs if nothing is loaded in the shared drive to process by the deadline ? Direct communication opened and established between Club financial leaders and admin financial leader to ensure all deadlines are met o Process Update: ? No update is needed ? Reimbursement Request/Cover Sheet o Previous Process: ? Submissions were processed based on a spreadsheet that the Clubs tracked in the shared drive. ? Manual verification of lines requested o Current Process: ? A cover sheet detailing the calculations of each line in the reimbursement request is required with each submission. Acknowledgment by Clubs that they have included/not included (timesheets signed in 3 places, receipts with no sales tax or other unallowable expenses, request submitted by the 15th of each month) via check boxes prior to authorized signature and date. ? All salary and benefit calculations must be completely detailed in the supporting documentation. This has remained difficult with all 20 organizations having different pay structures, paycheck layouts, benefit providers, etc. ? All supporting documentation must be present at the time of processing or line item requests are removed from overall submission. ? All submissions are compiled and sent to funders by their deadline on a monthly basis o Process Update: ? Additional calculation details will now be required for all submissions. We will add a separate box for the percentage breakdown to be charged to each grant to match supporting documentation exactly. ? All communication of errors will be in writing and detailed notes will be kept. No more phone conversations about corrections unless also documented in writing. ? If there are any unclear calculations in the request, it will be sent back to the Club to submit the following month. This will take the liability for the error off the admin and place it back with the Club. ? We will no longer allow miscellaneous benefits (other than payroll taxes) as an allowable expense for reimbursement as they are difficult to verify. ? 1:1 training will be conducted with each Club prior to their first reimbursement request for new grant cycles. With turnover and task sharing in our organization, this will ensure direct training and increase compliance. ? Quarterly financial update calls will be longer/more specific. ? We will no longer allow Clubs to combine requests over multiple months. This inconsistency tends to lead to errors. ? Additional admin support has been added to decrease the number of requests being processed by one individual per month. We have hired an additional staff member. ? Status of Funds o Previous Process: ? Clubs kept up with their budgets/available balances themselves o Current Process: ? Admin updates a running spreadsheet in the shared drive after each month's submission to ensure Clubs are aware of their available balances for each grant o Process Update: No update is needed Anticipated Completion Date: September 30, 2023

Finding: 2022-003 Cash Management Name of Contact Person: Ms. Robin Norwood Corrective Action: Automation clerk will work with NAF administration personnel to provide management of cash. Proposed Completion Date: August 21, 2023

Finding 2022-03: Special Tests ? Required Certifications and HUD Approvals and Environmental Reviews ? Significant Deficiency in Controls over Compliance and Noncompliance ALN #14.218? Community Development Block/Entitlement Grants Recommendation? Management should ensure that they have a mechanism for storing and backing up documentation pertaining to environmental review Responsible Party? Department of Planning and Development Corrective Action Plan? ? A Planning and Development staff member will attend HUD trainings on environmental reviews. That staff will complete environmental reviews before acceptance by supervisory staff and before any federal funds are expended. ? Beginning in FY23-24 all upcoming environmental reviews, including exempt activities, will be on HEROS, the system of record for HUD environmental reviews. Planning and Development will begin to implement these corrective actions immediately or on the timeline identified in the corrective action itself. Responsible Party: Luis Tamayo, Director of Planning and Development

Due to transitions in personnel and systems, written support for the approval of a request for reimbursement was not available. A new Director of Grants Accounting was hired in August 2023 and has reviewed and been trained on the cash management policy. Effective October 2023, written supporting documentation of the review and approval of requests for reimbursement will be obtained and maintained by Grant Accounting staff, in accordance with March of Dimes policy and federal cash management requirements.

The Board will require approval for such expenditures made in short succession and for the bid process to be followed as required by law when the ultimate result of the transaction is a purchase of goods or services of an amount exceeding $20,000.

United States Department of Education Education Stabilization Fund ? CFDA #84.425D/84.425U/84.425W Corrective Action Plan ? Noncompliance with Reporting Requirements Finding: 2022-003 Condition: The District has inadequate controls over reviewing and approving quarterly ?historical expenditure reports? filed with the Illinois State Board of Education. Plan: The superintendent will review and approve quarterly ?historical expenditure reports? and supporting documentation on a regular basis prior to electronic submissions. Corresponding documents will be manually signed and dated to indicate approval. Anticipated Date of Completion: January 1, 2023 Management Response: The District intends to implement the recommendations in FY 2023. Name of Contact Person: Jessica Sisil, District Superintendent

Corrective Action Plan: Catholic Charities Program Manager, Joanne Varnes, conducted a training on December 15, 2022 with all staff involved in the CACFP that included income eligibility/enrollment categorization and meal count accuracy. Catholic Charities staff will review each income form/enrollment and double check that children?s reimbursement rate is properly categorized based on their family?s income. Staff members will review each claim before it is entered for reimbursement to ensure the claim is accurate. Program Manager, Joanne Varnes, will oversee this process and conduct case record reviews quarterly for all providers under Catholic Charities Sponsorship. Contact Person Responsible for Corrective Action: Fritz Jones, Executive Director Anticipated Completion Date of Corrective Action: Immediately

Reporting views of responsible officials and planned corrective actions Management will open a new residual account for this HUD entity and will put controls in place to ensure that the calculated surplus cash balance is deposited into the account, if applicable, annually.

Reporting views of responsible officials and planned corrective actions Management will ensure that security deposits are tracked so they can be recorded accordingly when there is a move in and/or move out. Moving forward management will put in place controls to ensure that the calculation is done at the end of the fiscal year.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Sherry Lockard Contact Phone Number: 812-283-1500 Views of Responsible Official: The Town concurs with the finding. Description of Corrective Action Plan: The Town has assigned the duties to request reimbursement (LPA Invoice Voucher) from the IN Dept of Transportation to the Office Manager of Public Works. The Office Manager will prepare the LPA Invoice Voucher for INDOT and one of the two ERC?s, Public Works Director, or Assistant Public Works Director, will review for accuracy and sign off on the LPA Invoice Voucher. Anticipated Completion Date: May 9, 2023

Finding 2022-004 ? Higher Education Emergency Relief Fund, CFDA#84.425F The University is committed to following all guidelines in the HEERF programs and will amend any quarterly or annual reports as needed. All HEERF related transactions will be reviewed for compliance before executing the drawdowns or disbursements. The most recent disbursement of student funds followed a stringent process. HEERF requirements were reviewed prior to implementation between the business office and the financial aid office. Eligible students were verified by both offices. The disbursements were compiled by the controller and the amounts were put on student accounts by the director of student accounts. HEERF drawdowns were then requested from the general ledger accountant with the controller verifying the drawdowns reconciled with amount put on student accounts. Business office staff distributed the checks to students; signatures were required for pick up by the students. Responsible Parties: Eric McDonald, Interim VP of Finance and Administration emcdonald@limestone.edu 864-488-4522 Jeremy Whitaker, Associate VP of Finance and Administration jwhitaker@limestone.edu 864-488-4539

FINDING 2022-003 Subject: Staffing for Adequate Fire and Emergency Response (SAFER) Contact Person Responsible for Corrective Action: Dustin Dillard Contact Phone Number: 812-331-1906 Views of Responsible Official: We understand and agree with the importance of internal controls and segregation of duties at the District and we believe our policies, procedures, individual job descriptions and management oversight fulfill these necessary requirements, we intend to comply with the suggestions made by the auditing staff. Description of Corrective Action Plan: The SAFER Reimbursement Request spreadsheets are prepared by two administrative personnel who perform checks and balances on calculations, payroll reports, time-keeping reports and employee roster changes before submitting the information to the Fire Chief for review and submission. The District now requires both Administrative personnel to sign and date a cover sheet upon completion of the compilation. The Financial Administrative Assistant will reconcile the data entered into the FEMA portal by the Chief by initialing a printed copy of the dated request. Anticipated Completion Date: To be implemented with all future reimbursement requests following this date 8-23-23 More information about this finding is available in the Supplemental Report.

Finding Number: 2022-1 Payment of invoices before 30 days of received. The project staff was oriented about the importance of make a payment 30 days after receive the invoice. The plan of correction empathizes in verify weekly the supplier?s invoices and establish a payment date not more than 30 days of the invoice was received.

Reference Number: 2022-004 Description: Child Nutrition Cluster ? Reporting Corrective Action Plan: The pandemic-related policies for food service reporting ended on June 30, 2022. For the 2022-23 school year, the District has re-instituted the use of IDs and student numbers to track meal purchases by individual students. Reports from Skyward will be utilized and compared against claim data on a monthly basis . Anticipated Corrective Action Plan Completion Date: 9/1/2023 Contact Information: For additional information regarding this finding please contact Kevin Klimek, Director of Business Services, 414-371-6774

Financial Statement Finding Number: 2022-101 Lack of Documented Review of Reimbursement Requests Planned Corrective Action: This finding was identified during the 2020 audit which was not issued until February of 2022. Once issued, the City implemented new procedures where the Florida Public Assistance website sends an email to request approval of reimbursements. The public work director and public works assistant both approve the reimbursement. The public works assistant then uploads reimbursement into Florida Public Assistance website and signs electronically for reimbursement to document review and approval by the City of the reimbursement request. Anticipated Completion Date: 09/30/2023 Responsible Contact Person: Taylor Jeffreys, Public Works Assistant

Finding: 2022-037 Office of State Treasurer Response/Corrective Action Plan: The Office of State Treasurer does agree with finding that we were not in compliance with federal regulations as an overpayment to the county for reimbursement for law enforcement payroll is not an allowable use of federal funds. The corrective action plan as follows: 1. The Office of State Treasurer will work with ND Office of Management and Budget to determine county contact information and any prior data requested to keep records consistent. 2. The Office of State Treasurer will contact the county to request support from the county supporting allowable expenditures incurred during the period beginning March 1, 2020 and ending on December 31, 2021 to offset the overpayment as stated in recommendation A on the Schedule of Federal Findings and Questioned Costs sent to the Office of State Treasurer on February 9, 2023. Contact Person: Nicole Krivoruchka Director of Finance Anticipated Completion Date: March 23, 2023

Office of State Treasurer Finding: 2022-036 Office of State Treasurer Response/Corrective Action Plan: The Office of State Treasurer does agree with finding that we were not in compliance with federal regulations related to providing required information to subrecipients of Coronavirus Relief Funds (CRF). Corrective action planned: 1. The Office of State Treasurer will work with ND Office of Management and Budget (OMB) to communicate to subrecipients timely and create a template for future use that includes the required information that was missed as detailed on the schedule of federal findings and questions costs. 2. The Office of State Treasurer has discussed with OMB that the information will not be recommunicated to the subrecipients as OMB has been in contact with subrecipients in guiding them to necessary information and assisting with any needs. It has been determined that communicating the information retroactively would cause more confusion and issues among the subrecipients. Contact Person: Nicole Krivoruchka Director of Finance Anticipated Completion Date September 3, 2023