Corrective Action Plans

Corrective Action Plan 2022-001 This finding is caused by the District?s Food Service Fund?s fund balance exceeding the USDA?s threshold of 3 months average expenditures. The District is fully aware of this situation and has a Michigan Department of Education approved 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 to be before the end of the 2022-23 fiscal year. The persons responsible for the corrective action are Shelley Ritchie, the food service director and Nadia Hoover, the business manager. The anticipated completion date of the corrective action plan is before the end of the 2023 fiscal year. The plan for monitoring adherence is the food service director and business manager will work together to assess where the fund balance is after all of the projects from the spend down plan are completed.

Section II ? Financial Statement Findings 2022-001 [2021-001] ? Internal Control Issues for Payroll (Significant Deficiency) Repeated and Modified Responsible Official?s Plan: Business Manager will review payroll files to ensure that employee contributions are being calculated and withheld properly. ? Timeline for completion of corrective action plan: February 1, 2023 ? Employee position(s) responsible for meeting the timeline: Payroll and Kimberly Cordova, Business Manager 2022-002 [2020-001] ? Purchase Orders Payment Authorization and Supporting Documentation (Significant Deficiency) Repeated and Modified Responsible official?s view: District will continue to train and remind employees on the District and State policy in regard to payment of goods and services. ? Timeline for completion of corrective action plan: February 1, 2023 ? Employee position(s) responsible for meeting the timeline: Kimberly Cordova, Business Manager Section IV ? 12-6-5 NMSA 1978 Findings 2022-004 [2020-006] ? Improper Approval of Budget Adjustment (Other Non-compliance) Repeated and Modified Responsible Official?s Plan: District will ensure that all budget adjustments are recorded in the accounting system once they have been approved. ? Timeline for completion of corrective action plan: February 1, 2023 ? Employee position(s) responsible for meeting the timeline: Kimberly Cordova, Business Manager Section IV ? 12-6-5 NMSA 1978 Findings (Continued) 2022-005 [NM 2020-005] ? Improper Cash Controls Outstanding Warrants (Other Non-Compliance) Repeated and Modified Responsible Official?s Plan: Management will adequately monitor outstanding warrants and ensure that they are removed within the one-year time. ? Timeline for completion of corrective action plan: February 1 2023 ? Employee position(s) responsible for meeting the timeline: Vada Ortega, Accounts Payable/Payroll and Kimberly Cordova, Business Manager Section IV ? 12-6-5 NMSA 1978 Findings (Continued) 2022-006 ? Improper Reimbursement of Travel Expense (Other Non-Compliance) Responsible Official?s View: Management will ensure that they are reimbursing employees properly for qualified expenses and ensure that policies are consistent for all employees. ? Timeline for completion of corrective action plan: February 1, 2023 ? Employee position(s) responsible for meeting the timeline: Vada Ortega, Accounts Payable and Kimberly Cordova, Business Manager Section III ? Federal Findings 2022-003 Failure to Follow Davis Bacon and Capital Expenditure Requirements (Material Weakness and Other Matters) Responsible Official?s Plan: The District will establish a policy and implement internal control procedures regarding the review of all grant award letters to ensure that the District is aware of all requirements that are imposed on the District with accepting the funds. The District will work with the contractor to obtain weekly wage certifications going back from the beginning of the project forward to be able to demonstrate that the appropriate wages are paid during the full time-frame of the project ? Timeline for completion of corrective action plan: February 1, 2023 ? Employee position(s) responsible for meeting the timeline: Troy Green, Maintenance Supervisor/Kimberly Cordova, Business Manager

Corrective Action Plan Responsible Official: Iman Riddick, Registrar and T.J. Snowden, Director of Financial Aid Anticipated Completion Date: Dec 15, 2022 Finding 2022-001: Enrollment Reporting and Documentation of Controls Views of Responsible Officials and Planned Corrective Action: Management agrees with the recommended corrective action for which the Institute immediately began to remediate. This relates to the National Student Loan Data System (NSLDS) site modernization resulting in NSLDS functionality/operational pauses that included the data flow from National Student Clearinghouse (NSC) to NSLDS. This issue has been resolved. The Institute has established a procedure to ensure this does not happen again. It should also be noted that as of December 2022, the Director of Financial Aid and Registrar have implemented procedures and controls to ensure that all required reporting to the NSLDS is performed accurately and in a timely manner. Each month?s enrollment data submission to National Student Clearinghouse by the Registrar will be reviewed by the Director of Financial Aid to verify the consistency of the data in NSLDS; The Director of Admissions and the Registrar will review submission of the 10 business days after the original submission and on the 14th of each month prior to the submission of the next batch of enrollment data to the National Student Clearinghouse. This will allow IWP to correct any inaccurate reporting and verify timely submissions to both systems, providing a preventive control in addition to the resolution of the NSLDS functionality pause.

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2022 through December 31, 2022 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of April through December 2022, resulting in $234,254 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization will meet with subgrantees to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2022 as of August 30, 2023.

2022-003 Segregation of Duties ? Reporting Federal Assistance Listing Number: 10.CNC Management is cognizant of the District?s internal control structure and continues to evaluate cost effective opportunities to further improve segregation of duties. It is the District?s plan to train an individual in the process of submitting claims in order to create a review process of the grant management process. Responsible Official: Karl Volkmann, Business Manager Anticipated Completion Date: June 30, 2023

Name of contact person: Laura Shola, Business Manager Corrective Action: The process of reporting eligible federal expenditures will be modified to ensure that remittances to request reimbursement occur in a timely manner. Anticipated Completion Date: The District will implement the above procedure immediately.

Finding 2022-002 Name of Contact Person: Terry Dudney, Chief Finance Officer Corrective Action Plan: Management will implement controls and procedures to ensure that federal funds are expended in a timely manner. Proposed Completion Date: As soon as possible.

Elder Care One Inc. June 30, 2022 Corrective Action: Elder Care 1 Finding 2022-001 over payment of Payroll Reimbursement: Management will make an adjustment to the billing of payroll for September 1, 2022 to correct for the over billing . Responsible party: Michelle Cabana

Current Year Finding #2022-001- Repeat Finding for 2021-001 According to 2 CFR section 200.305(b)(5), when non-federal entities are funded under the reimbursement method, the entity should pay for costs for which reimbursement was requested prior to the date of the reimbursement request. During our audit, we noted the monthly claims for reimbursement were not compared to reports from the point of sale ("POS") system by an individual other than the preparer of the claims report prior to submission. We recommended that the district have an individual other than the preparer of the claims report, review the reports from the POS system prior to submission to verify that the number of meals claim based on actual meals served. Corrective Action: Effective July 30th, 2022, the Food Service Manager will prepare and review the meal count and meal reimbursement to the reports from the point-of-sale system, then prior to submittal will give to the reports from the POS system to the Business Administrator, Mr. Salvatore Carambia to verify and approve the reports from the POS system that the number of meals claimed was based on actual meals served.

Finding 2022-001 Subject: Medicaid ? Eligibility, Other Matters Audit Findings: 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 eligibility compliance requirements that are performed by the Special Education Cooperative on behalf of the School Corporation. Context: The School Corporation participates in a Special Education Co-op. In 2015, the Co-op provided an avenue through a third-party company, for the member school districts to obtain reimbursement for Medicaid services. It was discovered in 2021 that the yearly parental disclosure statements had not been completed for Medicaid eligibility compliance. Due to this oversight, each member school has had to voi transactions through the third-party company and pay back the amount of these transactions from August 9, 2015 through April 23, 2021. The School Corporation?s amount owed was $481,276 for the period identified during 2015-2021. The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. The amount related to this period July 1, 2020 through June 30, 2022 was indeterminable. The full amount was paid back prior to June 30, 2021. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Parental disclosure statements are completed annually for Medicaid eligibility compliance. This has already been implemented. Responsible Party and Timeline for Completion: Madeline Sandberg, Director of BCNWH Joint Services, 7/1/2021

Finding Number:2022-003 Finding: Management did not prepare reconciliations for a portion of the year of residual receipts and reserve for replacement accounts to ensure compliance with program requirements. Management has indicated that due to staff turnover reconciliations were not performed timely. We recommend management implement timely preparation and review of all cash accounts to ensure proper amounts are deposited into the restricted accounts each year. Corrective Action: The compliance oversight of the Project was maintained by the same individual from the Project's acquisition during 2016 through her retirement in 2022. Due to staffing shortages after the employee's retirement, there was a portion of the year when no review of account reconciliations of the reserve accounts were being completed and reviewed. Management has filled that position and subsequently brought the account reconciliations up-to-date. Anticipated Completion Date: 6/30/2023 Responsible Contact Person: Vice President of Finance

Corrective Action ? Management will update the existing Internal Control policy which will include a secondary review of monthly meal claim reimbursements prior to resubmitting revised claims. Management will ensure that all revised claims will be submitted within the 60-day timeframe.

Corrective Action ? Management will re-train and certify staff on the Internal Control policy.

Finding Number: 2022-002 Planned Corrective Action: The District has initiated an internal audit reconciliation system to confirm each month that all reimbursable breakfast and lunch reports agree. Anticipated Completion Date: 07/01/2022 Responsible Contact Person: Neil Laughbaum, Director of Operations

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