Corrective Action Plans

Sharon Armijo Clerk ? PO Box 197 (575) 533-6400 Joyce Laney Treasurer ? PO Box 407 (575) 533-6384 Lillie Laney Assessor ? PO Box 416 (575) 533-6577 Keith Hughes Sheriff ? PO Box 467 (575) 533-6222 Lucinda Howell Probate Judge 100 Main St. Reserve, New Mexico 87830 Buster F. Green Commissioner District No. 1 Audrey H. McQueen Commissioner District No. 2 Haydn Forward Commissioner District No. 3 Commission Office PO Box 507 ? (575) 533-6423 FAX (575) 533-6433 Loren Cushman County Manager 2022-001 (2018-003) Procurement of Goods and Services (Significant Deficiency) Condition ? During our test work of a sample of 35 transactions we noted the following: County not following disbursements policy and procedures: ? No PO, PO not attached (6 of 35) P cards (6 of 20) ? 1 month ? no documentation of commission review of monthly check register ? Invoice referenced but not attached ? Taxes paid on goods (6 instances) ? 2 instances with no supporting documents Procurement ? (under $20,000) ? 1 No PO ? 1 No supporting documents Procurement ? (> $20,000 & <$60,000) ? 3 instances of only 1 quote ? 2 No supporting documents The County continues to have documentation retention or application issues, no progress from prior year. Corrective Action Plan ? Staff has been proactive in ensuring that purchase orders and invoices are attached to checks and has created a filing system for processed checks. Staff has been proactive in confirming receipts of goods/services, requesting receipts from purchasers, and generally following the NM Procurement Code and County Procurement Policy. Checks are currently being backed up electronically along with purchase orders and other supporting documentation of purchase receipt and justification. Staff has been proactive in obtaining NTTC forms for businesses and utilizing vendors with current state contracts. Staff has created a binder for documenting monthly review of purchases by Commission including maintain original signatures of Commission members. In instances where procurement has found it impossible to obtain three quotations, staff has maintained adequate documentation of best efforts made to obtain said quotes and has conversed with legal to determine that best efforts is adequate in these instances. Responsible Position: Chief Procurement Officer/Accounts Payable Timeline for Correction: Completed Catron County Corrective Action Plan (continued) 2022-002 (2018-006) Local Government Budget Management System (LGBMS) Reporting Incomplete (Other Non-Compliance Repeated with modification. Condition ? The County did not include all budget expenditures in the LGBMS system. The County reported total budgeted expenditures for their original budget in LGBMS of $10,965,065. The actual budget amounts that should have been reported were $11,239,091. The County did not present a revenue budget to the Commission for approval when the Commission approved the expenditure budget. In addition the County did not enter the revenue budget into the budget to actual reporting system to aid in budget monitoring. The County continued to have budget compliance, monitoring and reporting issues in the current year, and therefore no progress has been made regarding budget in the current year. Corrective Action Plan ? We did hire a Finance Director and then almost immediately put him to work as Interim County Manager. A full time County Manager finally started March 22, 2023. The Finance Director?s goal is to have the County?s reporting to the DFA a routine matter ? accurate and on time. Responsible Position: Finance Director Timeline for Correction: June 30, 2024 2022-003 (2018-002) Maintenance of Capital Assets (Material Weakness) Repeated. Condition ? ? Construction In Process is not maintained and lacks a consistent process for adding to the depreciation schedule. ? Depreciation schedule was not updated or calculated for the entire fiscal year. The County digressed in its maintenance of capital asset records and documentation. Corrective Action Plan ? One of the goals of the new Finance Director is a complete review of Catron County?s capital asset records. Responsible Position: Finance Director Timeline for Correction: June 30, 2024 Catron County Corrective Action Plan (continued) 2022-004 Personnel File Maintenance (Significant Deficiency) Statement of Condition ? We tested a sample of 10 Payroll transactions and noted the following: ? Three instances (3 of 10) where the current payrate was not substantiated by a personnel action form. ? One personnel file did not include any current documents ? all documents were for 2017 and prior. ? One personnel file lacked a PERA membership application. Corrective Action Plan ? The County has made available training through NM EDGE where we can learn to improve procedures, and best practices to develop strategies on completing internal controls. Auditors did provide valuable feedback on what was necessary to complete Personnel files and those suggestions will be implemented form there on. Responsible Position: HR/Payroll Clerk Timeline: June 30, 2023 2022-005 Solid Waste Receipts Audit Trail (Significant Deficiency) Statement of Condition ? The Solid Waste department?s receipting system lacks a clear audit trail. ? No schedule indicating receipts by customer, only a total page of deposit amount (5 deposits for dump fees totaling $9,696) ? Cash deposits were co-mingled with other cash deposits for the day and therefore not traceable specifically to solid waste cash receipts (all solid waste receipts ? 10 receipts tested totaling $19,392) ? No receipts are issued for each customer (receipts only issued upon customer request) No copies or records of receipts that were issued were maintained (all solid waste receipts ? 10 receipts tested totaling $19,392) Corrective Action Plan ? 1. Solid Waste Clerk will attach a corresponding customer receipt to all spreadsheets. 2. Treasurer?s Office has reconciled the second issue listed above. 3. Convenience Center Attendants will immediately receipt all customers. Responsible Position: Solid Waste Clerk/Coordinator Timeline: April 30, 2023 2022-006 Travel and Perdiem Procedures and Regulations Not Properly Followed (Other Non-Compliance) Statement of Condition ? We tested a sample of 10 travel transactions and noted the following: ? 5 instances where no travel form (per policy) was attached to approve travel $2730.64. ? 1 instance where mileage rate reimbursed was $.46 per mile rather that $.45 per mile ? total over allowable reimbursement was $1.25. Corrective Action Plan ? New travel forms have been created pursuant to DFA Per Diem rates from Memo dated April 12, 2022. New staff has been proactive in ensuring that travel requests are handled timely and properly. Responsible Position: Accounts Payable Timeline: Completed Catron County Corrective Action Plan (continued) 2022-007 Lack of Maintenance of Grant Documentation (Material Weakness) Statement of Condition ? During our test work of federal award reimbursements and expenditures and New Mexico capital Outlay Appropriations, documentation and supporting invoices and reimbursement requests as well as grant award agreements were not available or present in County records. Reimbursement requests are not timely. County is not following award guidelines to maintain the accounting of grant activity for reimbursement requests, expenditures and supporting documentation. The County has numerous awards that are not managed and status of awards is not current. Corrective Action Plan ? The County hired a Finance Director. Even though he spent most of his first eight months as Interim county Manager, he was able to assemble grant documents and collect grant funds that had been waiting for years to be claimed. As we now also have a full time County Manager, this part of the Finance Director?s job should improve even more. Responsible Position: Financial Director Timeline: June 30, 2023 2022-008 (2020-007) Late Audit Report ? (Other Non-Compliance) Repeated with modification Statement of Condition ? The audit report was submitted to the State Auditor?s Office after the county due date of December 1, 2021. This finding remains essentially the same as prior year. Corrective Action Plan ? We are glad the auditor is taking part of the responsibility here. However, if the County can keep a consistent staff in the Commission Office following proper procedures, the audit will definitely go smoother and quicker. Responsible Position: Finance Director Timeline: June 30, 2024

Views of Responsible Officials and Planned Corrective Actions The timesheets did not reflect the correct hours charged to the program. After discussions with program management, it was discovered that correct communication to staff had not been completed regarding proper program and grant payroll coding for work done on the program. This has been corrected. The Foundation?s contract administrative staff is working more closely with program staff to ensure for each payroll that the time worked on programs is properly reflected on timesheets that are approved by employees and managers. Necessary changes are communicated between program and contract administrative staff to ensure that timesheets reflect work hours properly. Personnel responsible for implementation: Steven Hartman Position of responsible personnel: Associate Director, Contract Accounting Date of Implementation: August 31, 2023

Action item - Title 2022-002 - Time Elapsing Between Transfer of Funds and Disbursements Date Identified: March 2023 Status: (Open; In-process) In-process Description Time elapsed between the transfer of funds from the US Department of Education and UPPR disbursement, instances where found in which the time elapsed exceeds a reasonable time. Grantee Required Action: PUPR should identify a time control method to assist the University in reducing the time elapsing between the transfer of funds from the Federal awarding agency and its disbursements. Identified Root Cause: Lack of controls over the cash management requirement to maintain the advance method. Grantee resolution plan: Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the Grant monthly reconciliation to Federal and State Funds Administration Office, Compliance officer reviews the reconciliation and Director of Federal Funds Administration determine needed funds to be requested. A new Enterprise Resource Planning (ERP) software it?s under implementation and will address this issue as part of the implementation process. Anticipated completion date: September 2023 Name and Title of contact person responsible for corrective action: Pablo Salom Portela- Director, Federal and State Funds Administration Office Phone: 787-622-8000 ext. 683 Email: psalom@pupr.edu

Finding Number: 2022-001 Condition: The College drew down an estimated amount for student and institutional portion prior to the funds being disbursed to students or used for allowable expenditures. Planned Corrective Action: The College will review its cash management policies and in the future follow U.S. GAAP and the uniform guidance. Contact person responsible for corrective action: Tom Reynolds, Associate Vice President of Business Services and Deputy Treasurer Lakeland Community College Anticipated Completion Date: As soon as possible moving forward starting 12/19/2022

Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency was funded on March 8, 2022 in the amount of $12,428. Management will ensure that the residual receipts account is properly funded in the future. Completion Date: March 8, 2022

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency was funded on February 25, 2022 in the amount of $15,254. Management will ensure that the residual receipts account is properly funded in the future. Completion Date: August 1, 2022

Response and Corrective Action Plan: The District will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget. Kevin Posekany, June 30, 2023.

2022-001: Reporting Corrective Action: Due to ever-evolving processes, LCCC did not fully comprehend all reporting nuances for the HEER program. The Comptroller and Director of Sponsored Awards will continue to perform in-depth reviews of all reporting guidance and requirements to ensure accurate reporting. Anticipated Completion Date: June 30, 2023 Contact Persons: Nola Rocha, Comptroller and Jennifer McCartney, Director of Sponsored Awards and Compliance

2022-002 Condition and Criteria: The U.S. Department of Agriculture regulation located at 7 CFR Part 210, Subpart C, Section 210.14(b) states that the food service fund is to limit its net cash resources to an amount that does not exceed 3 months average expenditures. The cash and due from other funds balances in the Academy's food service fund exceeded the allowable amount at June 30, 2022. Cause: While the appropriate Academy employees were aware of the applicable compliance requirements, the Academy did not spend the necessary amount to reduce fund balance to the allowable limit. Effect: Noncompliance with the requirements of the Code of Federal Regulations. Recommendation: The Academy should develop and implement a plan to reduce its net cash resources to the allowable limit. Management Response: The The Academy through its management company has developed processes to ensure all costs related to the operation of the food service fund are properly recorded. Additionally, the Academy subsequent to year, made significant purchases to upgrade the kitchen equipment further spending the necessary amount to reduce the fund balance to the allowable limit.

Recommendation: The final payables listing that is approved and matches the grant drawdown amount should be retained to document proper approval. Planned Corrective Action: Management agrees with the findings and will review personnel needs with the objective of being able to better support the office staff and perform monitoring activities

Finding 2022-004 Contact Person Responsible for Corrective Action: Rhonda Morgan, FSD Contact Phone Number: 765-240-2386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Frontier School Corporation will have the Elementary and Jr/Sr High Kitchen Managers pull the monthly reports from eTrition for breakfast and lunch meals served for their respective schools. A blank Monthly Worksheet will be provided to each Kitchen Manager to be filled out using the data report from eTrition, the foodservice software. The reports and worksheets from each school will be given to the Food Service Director. The FSD will have independently prepared a complete report using data pulled from eTrition including both schools. The FSD will then compare the elementary Kitchen Manager?s report with the Master Report. The FSD will then compare the Jr/Sr High Kitchen Manager?s report with the Master Report. The Master Report will then be presented to each Kitchen Manager for their approval after checking to see that the data matches, initialing and dating the Master Report. The Food Service Director will then submit the Monthly Claims Report to CNPweb. The Corporation Treasurer will also have access to all data collected to ensure proper reportig. All data and internal checks will be filed in the Food Service Director?s office.. Anticipated Completion Date: The CAP will be in place by March 24, 2023 in preparation for the Monthly Claim of March 2023 to be the first month these internal controls will be implemented.

CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 Millersburg Area School District submits the following corrective action plan in response to the finding listed in Section III of the Schedule of Findings and Questioned Costs for Federal Awards for the year ended June 30, 2022: Significant Deficiency in Internal Control and Compliance Finding: Finding 2022-001 ? Cash Management and Reporting Condition: The District incorrectly filed its June 2021 quarterly report which in turn resulted in PDE halting payments and placing grant #013-210254 in dormant status. The District did not file any further quarterly returns in a timely manner within the 10-day requirement or the final expenditure report in a timely manner within the 30-day requirement. The District did not file the final expenditure report for grant #013-220254 in a timely manner within the 30-day requirement. The District did not file the final expenditure report for grant #200-200254 in a timely manner within the 30-day requirement. The District did not file the quarterly reports for grant #223-210254 and #225-210254 in a timely manner within the 10-day requirement. Views of Responsible Officials: The District will review and establish procedures to ensure that all required quarterly cash on hand and final expenditure reports are properly completed within the required time periods. Planned Corrective Action: A new federal programs coordinator has been hired and the district has consulted with an experienced federal programs coordinator to train that individual. Procedures are now in place to ensure that the District files all quarterly cash on hand reports within 10 days of quarter ending and final expenditure reports within 30 days after the funds are expended, but no later than 30 days after the ending date of the project. All existing compliance issues related to filing deadlines are being addressed and corrected. Person Responsible for Corrective Action Plan: Mr. Michael A. Lyter, Federal Programs Coordinator Anticipated Completion Date: June 30, 2023 Sincerely, Eric S. Petery, Business Manager

2022-004 Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Chris Holmes Title: Controller Phone Number: 202-235-1938 Estimated Completion Date ? ongoing Corrective Action PSI is refining its method for calculating drawdowns on federal awards that are near the end of the period of performance dates. For such awards, the Accounts Receivable team in Washington will work with the Program Management Teams to obtain specific projections of trailing costs from country offices.

Corrective Action: All staff involved in the receipting of these special type of revenues will receive extensive training to understand when to record unearned revenue. Workers will be required to attend and sign a memorandum of understanding after training completion. Proper monitoring by supervisors and the administrative officer of reimbursement programs will occur weekly over timesheets to ensure the timesheets include all time coded on the daysheets.

Condition: During our testing of special tests and provisions, we noted multiple payments to subrecipients that were not made within 30 days. Recommendation: A system needs to be put into place to track when payment requests are made to ensure payments to subrecipients can be made timely. Current Status: After completion of the prior year audit, Management developed a procedure and tracking system for the submission of payment requests from our subrecipients and reimbursement payments to the subrecipients to ensure payments are made within 30 days of the receipt of the request. This finding has been repeated as 2022-002. Due to the timing of the completion of the prior year audit, the findings identified in the current audit occurred before implementation of the prior year?s corrective action plans.

Finding 2022-001: Education Stabilization Fund??Governor?s Emergency Education Relief (GEER) and Elementary and Secondary School Emergency Relief (ESSER) Fund Semi-Annual Certification Procedures?Continued Pass-through entity: Michigan Department of Education (MDE) Assistance Listing Number(s): 84.425C and 84.425D Award Numbers: COVID-19 211202-2122, COVID-19 213712-2021, COVID-19 213722-2122 and COVID-19 213742-2122 Award Year End: September 30, 2023 Recommendation: The School District should provide training to educate all employees working in federal programs of the requirements for documenting personnel expenses under Uniform Grant Guidance, and the School District should require proper time-and-effort documentation to be timely prepared and certified by the appropriate program supervisor. Action taken: The School District will implement controls to ensure the appropriate time-and-effort documentation is completed timely and approved by the appropriate program supervisor by adding the topic to management meeting agendas and utilizing Outlook calendar events. Responsible Person and Anticipated Completion Date: Superintendent, December 2022. If the Michigan Department of Education has questions regarding this plan, please call Jim Nielsen at (231) 760-1309.

FINDING NO. 2022-002: Program Federal Assistance Listing Number and Title: 93.323 COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Award Number: 47746-2 Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Human Services Criteria: The Uniform Guidance and State Single Audit Guidelines require that local entities receiving federal and state awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations, and program compliance requirements. The Uniform Guidance and State Single Audit Guidelines further require auditors to obtain an understanding of the local entity's internal control over federal and state programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of monthly reports, which should be reviewed and approved by a responsible party other than the original preparer. Condition: All three of the CARS reports tested were not reviewed by an independent person before submission for reimbursement. Both of the special quarterly reports tested were also not reviewed by an independent person as required by the state. The sample was not statistically valid sample Cause: The City did not have internal control procedures in place requiring an independent person to review the reports before submission and ensure the reports were accurately and timely submitted. Effect: Reports were not submitted and those that were submitted could contain errors. Questioned Costs: None noted. Recommendation: The City should review its internal control procedures to ensure there are proper review and approval processes over completeness and accuracy of reports are in place before submissions to state agencies are completed. Management's Response: An individual other than the preparer will review the grant reports prior to submittal. Person responsible for report ? Karen Skowronski, Treasurer/Comptroller, 414.768.8048

2022-003 ?Significant Deficiency in Cash Management Recommendation: After the drawdown requests are completed, they should be reviewed and approved by someone other than the original preparer who would be knowledgeable enough to identify an error in the reconciliation. Planned Action The School plans to add an additional individual to the process to review and approve the drawdown requests. Proposed Completion Date: The School will review processes to ensure we are in compliance by January 31, 2023.

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Voucher Cluster Assistance Listing Number: 14.871 & 14.879 Passed Through: Direct Award Pass Through Number: N/A Compliance Requirement Affected: Special Provisions Award Period: 2022 Type of Finding: Material Weakness in Internal Control over Compliance. Recommendation: We recommend that the Authority design and implement internal controls over special provisions. Other provisions, such as reasonable rent, housing quality standards inspections, and HQS enforcement, should be reviewed by someone independent of the initial preparation/inspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will evaluate implementing reviews over tenant files, financial and performance reports, and other special provisions. Name of the contact person responsible for corrective action plan: Kim Wallace, Executive Director Planned completion date for corrective action plan: December 31, 2023

Finding 2022-004 ? Child Nutrition Cluster - Reporting Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Lunch reimbursement claims will be reviewed by a secondary individual prior to submission to IDOE and signed off on to document the review. Anticipated Completion Date: April 2023

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-004?Eligibility Program: Medical Assistance Program (ALN 93.778) Type of Finding: Material Weakness in Internal Control over Compliance; Other Matter Compliance Finding Condition: During our testing, we noted the following instances of noncompliance in the sample of 120 case files tested: ? One MAXIS case file had assets greater than their applicable household size asset limit. While beneficiaries may reduce their assets to continue to qualify, there was no documentation in the case notes showing the applicant reduced their assets subsequent to renewal in order to continue to qualify for benefits. ? One MAXIS case file had different bases of eligibility in MAXIS and MMIS where MAXIS indicated the beneficiary was ?EX? (age 65 or older) while MMIS indicated the beneficiary was ?DX? (disabled). ? One METS case file included documentation of verification of income that did not match the information entered into METS. ? One METS case file did not have a SSN entered at either the initial application date nor any of the subsequent renewal dates. No exemptions to the requirement to submit a SSN was noted in the case within METS. In addition, the County does not have effective internal controls over eligibility of the Medicaid program: ? The County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the MAXIS and METS systems. ? We were not able to review and test the automated application controls and the related ITGCs within the MAXIS, METS and MMIS systems, all of which are state systems that are administered by the state and required to be used by the County, to determine whether the system controls are adequately designed and implemented and operating effectively for the determination of eligibility. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will design internal controls to ensure eligibility inputs are correctly entered, and information required by contract is retained. Hennepin County Employee Responsible for the CAP: Jackie Poidinger Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS, METS, and MMIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

2022-011 COVID-19, Education Stabilization Fund: Higher Education Emergency Relief Fund - Student Aid Portion and Institutional Portion ? Federal Assistance Listing Nos. 84.425E and 84.425F ? Cash Management Recommendation: We recommend the University formally document, establish controls and monitor advances in federal funds to ensure time elapsing between the transfer of funds and disbursement is minimized and any interest required to be remitted is calculated and returned on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will formally document, establish controls and monitor advances in federal funds to ensure time elapsing between the transfer of funds and disbursement is minimized and any interest required to be remitted is calculated and returned on a timely basis. Name(s) of the contact person(s) responsible for corrective action: Assistant Controller, Sasha N. Lee. Planned completion date for corrective action plan: June 2023

Department of Agriculture Finding 2022-001: Child Nutrition Cluster Resource Management Procedures Pass-through entity: Michigan Department of Education Assistance Listing Number: 10.553, 10.555, and 10.559 Award Numbers: COVID-19 211971, COVID-19 221971, COVID-19 211961, COVID-19 221961, COVID-19 210904, COVID-19 220904, and Entitlement Commodities Award Year End: June 30, 2022 Recommendation: The School District should continue its spend-down plan to ensure it reduces its Food Service Fund net cash resources below the maximum allowable amount. Action Taken: The School District has ordered equipment totaling approximately $390,000 that was not received by June 30, 2022. Once the equipment is received and paid for the School District will be in compliance with this requirement. Responsible Person and Anticipated Completion Date: Director of Finance, June 30, 2023 If the Michigan Department of Education has questions regarding this plan, please call Todd M. Hronek at (231) 788-7100.

The District will continue to file reimbursement for all meals served in the fiscal year.

Management concurs with the finding. The Project will ensure the surplus calculation is completed timely and the required deposit to the residual receipts reserve made by February 28th, the 60 day requirement, if necessary. We will implement this procedure in 2023.