Corrective Action Plans

FINDING 2024-004 Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness, Other Matters 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 cash management compliance requirement. Context: In a sample of 5 monthly claims for reimbursement selected for testing, the following compliance exceptions were noted: • Management failed to submit the April 2023 claim for reimbursement in a timely manner (within 90 days) to the IDOE and was not reimbursed for meals served as a result. • For the other 5 claims tested, the number of meals claimed did not agree to the supporting meal system reports. There was a gross overstatement of meals claimed of $21,189 and a gross understatement of meals claimed of $538.35 resulting in a net over-reimbursement of $20,650.47. We noted that the School Corporation has a secondary review control in place designed to review claims prior to submission to the IDOE. However, the control was not operating effectively to detect and prevent errors in the amount claimed for reimbursement. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management has revised and implemented a more thorough control process over the preparation and submission of the monthly claims for reimbursement. A reconciliation sheet has been created and implemented for verification and will be completed every month. Responsible Party and Timeline for Completion: Jessica Defossett and Kendra Franks, January 2025

Annually update the college website with contract and/or cost information regarding the third-party provider. Provide contract information URL to ED for publication in the Cash Management Contracts Database.

Finding 2024-002 – Documentation of Costs and Vendor Invoices – Financial Reporting and Internal Controls ALN 14.850 & 14.871– Noncompliance & Material Weakness Recommendation: We recommend that the Authority amend policies and procedures to better facilitate effective purchasing controls. A clear audit trail should be maintained to ensure proper approval, as well as documentation to support the allowability and eligibility of costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will enhance our internal controls over purchasing and Develop detailed procedures for creating, approving, and managing purchase orders. Name(s) of the contact person(s) responsible for corrective action: Navonya Kolani, Executive Director Planned completion date for corrective action plan: September 30, 2025.

Finding 2024-001 – Capital Fund Program Accounting– Cash Management & Program Compliance ALN 14.872 – Grant years 2018, 2019, 2021, 2022 – Noncompliance & Material Weakness Recommendation: We recommend that the PHA establish an appropriate cash management procedure that facilitates timely requests and reimbursements of grant costs as incurred. We also recommend that the applicable PHA staff undergo Capital Fund training to ensure grant requirements are met prior to their deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will conduct a comprehensive review of existing cash management policies and procedures and update policies to align with current best practices and regulatory requirements for the Capital Fund Program. We will ensure that all staff members are informed of the updated policies and receive appropriate training. Name(s) of the contact person(s) responsible for corrective action: Navonya Kolani, Executive Director Planned completion date for corrective action plan: September 30, 2025.

FINDING 2024-004 – Significant Deficiency in Internal Controls over Compliance – Allowable Cost Principles – Calculation of Project Costs Audit Recommendation: Moss Adams recommends that management perform an in-depth review of all project costs, including a review of any data used in its calculation, prior to the submission of project applications to FEMA or other federal agencies. Corrective Action Plan: PH management will put incorporate additional review processes for reporting to external agencies involving project costs and calculations. This will involve secondary review to identify potential errors. Contact Person Responsible for Corrective Action Plan: Melissa Wallace, Vice President of Finance, and Maritess Delosantos, Director of Finance Special Projects Anticipated Completion of Corrective Action Plan: June 2025 Status: 75% completed The District is continually improving processes to correct and prevent these deficiencies from recurring.

Identifying Number: 2024-004: U.S. Department of Education: Education Stabilization Fund: Institutional Portion – 84.425F Finding: Due to receiving reimbursement on outstanding purchase orders that were paid months later, or not at all, the District received, but did not disburse, the funds within the allowed three-day timeframe. Corrective Action Taken or Planned: Reimbursement requests will be submitted on a timely basis and after payments for the expenses are made. This will help ensure that reimbursement is received at the same time or after payment has been made. Contact person: Mike Stephens, Director of Accounting Status of finding – The above corrective actions will be implemented beginning April 1, 2025.

Identifying Number: 2024-003: U.S. Department of Education: Education Stabilization Fund: Institutional Portion – 84.425F Finding: The District used outstanding purchase order obligations to request reimbursement at the end of the liquidation period, but did not spend all of the outstanding purchase orders; therefore, receiving reimbursement for items that were never purchased. Corrective Action Taken or Planned: The School will designate finance staff to review reimbursements to ensure they have proper expenses as backup. A further review by the School District will help to ensure that funding is spent on items and requests for reimbursement only after expenses have been paid. Contact person: Mike Stephen, Director of Accounting Status of finding – The above corrective actions will be implemented beginning April 1, 2025.

Management concurs. The City will implement policies and procedures at the appropriate level of management in reviewing cash drawdown requests. Once completed, reconciliations will be reviewed and approved by someone other than the preparer to ensure that errors and or/adjustments are identified and corrected in a timely manner.

Department: Defense, Veterans and Emergency Management Administrative and Financial Services Title: Internal control over DG – PA program cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Departments collaboratively developed cash management procedures to address prior year finding 2023-097. The Departments implemented a new cash management process, including weekly reconciliation of draw requests The Departments modified the Treasury-State Agreement with the Office of the State Treasurer to list a Weekly Drawdown - Actual & Estimate funding technique for FY2025. Completion Date: December 13, 2023, December 18, 2023, and June 25, 2024, respectively Agency Contact: Sunny Cyr, MEMA Business Office Director, DVEM, 207-707-2507

Department: Health and Human Services Title: Internal control over Medicaid Nursing Facility audits needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department is working to hire staff for the Medicaid Audit unit. The Deputy Director will assign Nursing Facility audits to auditors who have been working on COVID fund audits. The Department will hold monthly meetings with the Director, Deputy Director and Senior auditors to discuss strategies for completing the Nursing Facility audits timely. Completion Date: Ongoing, July 1, 2025 and February 1, 2025 respectively Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2778

Department: Health and Human Services Title: Internal control over TANF program subrecipient cash management needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Department is in compliance with the requirement for minimizing the time between payments to our subrecipients and the disbursement of funds. Payments are made as close as administratively feasible. The Compliance Supplement suggested audit procedures for Cash Management for pass-through entities refers to 200.305(b)(1). That same paragraph states that the timing and amount of advance payments must be as close as is administratively feasible. Completion Date: N/A Agency Contact: Anthony Madden, Deputy Director of Audit, DHHS, 207-287-2834

Department: Health and Human Services Title: Internal control over ICA program subrecipient cash management needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Department is in compliance with the requirement for minimizing the time between payments to our subrecipients and the disbursement of funds. Payments are made as close as administratively feasible. The Compliance Supplement suggested audit procedures for Cash Management for pass-through entities refers to 200.305(b)(1. That same paragraph states that the timing and amount of advance payments must be as close as is administratively feasible. Completion Date: N/A Agency Contact: Anthony Madden, Deputy Director of Audit, DHHS, 207-287-2834

Department: Health and Human Services Title: Internal control over CSLFRF subrecipient cash management needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Department is in compliance with the requirement for minimizing the time between payments to our subrecipients and the disbursement of funds. Payments are made as close as administratively feasible. The Compliance Supplement suggested audit procedures for Cash Management for pass-through entities refers to 200.305(b)(1). That same paragraph states that the timing and amount of advance payments must be as close as is administratively feasible. Completion Date: N/A Agency Contact: Anthony Madden, Deputy Director of Audit, DHHS, 207-287-2834

Department: Health and Human Services Administrative and Financial Services Title: Internal control over WIC cash balances needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will contact the Federal Awarding Agency to identify steps needed to resolve the cash discrepancy. Completion Date: September 30, 2025 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626

Department: Health and Human Services Title: Internal control over WIC subrecipient cash management needs improvement Questioned Costs: None Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding. The Department is in compliance with the requirement for minimizing the time between payments to our subrecipients and the disbursement of the funds. Payments are made as close as administratively feasible. The Compliance Supplement suggested audit procedures for Cash Management for pass-through entities refers to 200.305(b)(1). That same paragraph states that the timing and amount of advance payments must be as close as is administratively feasible. Completion Date: N/A Agency Contact: Anthony Madden, Deputy Director of Audit, DHHS, 207-287-2834

Department: Education Administrative and Financial Services Title: Internal control over CNC cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department has developed and implemented new procedures to confirm that batch payments are paid on time. Completion Date: March 15, 2025 Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

Department: Education Title: Internal control over CNC eligibility needs improvement Questioned Costs: Known: ALN 10.559 $628,924 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Department will create procedures for Application Approvals with site classification, eligibility and non-congregate plan requirements. The Department will develop procedures for Revisions on Claims and Applications. For the Summer Food Service Program, the Department will request an edit check enhancement in CNPWeb to add actual enrollment be added to claims. Completion Date: May 1, 2025, first and second item, and May 1, 2026, third item Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

2024-002 Assistance Listing Number 10.558 – Child and Adult Care Food Program: Provider Monitoring Performance and Documentation Criteria: Per the Florida Department of Health Care Food Program (CCFP) Procedure Manual for Sponsors of Day Care Homes, sponsors are required to performs at least three monitoring reviews of any providers operating for 9 to 12 months during the federal fiscal year. Per the Procedure Manual, sponsors must maintain all completed Provider Review Forms and supporting documentation for a minimum of three fiscal years past the current fiscal year, or until all outstanding audit issues are resolved. Contact Person: Jennifer Nadelkov, Completion Date: 2/14/25 Identified Problem: Due to the CCFP program shutting down the third monitoring did not occur prior to last day of program operation. Action: As this program is closed there is no further action to be taken in this matter.

Response: The District has operated the LINKS afterschool program supported by 21st Century funding for over 20 years. The Office of Public Instruction (OPI) performs monitoring of schools with 21st Century funding every 4 to 5 years. The OPI did a monitoring of the District in 2020 and found no compliance issues. In August of 2024, OPI informed the District that we were not in compliance with changes to the federal regulations made in 2018. In February of 2025, OPI sent a letter to the District indicating that parent fees charged in FY24 and FY25 would need to be applied to reduce federal funding in the future due to the new rules established in 2018. The District is in the process of appealing this finding from OPI and has stopped charging parent fees as of October 2024, while considering the impact of reduced funding to this community program.

Federal Program Information: Funding Agency: U.S. Department of Education Title: Education Stabilization Fund Assistance Listing: 84.425 U Passthrough: N/A Award Year: 2024 Criteria: APPENDIX II TO PART 200—CONTRACT PROVISIONS FOR NON-FEDERAL ENTITY CONTRACTS UNDER FEDERAL AWARDS (D) Davis-Bacon Act, as amended (40 U.S.C. 3141–3148). When required by Federal program legislation, all prime construction contracts in excess of $2,000 awarded by non-Federal entities must include a provision for compliance with the Davis-Bacon Act (40 U.S.C. 3141–3144, and 3146–3148) as supplemented by Department of Labor regulations (29 CFR Part 5, ‘‘Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction’’). In accordance with the statute, contractors must be required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination made by the Secretary of Labor. In addition, contractors must be required to pay wages not less than once a week. The non-Federal entity must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a contract or subcontract must be conditioned upon the acceptance of the wage determination. The non-Federal entity must report all suspected or reported violations to the Federal awarding agency. The contracts must also include a provision for compliance with the Copeland ‘‘AntiKickback’’ Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFR Part 3, ‘‘Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States’’). The Act provides that each contractor or subrecipient must be prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she is otherwise entitled. The non-Federal entity must report all suspected or reported violations to the Federal awarding agency. Condition: During our review of the requirements of Special Tests provisions of the Compliance Supplement and the District’s implementation of controls related to compliance with these provisions for the Education Stabilization Fund, we identified the following issues: The District did not meet the requirement for the Davis-Bacon Act prevailing wage requirement. The District had not included the prevailing wage requirements in the contract with the vendor who was replacing fire panels in the District nor did the District obtain the weekly certified payroll reports from the contractor for each of the projects. Questioned Costs: Unknown. The vendor would have obtained a state wage determination rate because of the dollar-value of the contract, which would have required wages which would meet the Davis Bacon requirements. The District did obtain permission from the New Mexico Public Education Department before beginning the project, and the PED did reimburse all costs, so it is likely that questioned costs may not exist. Cause: District personnel were unaware of the requirement to include language in contracts regarding the Davis- Bacon Act or the Copeland “AntiKickback” Act with companies providing construction or maintenance work for the District when Federal funds are being used to pay for those services. State personnel told the District incorrectly that Davis-Bacon did not apply unless the value of the contract was greater than $60,000 per project or on Native American lands, even though the grant guidance puts the level at $2,000. Effect: The District is not in compliance with Federal requirements when using grant funds to pay for construction or maintenance projects in excess of $2,000. Noncompliance with these provisions could cause reimbursement of these funds to be questioned or require the District to reimburse the granting agency for any costs incurred under these projects. Additionally, companies providing these services may not know they are subject to particular wage rate determinations for the project which may cause them to bid or quote amounts that do not provide for payment of required wages to the employees participating on those projects. Auditor’s Recommendation: We recommend that the District establish a practice of including the required language for the Davis-Bacon Act and the Copeland “AntiKickback” Act in contracts with all companies which provide construction or maintenance projects to the District. When companies are selected that have Cooperative Educational Services agreements, the District should require an additional contract be signed by the company which includes these provisions. Additionally, we recommend that District personnel be trained in identifying which funds fall under Federal regulations versus State regulations so that when purchase orders are created and contracts are entered into that these individuals know they are including the proper requirements. Responsible Official’s Plan: ● Specific corrective action plan for finding: o When receiving new funding, management will review laws and regulations to make sure the district complies with them. Training will be seek if necessary ● Timeline for completion of corrective action plan: o November 30, 2024 ● Employee position(s) responsible for meeting the timeline: o Superintendent- Ray Maestas, Maintenance Supervisor- Tim Callis and business manager- Zach Barsalou

Concur. Due to key vacant positions and the inability to fill these positions, the required reports were not completed and submitted on time during the fiscal year ending June 30, 2024. During the current fiscal year, the County has been successful in recruiting these positions and will ensure that the timely and accurate reports are submitted. In addition, policies and procedures will be documented on reporting requirements to ensure that they are performed on a timely basis.

Federal Programs ALN: 93.575, 93.596, 93.558, and 93.667 Criteria: The Organization is required to remit all interest earned on federally funded advances to DEL within 30 days after the fiscal year end per DEL Program Guidance 240.01 Cash Management and 2 CFR 200.305(9). Condition: The Organization failed to remit all earned interest to DEL within the 31 day deadline in accordance with the grant agreement. Cause: The Organization experienced high management turnover which delayed the calculation of interest earned and remittance to DEL. Effect: The Organization did not meet the remittance submission deadline requirement as set forth by DEL Program Guidance 240.01 Cash Management and 2 CFR 200.305(9). The earned interest was remitted on March 11, 2025. Recommendation: We recommend the Organization designate an individual to calculate interest earned and closely monitor the submission deadline. Corrective Action Plan: Coalition management will make sure that measures are in place to ensure all interest earned is reconciled monthly and paid timely back to DEL. Responsible Party: Xaviera White, Chief Executive Officer Anticipated Completion Date: March 2025

Contact Person Dara Lee, Executive Director of Clay County HRA (Authorized Representative and Agent) Corrective Action Plan The Corporation is aware of the issue and has taken subsequent steps to ensure internal procedures are followed as established. Planned Completed Date for CAP Immediately

Finding: 2024-003 – Special Tests and Provisions – Return of Title IV Funds Condition: During the testing of the return of Title IV funds, it was noted that on three (3) of five (5) tested calculation of funds to be returned had no documentation to determine if returns were completed timely as the College did not retain the lists of students associated with drawdowns and/or returns and two (2) of five (5) tested had not been returned as of the date of fieldwork which exceeded the required timeframe to return funds. Recommendation: Policies and procedures should be written to provide internal control over the documentation used to complete the drawdowns, including returns, from Department of Education. We recommend the College establish a communication and record retention process that allows for the notification of students withdrawing and a control in place that allows the financial aid department to know the student financial aid was returned to Department of Education within the required timeframe. Views of responsible officials and planned corrective action: Areas of focus will be to put in place written policies and procedures for the Financial Aid office, including the area of disbursements that includes additional controls and documentation of such. Our objectives will be that all Financial Aid staff will be required to maintain documentation of any drawdowns of funds related to student financial aid. We have put in place a shared OneDrive electronic folder with restricted access to provide confidentiality and provide documentation of the shared communication between offices. Documentation of drawdowns and/or returns will be maintained within this folder. Staff will be trained on using the daily generated reports from Poise to monitor students who have withdrawal on their records so that this can be updated and proper calculations done. All financial aid staff will attend training to stay up to date on regulations and changes. Starting in July 2025 the new J1 system will be integrated with JFA (financial aid system). This will create operational efficiencies and reporting capabilities that are not currently available. Less manual transactions will also provide more accurate student reports. Measurable targets will be achieved by documenting the records within the OneDrive shared electronic folder between the Financial Aid office and the Business Office, who handles the return of funds. Daily changes and/or withdrawal of students will be monitored and funds will be returned as required. This will become of a part of the regular duties of staff.

Finding: 2024-002 – Special Tests and Provisions – Payment to Students Condition: During our testing of the financial aid disbursements, it was noted the College is not maintaining records of what students the drawdowns were for, therefore we were unable to determine if the amounts were posted to the student accounts within the required time frame and subsequently were paying out any credit balances created on student accounts. Recommendation: Policies and procedures should be written to provide internal control over the documentation used to complete the drawdowns from the Department of Education. We recommend the College establish a communication and record retention process that allows for the notification of the student financial aid proceeds and a control in place that allows the financial aid department to know the student financial aid was applied to the student’s account timely. Views of responsible officials and planned corrective action: Areas of Focus will be in the documentation of policies and procedures to provide clear expectations of internal control documentation used to complete the drawdowns from the Department of Education and for a process of record retention. Our objective would be to formalize the policies and procedures in the Financial Aid policy manual. The policies and procedures will have shared access between the Financial Aid office who approves the aid, the Business Office who ultimately pulls down from the Department of Education, and with the Cashier who distributes any refunds. A OneDrive electronic folder has been created with restricted access to provide confidentiality and provide documentation of the shared communication between offices. The POISE system generates a listing of students. The list of students will be created for each draw-down that is initiated and will be placed in the shared folder in OneDrive. Draw-downs will not be initiated without a corresponding student list that shows the student account has been credited with the financial aid award. The documentation will be found in the shared OneDrive electronic folder, which has already been implemented. The transfer (interface) of student records into the financial system is being done weekly and documentation is retained of students for which transactions occur.