Corrective Action Plans

Daily meal county reports will be reviewed and verified that it agrees to the edit check worksheets prior to monthly reimbursement submission. Any differences will be properly investigated and resolved.

Corrective Action Plan: The District will implement appropriate internal controls over grant claims in order to ensure that amounts claimed for reimbursement are appropriate and match documentation. Anticipated Corrective Action Plan Completion Date: 6/30/2025 Contact Information: For additional information regarding this finding, please contact Patti Hoppus, District Bookkeeper at 262-835-2929

Corrective Action Plan: The District will monitor expenditures related to Federal grants in order to appropriately record these expenditures. The District will compare recorded expenditures to grant claims prior to claim submission to ensure that the claims match the accounting records. Anticipated Corrective Action Plan Completion Date: 6/30/2025 Contact Information: For additional information regarding this finding, please contact Patti Hoppus, District Bookkeeper at 262-835-2929.

Management agrees with the finding and is in the process of revising internal controls to address this issue.

Action Taken: The district concurs with this finding. The district has already addressed and taken action on this item. The 90K fiscal action from TDA was agreed upon. Sodexo reimbursed $45K by applying credit on the food service cost invoice. The administrative assistant to the CFO has been trained on TDA Basic Claims process and prepares the claim monthly using reports from Systems Design. Going forward The Deputy Superintendent will provide oversight on the food service management company and the claims processing.

Finding 2024-001: Student Financial Aid Cluster Cash Management View of Responsible Officials and Planned Corrective Action: The College has documented procedures in place - Prior to drawing funds from the DOE, Student Accounts and Financial Aid will review the amount showing available on COD and the disbursement amount that was made to students for the first draw of the AY, and then from each draw to the next for the remaining draws for an academic year. The amount drawn will be determined by the posted amounts to students' accounts. After COD is updated with the drawn funds Student Accounts and Financial Aid will again review to see if any excessive funds were drawn, and will return these funds to the DOE within seven days.

FINDINGS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2024-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Auditor Recommendation: Management should deposit $4,400 into the residual receipts account to refund the unapproved withdrawals. Management should also contact the HUD Project Manager to develop a plan to get current with vendors and fund the residual receipts account. A rent increase may be necessary. S3800-130: Response Indicator: Agree. S3800-140: Completion Date: February 3, 2025 S3800-150: Action Taken: The board had decided to change property management firms because of the history and severity of financial statement findings and major program fundings prior to the discovery of the unrecorded expenses. The board believes that the new management firm has a properly designed and functioning system of internal controls to prevent such future occurrences. As a result of the discovered unpaid invoices discussed in Finding 2024-001, property management will be unable to make the required residual receipts reserve deposit and pay all vendors without a rent increase from HUD. Management plans to contact the HUD Project Manager to develop a plan to get current with vendors and fund the residual receipts account. A rent increase may be necessary.

Finding (Condition): The supporting documentation for expenses that the School DIstrict incurred did not agree to amounts requested for reimbursement. Recommendation: That applications for reimbursement are reviewed to ensure that supporting documentation agrees to amounts requested for reimbursement. Method of Implementation: Review and enhance internal controls, including report analysis prior to NJDOE Submission. Person Responsible for Implementation: School Business Administrator & Director of Special Education Implementation Date : 02/01/2025

From the desk of Rev. Vickie Keys, Executive Director. Date: January 20, 2025. Re: Lost Monitoring Visit form - Audit Finding Reference: 2024-001. The following corrective action plan will be implemented February 1, 2025 to ensure monitoring view forms are not misplaced. Step 1: The Director of Operation will make monitoring visit assignments for the month. Step 2: Each Compliance Officer is to submit the monitoring form to the Director of Operation no later than the last day of the month the visit was due to be performed. Step 3: The Director of Operation will follow up with each Compliance Officer to ensure forms were received, review the form, and enter the date the visit was completed into the data base to ensure visits are made as TDA requires. Step 4: The Executive Director will review the final report of all visits conducted for the month to sensure forms are accounted for. Step 5: The Director of Operation and the Office Clerk will perform random binder checks to see if forms are filed correctly. Step 6: The Director of Operation will oversee the labiling and thinning process of forms and binders before sending boxes to storage. This will ensure stored files can be easily located. The Executive Director has final responsibility for the implementation and maintenance of this procedure.

U.S. Department of Education Passed-Through Entity: New York State Department of Education Finding 2024-002 (Significant Deficiency) COVID-19 - Education Stabilization Fund: ARP Homeless II (Assistance Listing# 84.425U) ARP Leaming Loss (Assistance Listing# 84.425U) ESSER II (Assistance Listing# 84.425D) ARP Summer Enrichment (Assistance Listing# 84.425U) ARP Comprehensive After School (Assistance Listing# 84.425U) ARP ESSER III (Assistance Listing# 84.425U) Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Criteria - Expenditures must be used to prevent, prepare for, and respond to COVID-19. These programs are authorized, as applicable, by the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act, 2021, Pub. L. No. 116-260 (December 27, 2020), and the American Rescue Plan (ARP) Act of 2021, Pub. L. No. 117-2 (March 11, 2021). The regulations in 34 CRF Part 76 (State Administration), 2 CFR Part 200 (Uniform Administrative Requirements, Cost Principles, and Audit Requirement for Federal Award and 31 CFR Part 205 (Cash Management Improvement Act) apply to these programs. The School District must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control Integrated Framework", issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statues, regulations, and the terms and conditions of the Federal awards. (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards. ( d) Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings. (e) Take reasonable measures to safeguard protected personally identifiable information and other information the Federal awarding agency or pass-through entity designates as sensitive or the non-Federal entity considers sensitive consistent with applicable Federal, State, local and tribal laws regarding privacy and responsibility over confidentiality. Condition/Context - We haphazardly sampled five COVID-19 - Education Stabilization Fund (ESF) expenditures. Our audit procedures found one disbursement where management overrode documented internal control procedures. We viewed invoices, purchase orders, and payment support and noted the disbursement was processed and paid without proper documentation to support the payment made and the payment was processed without the internal claims auditor's review prior to payment. Cause - Management override of established controls. Effect - Revenues and expenditures for one of the ESF grants were overstated prior to adjustment. Adjustment resulted in recording a receivable from the vendor and an offsetting liability to the passthrough agency providing the grant funding. Questioned Costs - None. The improper payment was subsequently adjusted out of expenditures. Recommendation - We recommend that the School District ensures that only disbursements that have been processed and approved by the internal claims auditor to be paid. Management Response - School District management concurs with the finding and will take corrective action. Corrective Action - The Business Office will review and adhere to all cash disbursements procedures and protocols. Completion Date - Effective immediately. Respectfully Submitted, Dr. Brett Miller, Assistant Supt. for Business

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that it failed to make required deposits into the Residual Receipt account in the amount of $12,574 for the year ended June 30, 2023, and acknowledges that there was no HUD approval for non-payment. b. Action(s) Taken or Planned on the Finding Management has initiated a transfer of funds into the Residual Receipt account as of 9/23/2024. The General Partner has also assigned a permanent Asset Manager to ensure required payments are made in accordance with agreements.

1. Finding 2024-001 a. Comments on the Finding and Each Recommendation Management concurs that the Project withdrew from the residual receipts reserve in the amount of $8,409 without HUD approval. Management is in agreement with the recommendation to deposit $8,409 into the residual receipts reserve. b. Action(s) Taken or Planned on the Finding Management has made changes to internal controls to prevent and detect unauthorized withdrawals from reserves. Management further notes that they have re-trained staff, and reaffirmed the review and approval process to ensure required residual receipt reserve withdrawals are completed with proper HUD authorization. Management will complete the required reimbursement to the residual receipts reserve by October 31, 2024.

Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004 Inaccurate Resources Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Finding 2024-005 Inadequate Request for Information Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/09/2024 and 10/17/2024 Finding 2024-006 Untimely Review of SSI Terminations Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: 10/17/2024 Section III - Federal Award Findings and Questioned Costs (continued) Training has been conducted on the Inaccurate Resource topic with staff specifically concerning the finding areas and ensuring all verified resources are appropriately updated in the NC FAST evidence. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Inadequate Request for Information topic with staff specifically concerning the finding areas and ensuring all required requests for information are sent via 5097/20020 where applicable. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. Training has been conducted on the Untimely Review of SSI Terminations topic with staff specifically concerning the finding areas and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review ensure that proper procedures are being followed with regard to these policies. 170

Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the Organization document review of all billings Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CommUnity has recently hired a Chief Financial Officer (CFO), which will provide an additional layer of financial approval and review. Finance Director will complete billings and CFO will review for accuracy each month, which will provide for additional oversight. Name(s) of the contact person(s) responsible for corrective action: Jennifer Steines and Angie Meiers Planned completion date for corrective action plan: February 2025

UWGC does not have specific policies and procedures in place as to how monthly personnel costs across federal programs will be aggregated and charged and reported to federal programs. Management’s Corrective Action Plan: UWGC has developed a procedure as outlined below in “Payroll Allocation Grants” to ensure that prior to submission of invoices to federal awarding agencies, management prepares a monthly analysis based on 211 call logs to support the actual amounts allocated across all programs and invoiced to the awarding agencies that are reconciled to payroll reports, which then will allow UWGC to present evidence that all hours submitted for reimbursement are supported with the appropriate allocation. The process will include management staff from both 211 and finance departments thus maintaining internal controls. Additionally, this procedure will be reviewed at least annually by both departments as it relates to the allocation methodology to ensure that its appropriate given changes in the program and workforce.

2024-002 - Activities Allowed or Unallowed; Allowable Costs/Cost Principles UWGC does not have specific policies and procedures in place as to how monthly personnel costs across federal programs will be aggregated and charged to federal programs. Management’s Corrective Action Plan:UWGC has developed a procedure as outlined below in “Payroll Allocation Grants” to ensure that prior to submission of invoices to federal awarding agencies, management prepares a monthly analysis based on 211 call logs to support the actual amounts allocated across all programs and invoiced to the awarding agencies that are reconciled to payroll reports, which then will allow UWGC to present evidence that all hours submitted for reimbursement are supported with the appropriate allocation. The process will include management staff from both 211 and finance departments thus maintaining internal controls. Additionally, this procedure will be reviewed at least annually by both departments as it relates to the allocation methodology to ensure that its appropriate given changes in the program and workforce. PROCEDURE: Payroll Allocation Grants Purpose UWGC requires the practice of responsible and reasonable procedures related to methods of allocated staff time and costs to 211 grants and/or contract funded initiatives/programs which is effective as of April 15, 2024. This procedure describes the steps that will be implemented and adhered to when allocating staff salary costs to 211 programs. The goal of this process is to ensure that consistent, adequately documented, and all appropriate materials are generated and reviewed monthly. Procedure 211 Call Logs: at the end of each month the 211 Manager will generate a monthly call log which tracks 211 calls by categories that coincide with specific programs and/or geographic area for services. The report is then emailed monthly to the Finance Senior Director who then utilizes the report to create a percentage of time spent on each program and then attributes staff salaries and benefits in line with the percentage of calls for each month. Staff who work on isolated call programs, for example 311, Utilities,OHIZ programs, will be excluded from the call log allocation method as the calls for these teams are specifically driven. Supervisors who oversee more than one program will perform a time allocation study at least annually or when there is a change in program supervision responsibility. Program Billing: The Finance Manager and/or responsible Program Billing Manager will utilize the call log percentages journal to allocate time to programs for reporting information in the appropriate monthly, quarterly, or annual report to the funding source.

The District will reduce net cash resources by investing in capital equiment where necessary and allocating direct cost overhead expenditures.

Identifying Number: 2024-001 Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Corrective Actions Taken or Planned: Federation typically receives vouchers from 14 subrecipient organizations approximately ten days after the end of each month. The number of vouchers per agency depends on the number of programs they provide. Staff reviews the vouchers for allowability and accuracy and submits them to the Illinois Department of Human Services (IDHS) within 24 days of month end. During fiscal year 2024, the IDHS remitted payment to Federation anywhere from 48 to 124 days after the month end. Upon receipt of the cash, Federation pays subrecipient organizations within thirty days. In the instances identified by the auditors, the IDHS remitted payment over 30 days after Federation submitted the vouchers for reimbursement. Federation’s longstanding policy has always been to reimburse each subrecipient agency after it has received payment from the IDHS. Prior to fiscal year 2024, the IDHS usually provided payment within 15 days of receipt of our voucher and therefore Federation was able to comply with the 30-day requirement. However, reimbursement delays from IDHS occurred during fiscal year 2024 resulting in the findings describe herein. To ensure compliance with the 30-day reimbursement requirement, Federation will formally request an advance from the IDHS. Kyu Kim, Director of Finance and Contract Compliance, Refugee Services will be responsible for the oversight of the reimbursement payments and will ensure the Federation adheres to the 30 day requirement going forward. Responsible Person: Kyu Kim Anticipated Completion Date: July 2025

Recommendation: Closer attention should be paid when performing the review of payroll to ensure that all employee hours and dollars are accurate and in agreement with the supporting documentation (ie. employee time sheets). Also, the employee should be retroactively paid. Action Taken: The underpaid employee already received retroactive compensation in the pay period ended August 30, 2024 to rectify the error. A secondary review process will be implemented which will involve a designated staff member reconciling hours recorded on timesheets with the payroll system entries before final approval. Staff involved in payroll processing will be reminded on the importance of accuracy and the potential implications of errors. This will include step-by-step instructions for validating payroll entries.

Recommendation: Closer attention should be paid when preparing the requests for reimbursement to ensure only allowable expenses are being included in the request. A secondary review of the request and supporting documentation should be performed by someone other than the preparer. Action Taken: A detailed checklist will be introduced to ensure all requests for reimbursement match supporting payroll documentation. This checklist will include a reconciliation step for timesheet data and payroll disbursement records. Staff involved in grant management and reimbursement preparation will receive additional instruction on federal compliance requirements, with a focus on allowable costs and activities.

2024-003 – Education Stabilization Fund – Prevailing wage rate requirements Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborers must be paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL). Nonfederal entities shall include in their contracts, subject to wage rate requirements, a provision that the contractor or subcontractor comply with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the District weekly payrolls and a statement of compliance (certified payrolls). Condition: There was one Education Stabilization Fund construction project performed by a subcontractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $33,192. There was not a prevailing wage clause in the contract and certified payrolls were not received. Cause: The District was not aware that wage rate requirements applied to the construction project. Effect: A reimbursement request was made for expenditures that did not comply with wage rate requirements. Questioned Costs: $33,192 Auditor’s Recommendation: Establish controls to comply with wage rate requirements related to the Education Stabilization Fund. Management Response: The District will comply with the wage rate requirements for the Education Stabilization Fund going forward. Contact Person: Cary Brommerich Anticipated Completion: Not applicable

U.S. Department of Housing and Urban Development Caritas Manor, Inc., HUD Project No. 065-EE003-CA, respectfully submits the following corrective action plan for the year ended September 30, 2024. Audit Firm: McNorton Ishee & Jones, P.C. P.O. Box 161425 Mobile, Alabama 36616 Audit period: September 30, 2024 Finding 2024-001 – Special Tests and Provisions State of Condition: The project has not made the required residual receipts deposit. Corrective Action: Management will ensure to make the required residual receipts deposit. If the Department of Housing and Urban Development should have any questions or comments regarding this plan, please contact Craig Bounds at (228) 435-1642.

Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Questioned Costs: N/A Action taken in response to finding: This is a repeat finding that was first presented to the University in conjunction with the release of the 2023 audit report in May 2024. The 2023 audit was completed after substantially all of Fiscal Year 2024 had elapsed, so there was not adequate time for the University to fully implement corrective action. The University is strengthening its accounts payable processes and sign-off approvals to help ensure reimbursements to subrecipients are paid timely. Principal investigators and designated administrative personnel within academic departments will be reminded of the need to initiate payments to subrecipients timely. Name(s) of the contact person(s) responsible for the corrective action: Mr. Robert Dixon, Director, Grants and Contracts Fiscal Administration at Oklahoma State University and Mr. Chris Kuwitzky, Vice President for Fiscal and Administrative Affairs. Planned completion date for corrective action plan: March 2025

a. Significant Deficiency | Single Audit – “We recommend the District record reimbursements in the correct fiscal year.” b. Plan of Action – The District will establish a multi-step review process for all NSLP monthly meal claims to ensure accuracy. For the year-end claims (May/June) – should they be received after the end of the fiscal year they were claimed for – a journal entry that recognizes Accounts Receivable for the claim amount will be created and be reviewed for accuracy before being approved. c. Timeframe for (or date of) implementation – The multi-step review process for monthly NSLP meal claims has already been established (started in September 2024). The year-end journal entry process/review will be implemented in June 2025.

a. Significant Deficiency | Single Audit – “We recommend the District use someone other than the claim preparer to review the claims before being submitted, and document said review with initials and dates.” b. Plan of Actions – The District will establish a multi-step review process for all NSLP monthly meal claims to ensure accuracy. This process will include data input/review by the Nutrition Services Coordinator and review by the Director of Finance/Senior Accountant before submission to the state. c. Timeframe for (or date of) implementation - The multi-step review process for monthly NSLP meal claims has already been established (started in September 2024).