Corrective Action Plans

Re: Corrective Action Plan for Findings Related to Monthly Claims for Reimbursement and Free/Reduced Meal Applications In response to the findings regarding the District's internal controls over monthly meal count reporting, Claims for Reimbursement, and the review of Free and Reduced Meal applications, Hannibal School District 60 has developed the following Corrective Action Plan (CAP) to address the identified issues and ensure compliance with federal regulations under 7 CFR 210.B(a), 7 CFR 220.11(c), and 7 CFR 245.6(c)(4). Corrective Action Plan Details: 1. Finding 1: Lack of Oversight on Monthly Claims for Reimbursement Condition: The District did not conduct a review of monthly Claims for Reimbursement before submission to the Department of Elementary and Secondary Education (DESE), nor was a subsequent review performed after submission. Additionally, the Claims for Reimbursement for February and April were submitted with the lunch and breakfast meal counts incorrectly switched. Planned Actions: o Review Process for Claims: The District will establish a clear and documented procedure for reviewing the monthly Claims for Reimbursement before submission to DESE. This process will include a verification checklist to confirm the accuracy of meal counts for both breakfast and lunch. o Secondary Review by Senior Staff: A second, independent review will be conducted by the Food Service Supervisor or another designated senior staff member before submission. The purpose of this review will be to ensure that meal counts are correctly reported and to identify any discrepancies before the claims are submitted. o Training: All staff involved in the preparation and submission of monthly meal claims will undergo additional training on the accurate completion of meal count reports and claims for reimbursement. 2. Person(s) Responsible: o Food Service Director: Oversee the implementation of the new review procedures for monthly Claims for Reimbursement. o Food Service Supervisor: Conduct a secondary review of the monthly meal count reports before submission. 3. Anticipated Completion Date: The review procedures and training will be fully implemented by January 1st, 2025 4. Finding 2: Inadequate Review of Free and Reduced Meal Applications Condition: During testing, it was noted that one app.lication had illegible numbers, resulting in unclear income figures. The household was assumed to be eligible for free meals, but the accuracy of the income figures was not verified, which could have led to improper eligibility determination. Planned Actions: o Review and Verification Process: The District will implement a formal review process to ensure that all Free and Reduced Meal 58 applications are thoroughly checked for legibility and accuracy. This review will include verifying income calculations and ensuring that illegible numbers or unclear data are clarified before eligibility determinations are made. o Enhanced Application Procedures: A standardized checklist will be developed for reviewing applications, with specific attention to legibility, accuracy, and completeness. The checklist will be used by staff during the application review process. o Follow-up with Households: If any data on an application is unclear or illegible, the District will contact the household to clarify the information before proceeding with the eligibility determination. o Training: The Food Service Director and application review staff will receive training on the proper review and verification of Free and Reduced Meal applications, including the importance of ensuring that all information is clear and accurate. 5. Person(s) Responsible: o Food Service Director: Oversee the review and verification process for Free and Reduced Meal applications. o Food Service Staff: Review applications for legibility and accuracy, and follow up with households if necessary. 6. Anticipated Completion Date: The new review process and training will be fully implemented by January 1st, 2025 7. Cause of Findings: The primary cause of these findings was the misinterpretation of handwritten reported income by the applicant and a mix-up of breakfast and lunch counts during the reporting of Free and Reduced meal counts for one school over the course of a few months. 8. Effect of Findings: Without a robust review process in place, there is a risk of submitting inaccurate meal count data and miscalculating eligibility for free and reduced meals. This could result in the District receiving either too much or too little funding from DESE, affecting the financial stability of the program. Additionally, failure to ensure accurate eligibility determinations could result in noncompliance with federal regulations, potentially leading to penalties or loss of funding. Implementation and Monitoring: • Ongoing Monitoring: The Food Service Director will regularly monitor the new procedures to ensure they are being followed correctly and will conduct random spot checks of meal counts and application reviews to ensure compliance. • Reporting: The Food Service Director will report on the status of the corrective actions to the Superintendent on a monthly basis until the corrective actions are fully integrated into the District's operational processes. We are committed to ensuring the accuracy and integrity of our meal count reporting and eligibility determinations. The District will implement these corrective actions in a timely manner to address the identified findings and ensure compliance with applicable federal regulations. If you have any questions or require further details, please do not hesitate to contact me. Sincerely, Susan Johnson Superintendent of Schools Hannibal School District #60

Recommendation: We recommend the Council updates in payment process to ensure that all providers are paid timely after receipt of grant funds. Action Taken: We have established a streamlined process to ensure timely disbursement of funds to providers upon receiving grant funds. Additionally, we have implemented a monitoring system to track payment timeliness and promptly address any delays. Responsible Party: Jeremy Ashbaugh, Director of Finance. Anticipated Completion Date: The issue has been corrected.

The District will ensure that Additional or Compensatory Special Education or Related Services (ACSERS) funds are not used to fund Substitute Services due to the teacher shortage.

Finding 2024-001 – Special Tests and Provisions State of Condition: The project did not make the required residual receipts deposit. Corrective Action: Management will ensure that the required residual receipts deposit is made.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.

Criteria: All services billed (SBS) must be identified in the students' IEP. Cost reimbursement is disallowed for Medicaid-coverable services not specified in the student's IEP. Condition: Two students from the auditor's sample were billed for nursing services that were not included in the students' IEPs. Cause: The District billed for services that were not listed on the students' IEPs. Effect: Billing for services not listed on the IEP is not allowed and may result in improper use of federal funds. Questioned Costs: $1,670 Recommendation: The District should review procedures with the third party billing service to ensure there is proper communication regarding the allowed services being billed under IEPs. Additionally, the District should implement regular review of billed services to verify compliance with Medicaid requirements and ensure that all billed services are properly documented with students' IEPs. Grantee Response: The District will implement a process to verify all billed services are documented in the IEPs and provide training to staff to prevent future occurrences. Contact Person: Ross MacPherson Anticipated Completion: June 30, 2025

ALN 14.872 – Public Housing Capital Fund Program – Lack of Data Available to Audit Federal Compliance Requirements Applicable to the Public Housing Capital Fund Program (Material Weakness, Potential Material Noncompliance) The PHA's management and staff continue to work to clear up prior year's compliance and supporting balance issues and expects to finalize these issues prior to March 31, 2025's submission of the unaudited financial data schedule. Person Responsible for Correction of Exception: Mr. Arturo Puckerin, Executive Director Projected Completion Date: March 31, 2025

To Whom it may concern: This document serves as the response to the 2023-2024 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and addressed the comments that were included in the Uniform Guidance Major Program Findings. Please review the corrective action items in response to the Audit Results and Comments: Education Stabilization Fund (ESSER Grant): The school was unable to provide construction contracts to allow auditors to verify that the required Davis-Bacon Act wording was included. ● The Principal, Angel Jackson-Anderson, and Dean of Operations, Kayla Marshall, will ensure that the proper contracts are received and filed for all services conducted under ESSER grants. Child Nutrition: The school did not maintain tally sheets to support the number of meals served. ● The Dean of Operations, Kayla Marshall, will ensure that the proper physical files (tally sheets) are maintained and filed monthly, both in digital and paper form. The principal will review these files monthly to ensure documents are not lost or misplaced. If you have any questions, concerns, or comments, please feel free to contact me the school principal, Angel Jackson-Anderson, Aanderson@believeschools.org. Many thanks, Angel Jackson-Anderson Principal, BELIEVE Circle City High School Kayla Marshall Dean of Operations, BELIEVE Circle City High School www.believeschools.org @believeschoolsindy admin@believeschools.org 317-296-1954 Angel Jackson-Anderson 11/07/2024 02:25PM UTC

Approval of draw requests Recommendation: We recommend that the client keep physical sign of review or approval of the draw downs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: There is no disagreement with the audit finding. Management will update the current review and approval process going forward. Name(s) of the contact person(s) responsible for corrective action: Pam Gallagher, CFO Planned completion date for corrective action plan: December 31, 2024

The District has obtained a signed and dated Form M-5 for the one student missing a signed form during testing and will review that M-5 forms are on file for all eligible students.

We will review the respective requirements to evaluate and determine the most efficient and effective solution to ensure all required reports are prepared, reviewed, and submitted within the COVID-19 State and Local Fiscal Recovery program’s required timeframes, and with the correct amounts.

Response: With the multiple award year of ARPA federal funds, and the addition of both Federal funds and state funds being awarded in multiple fiscal years for water project (DWSRF); the ability to track these funds and appropriately ledger/journal notes these expenditures were lacking. There was question as to if the amount the City's received was over the $750,000 threshold due to invoicing and payment dates being in multiple fiscal years. Going forward, the City is aware that the invoicing for the use of Federal Funds are the amounts to be looked at when deciding if a single audit needs to be completed. The City will make the auditors aware of the need for a single audit prior to them completing the normal annual audit each year it is necessary. Timeframe: Immediate. Contact Person Responsible for Corrective Action: Finance Director/Treasurer Katy Posey

We were made aware of this issue by a desk review from the National Science Foundation and we have developed and implemented the following policies and internal controls to ensure grant funds are drawn down only after qualifying expenditures on a monthly basis.: If a grant is awarded on a cost-reimbursement basis, Future Earth draws down funds approximately once a month, unless the funder requires another way of accessing their funds. Funds are not drawn down until they have been spent. Before each drawdown, the third-party accounting firm will confirm the grant's cash balance. If there is a positive cash balance, the third-party accounting firm and COO will investigate the cause and correct it immediately. Grants with negative cash balance will be checked by third-party accounting firm to confirm that the grant was active when the expenses were incurred. The third-party account firm will provide a report of the associated transactions of the negative cash balance. The PI will confirm the report transactions and approve the drawdown request. Once approved, the third-party accounting firm will create an invoice and journal entry in the Quickbooks accounting system and the COO will request the drawdown from the funder.

Bank Reconciliations, Interfund Balances Reconciliations and Other Balance Sheet Accounts Year ended June 30, 2024 Auditors’ Recommendation: We recommend that the District prepare bank reconciliations soon after the end of each month. As part of the reconciliation process the District’s general ledger cash balances should be compared against the bank reconciliation, with any differences being immediately investigated. Once complete, the bank reconciliation should be reviewed by someone independent of the preparer. In addition, a worksheet should be developed which reconciles interfund balances on a monthly basis. Any differences in the reconciliation process should be immediately investigated. We recommend that asset and liability accounts be reconciled on a regular and routine basis. Further, reconciliations should be reviewed by management to ensure their accurate and timely completion. District’s Response: The School Business Administrator, Amy Ginnitti, and Treasurer, Hilary Hadden, will ensure that bank reconciliations are prepared in a timely manner and verify that balances within the general ledger cash accounts agree to the bank reconciliation, along with ensuring that interfund balances reconcile and that balance sheet asset and liabilities are reconciled to supporting documentation for the year ending June 30, 2025.

Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendations: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Response indicator: Agree. Response: The Company will work with the financial institutions to ensure that HUD’s requirements are followed. Completion date: September 30, 2024

Action taken in response to finding: LCHC management has implemented a robust task-management software to assist with internal controls, especially when related to grant management. Furthermore, a cloud-hosted warehouse for internal procedures was implemented to properly manage the assignment and transfer of accounting roles/responsibilities like the review and approval of grant drawdown request. Name(s) of the contact person(s) responsible for corrective action: Jeff Nelson, Accounting and Financial Analysis Director Planned completion date for corrective action plan: 9/30/2024

Upon identification of costs allocated to more than one grant, the Organization identified allowable costs previously charged to program income and reallocated the duplicated expenditures without creating other instances of noncompliance (such as cash management or period of performance). Although the initial support provided to auditors contained instances of expenditures charged to more than one grant, expenditure justification has been updated to reflect corrections and all subsequent grant expenditure detail has been reviewed to ensure no recurrence in the subsequent period. The Organization has also reviewed our internal processes to capture all salaries supported by grants accurately and timely. Additional internal controls such as limiting the number of grants an employee can be on at one time and the reduction of more catch-up drawdowns to account for staffing changes within the organization were implemented. We are also working with our accounting software vendor and payroll vendor to automate the allocation of grant salaries based on time and effort of each individual rather than after-the-fact allocations to grants. This will reduce the need to maintain manual spreadsheets to track staff and essentially eliminate the risk of charging expenditures to more than one grant. Further, relevant staff participated in a training focused on CHC grants management matters in December 2024 and will continue to look for learning opportunities to support and challenge compliance matters. Official Responsible for Ensuring the Corrective Action Plan: Danielle Hahn, Progressive Community Health Center Chief Financial Officer. Planned Completion Date for the Corrective Action Plan: The Organization has implemented the corrective action plan as of December 2024 and will continue to monitor throughout the year.

2024-005: Documentation Contact Person – Carol Anderson, Executive Director Corrective Action Plan – This finding is noted together with the Board. The Organization will keep copies of quarterly NDDOT reimbursement reports to support the audit of federal programs. Completion Date – The Organization will implement the change in the fiscal year ended on June 30, 2025.

We will implement stricter adherence to deadlines and ensure that all required annual deposits to residual receipts are completed within 90 days of year end.

The Housing Authority of the Town of Carrollton, Missouri, is a small PHA defined by HUD and lacks in segregation of duties for Internal Control. The Director has developed a spreadsheet to track obligation dates, amounts, contracts, and expenses to justify the amount obligated each month in the system.

Recommendation: We recommend the College implement procedures to ensure all requirements of a Tier One arrangement for Third Party Servicers are being met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are no longer using a Tier One processor for our financial aid refunds. Name(s) of the contact person(s) responsible for corrective action: Margaret Antilla Planned completion date for corrective action plan: Implemented July 2024 when we changed from Bank Mobile to TouchNet.

2024-002 Federal Agency: U.S. Department of Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: None Pass-Through Agency: Maryland State Department of Education Pass-Through Number: 211837-01 Award Period: 3/3/2021 – 12/31/2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that the Board continue with established policies and procedures implemented in November 2023 to ensure that documentation supporting the Board’s review and approval of the monthly FSR reimbursement requests are retained for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Reporting and Grants Management will ensure that the Board’s review and approval of monthly FSR reimbursement requests and documented and retained. Name(s) of the contact person(s) responsible for corrective action: Ruth Grasty Director of Financial Reporting and Grants Management Planned completion date for corrective action plan: For immediate implementation and ongoing.

Condition: To determine that an accurate final expenditure report was filed with the Illinois State Board of Education. The District submitted budgeted expenditures for reimbursement instead of actual expenditures for ESSER II. Recommendation: We recommend reconciling the budgeted amount to the general ledger totals and reconciling those to expenditure reports before submitting. Management Response: The District will review the budgeted cost of items and the amount recorded in the general ledger against the expenditure reports before submitting.