Corrective Action Plans

Finding 2023-005: Uniform Guidance Policies and Procedures - Noncompliance Recommendation: We recommend that the County document, and where applicable, implement policies and procedures that are aligned with the Uniform Guidance to limit the risk for noncompliance with the terms and conditions of its federal award programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding has been resolved. The County contracted with a private entity for oversight on the distribution of ARPA federal awards. We will continue to get guidance from auditors and other municipalities to ensure uniform guidance is followed. Name(s) of the contact person(s) responsible for corrective action: Director of Budget and Finance Planned completion date for corrective action plan: Completed June 2023

Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: The Operation Administrator is overall responsible the operation of Tri-County Senior Center and Housing; working together with the bookkeeping staff and Executive Director as partners to maintain financial records and budgets. The Executive Director will sporadically review tenant eligibility of new certifications and re-certifications, HAP Contracts, samples of monthly HAP Assistance Payment requests, and her presence when auditors are in-house as well any other assistance requested by Administrator. To ensure the health, safety, and well-being of the residents and staff, the Administrator oversees the responsibilities and duties of all other staff in their roles, (Administration Assistant/Program Administrator-Senior Center Activities; Administration Assistant-Membership, monthly newsletters, answer phones and any other duties requested by the Administrator), to guide them in their specific roles so they understand their duties and responsibilities as administrative staff, and ensuring the facility meets all regulatory compliance standards. If there are questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.

Views of Responsible Officials: Management acknowledges that prior approval must be received before allocating any cost to an award that is incurred outside of the period of performance. While in this case approval was ultimately not granted, the cost was returned to the original project and removed from the affected project and subsequent drawdowns adjusted accordingly. To avoid incurring costs outside the period of performance, the following actions will be implemented:  Update the Global Center procurement guidelines to explicitly emphasize period of performance requirements when incurring expenses on grants and contracts.  Systematically confirm all purchase requests, vendor contracts, consulting agreements and subawards fall within the period of performance by including the start and end date of the grant or contract on all associated documentation. Responsible Officials: Daniel Grimshaw, Director of Finance Anticipated Completion Date: December 31, 2024

An internal procedure was created, in addition to former procedures that shows a more detailed approach of ensuring every invoice involved with each drawdown are accounted for and paid on a timely basis to each vendor. The Authority believes this instance was a one-time item that will be corrected.

Corrective Action: Management will update written procedures and train the Grants Accounting team regarding period of performance to ensure all requests are made within the proper period based on the period of performance. The procedures and training will include grant period close, cost allowability, requirements for documentation, and review of charges prior to requests. In addition, Grants Accounting has initiated monthly meetings with grantors to closely monitor grant spenddown, address any processing issues, and ensure proper cut-off. These meetings will be instrumental in tracking progress and oversight in our grant management process. Name of Responsible Individual(s): Jason Brenier, Shelly Courtois, and Judy Bokhari Anticipated Completion Date: April 2024

Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, and Luz Gonzales-Toscano Anticipated Completion Date: December 2025

A copy of the November 2023 Report has been filed.

The Township will adopt a written policy regarding cash management of funds designed to minimize the time elapsing between the transfer of funds from the US Treasury and when distributed by the Township.

Condition: During our testing, we noted that expenses submitted on forms for reimbursement were allocated to the wrong budget category line items and did not agree to the underlying accounting records. Response: The Organization’s Board, CEO, and key HCEDC staG acknowledge the importance of refining internal controls to ensure expenses are used as approved. In this case, the funding agency, Indiana Department of Education, classified some expenses in ways that the auditor and organization leadership felt did not align with the approved final use. This use was reiterated by organization leadership in the grant submission to the funding agency. The funding agency indicated that the response was forwarded to their finance team but provided no further instructions for amending budget categories within the project. All expenditures under the grant project complied with allowable uses within the approved grant submission scope. Organization leadership continued to request reimbursement according to the categories assigned by the funding agency while achieving the project objectives and operating within the established framework. Moving forward, organizational leadership has implemented additional checks and balances through the onboarding of a Grants Management System engagement of CliftonLarsonAllen LLP to better align assigned categories with approved use. Timeline for Implementation: • Grant Management Software – October 2024 • CliftonLarsonAllen LLP engaged – March 2024

Condition: During our testing of federal expenditures, we noted that certain expenses were submitted twice for reimbursement. Response: The Organizations’ Board and Chief Executive Officer (CEO) and key HCEDC Staff recognize the need to further refine internal controls. Management recognized one instance in which duplicate reimbursement occurred. The duplication was reported to the funding agency (Indiana Department of Education) upon discovery and reconciled in order to place grant expenditures in good standing. Corrective Actions Taken: HCEDC staff has been working with CliftonLarsonAllen since March 2024 to design and implement new controls to prevent these types of errors occurring in the future. HCEDC is also onboarding a Grants Management Software to provide additional tracking and reporting transparency for funders and audit purposes. Timeline for Implementation: • Grant Management Software – October 2024 • CliftonLarsonAllen LLP engaged – March 2024

2023-001 Inadequate Supporting Documentation Material Weakness The Chairman of the Tongue River Valley Joint Power Board will make two copies of all invoices. One set of invoices will be retained by the Chairman and the other will be retained by the treasurer to improve the necessary documentation. This process is becoming more streamlined now that the board is current on its invoices. This an ongoing process.

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-009 Cash Management Program: Congressional Directives (ALN 93.493) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: The county hospital could not provide documentation that a review and approval of grant reimbursement requests was conducted prior to the request being submitted for payment. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin Healthcare System, Inc. (HHS) has processes in place to review and approve grant reimbursement requests however this was not documented for this grant in 2023. HHS will review all current grants as well as new grants to ensure this documentation is being captured. Hennepin County Employee Responsible for the CAP: Mark Willmert Planned Completion Date for CAP: December 31, 2024

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-007 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 8 instances of noncompliance in the sample of 120 case files tested: • Five MAXIS (eligibility determination system) case files had different bases of eligibility in MAXIS and MMIS (payment system). For three of the five cases, MAXIS indicated the beneficiary was “EX” (age 65 or older) while MMIS indicated the beneficiary was “DX” (disabled). For one of the five cases, MAXIS indicated the beneficiary was “1619(b)” (people who no longer receive an SSI cash benefit and maintain their disability status) while MMIS indicated the beneficiary was “DX” (disabled) and the final case indicated the beneficiary was “DC” (disabled child 18-20) in MAXIS while MMIS indicated the beneficiary was “DT” (disabled child under TEFRA option). • Two MAXIS case files did not have a signed application on file. • One MAXIS case file did not have citizenship verified. In addition, the County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the two eligibility determination systems, MAXIS and METS. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Vickie Goulette Planned Completion Date for CAP: December 31, 2024

Criteria The Entity is required to maintain residual receipts in an interest-bearing account. Condition The Entity’s residual receipts were not maintained in an interest-bearing account. Cause The interest rate on the account was changed by the bank, which was not noticed by management personnel before the year end. Context When performing out audit, we noted that the Entity's residual receipts did not earn interest in 2023. Questioned Costs none noted. Effect The Entity was not in compliance with the requirement to maintain its residual receipts in an account that bears interest. Recommendation We recommend the Entity contact the bank to correct the interest rate on the account or move the balance to an interest-bearing account. Views of the Responsible Official See Corrective Action Plan

Corrective Action Plan for Audit Finding Town of Litchfield Corrective Plan Information: Audit Finding Number: 2023-001 Finding: Document Policies and Procedures over Federal Awards Type of Finding: Compliance Criteria: OMB's Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (UG) established significant requirements related to federal awards. The requirements stipulate that federal award recipients must document their policies and procedures over certain aspects of financial program management. Specifically, written policies are required for the following: • Cash management • Determination of allowable costs • Employee travel • Procurement • Conflicts of interest • Subrecipient monitoring and management Corrective Action Taken Adoption of Policy "Federal Grant Acceptance and or to be Taken: Compliance Policy" by the Board of Selectmen and implementation across all departments. See attached Date of Completion or Policy Federal Grant Acceptance and Compliance Policy" estimated Date of Adopted by the Board of Selectmen August 12, 2024 Completion: Issued to all department heads 8/13/2024 Shared drive for grant documentation created and shared with department heads Town Purchasing Policy amended to include reference to Grant policy 8/12/2024. Policies updated on Town website - 8/14/2024 Management The Town of Litchfield agrees with the finding as no Response: formalized Policy or Procedures existed at the time of Audit. Town Contact Kim Kleiner Responsible for Town Administrator Corrective Action: 2 Liberty Way, Litchfield, NH 03052 603-424-4046 x1250 Email: kkleiner@litchfieldnh.gov

Finding No. 2023-002: Audit and SEFA Adjustments Responsible Officials: Angela Wilkerson, Mayor Corrective Action Plan: The City will make every effort to make accurate accounting adjustments throughout the year. When recording a journal entry that is unfamiliar, the Finance Officer will inquire on how to make the correct entry. The Finance Officer will make every effort to make sure the accounting adjustments are made correctly. Capital assets will be reviewed monthly by the Finance Officer and capitalized in a timely manner. Some of the ambulance receivables will be analyzed and adjusted by Accounting Clerk on a monthly basis. Anticipated Completion Date: Ongoing

2023-002 U.S. Department of Housing and Urban Development– Assistance Listing # 14.239 Home Investment Partnerships Program Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The condition reported as item 2023-001 above also applies to the Township’s internal control over compliance with the requirements of federal programs. Planned Corrective Action: The Township acknowledges the potential effects of this condition. However, for such a small organization as we are, the Township believes that it would not be cost beneficial to hire additional personnel to provide for adequate segregation of duties at this time. The Board of Supervisors continues to closely monitor the financial transaction processes and has several control procedures in place to provided for as much segregation of duties as possible given the size of the Township’s staff. The following are the control procedures over federal programs that the Township currently has in place: • One Township supervisor is involved in the day-to-day activities of the federal program as he serves as the project manager for all Township projects. • The three Township supervisors personally review and formally approve the list of all bills proposed for payment (including those for federal programs and projects) at their monthly public meetings. In addition, the Township has a requirement that all checks require two authorized signatures, one of which must be a Township supervisor. • Each month’s complete financial statements are reviewed by the three supervisors at the monthly public meetings, and grant activities and updates are presented and discussed as well.

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

Views of Responsible Officials: IJD acknowledges that it is holding federal funds in excess of immediate operational need. The funds were drawn down to finance IJD’s Reporters Shield initiative, so that IJD could establish the risk pool to provide legal protection to investigative journalism organizations; without the cash in place to finance the risk pool, IJD cannot credibly offer to protect investigative journalism organizations from legal threat. The drawdown of federal funds was exactly in line with the proposal originally submitted to the federal funder (USAID), and the funds were drawn down with the agreement and understanding of the USAID program officer responsible for the grant. We note that IJD is in a chicken-and-egg situation, since without the funds first being in place, it will not be possible to recruit new members to join the risk pool. The corrective plan is to grow the membership pool as quickly as possible, so that the funds are used for their intended purpose, i.e. protecting journalists. Name and Title of Responsible Official: Clothilde Redfern, Executive Director International Journalism Defense Anticipated Completion Date: Not applicable

Management concurs with the recommendation as proposed and is implementing policies and procedures to provide for proper segregation of duties over grant activities. This has been implemented effective immediately.

For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Cynthia Sikina, Interim CFO Wendy Perry, Director of Budget & Contracts Corrective Action Planned: Contract terms will be reviewed to ensure understanding of the billing terms and will be documented in the contract management system in accordance with the Samaritas contract approval procedure. Cash draws will be aligned with actual cash expenditures for any cost reimbursement contract/grant to limit draws to immediate cash needs in accordance with Title 2 U.S. Code of Federal Regulations Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards (the Uniform Guidance), Subpart D – Post Federal Award Requirements, Section 200.305 Federal Payment. Anticipated Completion Date: Date completed June 30, 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Prior to any cost reimbursement invoices submitted, the invoices will be reviewed and approved by the State Manager or a Director of State Engagement to ensure amounts requested for reimbursement were incurred prior to the reimbursement request and are related to costs that were properly allocated to the federal program. Anticipated completion date: Implemented October 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Prior to any cost reimbursement invoices submitted, the invoices will be reviewed and approved by the State Manager or a Director of State Engagement to ensure amounts requested for reimbursement were incurred prior to the reimbursement request and are related to costs that were properly allocated to the federal program. Anticipated completion date: Implemented October 2023