Corrective Action Plans

Management will continue to attempt to contact the Project's HUD Project Coordinator in order to obtain the required approval for the withdrawal from the reserve for replacements account

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

2023-003 – ALN 14.850 – Public & Indian Housing – Activities Allowed or Unallowed Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised HUD that it is in the process of marketing and selling its affordable property portfolio. The management company has reached an agreement in principle with a buyer for the sale of a significant portion of its affordable property portfolio. The buyer has significant experience in the affordable housing industry and is well-positioned to own and manage these properties. The parties are in the process of drafting all necessary documents and will work with HUD on all necessary documentation and approvals promptly once the underlying documents are fully negotiated. The management company is confident that there will be sufficient funds at the conclusion of the collective transactions with the buyer for the (re)payment of amounts to address the Findings identified herein. The management company anticipates closings by the end of 2024.

Corrective Action Plan: The Fogarty Center ("the Center") had this finding in 2022-02 as well. The Center reported in the 2022 corrective action plan, that the Center was in contact with the State of Rhode Island representative regarding these items throughout the year; however, some of the email conversations occurred after the deadlines had passed. At the end of the contract, the State of Rhode Island did send an email stating that they understood the reasons for the delays and that the reports were accepted as submitted and are in compliance.

Finding 2023-003: Internal Control Deficiency Cash Management Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: There is no evidence of internal controls in place to ensure that requests for reimbursement are based on expenses paid for by AdviseWell. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-02 finding, to ensure drawdowns are made on expenses paid for by AdviseWell and not on unpaid obligated funds before proceeding by having a secondary review by appropriate staff. Documentation will be maintained to support those payments preceded drawdowns and secondary review has been completed. Management will ensure all duties are appropriately segregated. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

The University agrees with the finding. The University has had a significant amount of staff turnover and reorganization in FY 2023 in the financial aid office. The Interim Director of Financial Aid is collaborating with the controller’s office to make sure that the University has internal controls in place over Federal programs to assure that the Pell reporting requirements are executed in compliance with Federal statutes, regulation and terms and conditions of the federal award. The University is investing in making sure that the Financial Aid Office is staffed and create policy and procedure that assure that we improve internal controls on the Pell process.

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another two disbursements included expenses for other clubs outside the grant agreement that was charged to the grant. The last disbursement was missing supporting documentation for the costs charged to the grant. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that the Organization verify that costs submitted for reimbursement are valid and allowable expenses. Additionally, the Organization needs to properly allocate costs in accordance with the grant agreements. Corrective Action. Management concurs with the finding. The Organization will ensure valid and allowable expenses, including proper allocation of costs, are remitted through enhancement of the current review processes. Responsible Person. Stacy Holman, Chief Financial Officer. Anticipated Completion Date. December 31, 2024.

Upon discovery (during 2023) of the failure of the College to determine the amount of excess cash it had retained, and to timely return it ot the Secretary of Education, the College immediately implemented a corrective action plan that included a strengthening of procedures with corresponding internal controls, and the immediate return of any excess cash. The Correction Action Plan included Student Financial Aid training sessions for Business Office Staff responsible for Title IV cash management oversight. To further address this situation, the College engaged an independent consultant to assist in the review and revisiion of existing Business Office Title IV policies and procedures, which were immediately adopted and implemented.

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.

The County Clerk & Treasurer are continually looking for effective control over SEFA funds. The county has hired a part-time employee to help in the Treasurer's office to continue these efforts, which will include a new filing system for SEFA funds.

Management recognizes the importance of record retention and filing systems. When management became aware of the misplaced records related to wage and hour reports, management undertook a detailed review of the compliance requirements in the grant agreement and examined expenditures under the federal award to ensure the entity is in compliance with laws and regulations

Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that Provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. Planned Corrective Action: County management will develop written policies and procedures for grants. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

Since taking over the financial management of ELFHCC in December 2022 we have hired an auditing firm (Louis Plung & Company) to perform the 2021, 2022, and 2023 Single Audit submissions and are now up to date. Moving forward, all audits will be completed before the submission due dates each year

Since taking over the financial management of ELFHCC in December 2022 we have hired an auditing firm (Louis Plung & Company) to perform the 2021, 2022, and 2023 Single Audit submissions and are now up to date. Moving forward, all audits will be completed before the submission due dates each year

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 113004 AND 112605, YEAR ENDED JUNE 30, 2023 Name of contact person: County Commissioners Corrective Action: The Board of Commissioners along with the Department Head will work with the Budget Manager to adjust the structure of the budget to separate expenditures by cost category. Furthermore a procedure will be developed to review the grant reimbursement report prior to submittal. Proposed Completion Date: Immediately

Due to administration errors, the drawdowns were incorrectly performed. We will ensure that all the drawdowns support is reviewed and approved by the department head before any drawdowns are made.

Assistance Listing No. 93.659 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review and update existing controls. Document approvals throughout the process. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2024

Assistance Listing No. 93.576 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review and update existing controls. Document approvals throughout the process. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2024

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Corporation for National and Community Service Finding, 2023-002: Major Program: AmeriCorps, Federal Assistance Listing Number 94.006 RECOMMENDATION The auditor recommends the Organization adjust the internal control process to have the bills verified internally, before sending to AmeriCorps. ACTION TAKEN The Organization will be contacting AmeriCorps regarding the overbilling and intends on implementing a modification to the procedures for billing cost reimbursement contracts.

Finding: The Organization allowed payroll related costs to be submitted for reimbursement under the grant for time that did not match approved timesheets. This is not in compliance with program allowable cost requirements. The amount of payroll and related costs discovered to be incorrect was a net amount of $1,336, which when projected onto the remaining payroll and related costs that were not tested, amounted to $28,521. Corrective Action Taken or Planned: The Organization will review audit findings and ensure accurate future reimbursements, develop a comprehensive process for verifying time sheets against service delivery, and implement a paper timesheet system in which supervisors must enter time based on timesheets, ensuring 1:1 reimbursement. Name of Contact Person: Jacob Ducey, Grants Manager Phone Number of Contact Person: (540) 907-4555 Projected Completion Date: October 31, 2024

CDFI ERP Program (COVID-19) – Assistance Listing No. 21.033 Recommendation: Management should develop a procedure to track its federal award advances to ensure those funds are placed in interest-bearing accounts, when applicable, and any interest earnings on those funds are separately tracked, reported, and remitted in accordance with the program requirements. A documented review of this activity should be performed by a knowledge individual who is aware of the program requirements prior to reporting or remitting payment back to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure funds that are not being used from federal awards be placed in interest-bearing accounts and any interest earnings on those funds will be tracked. Name(s) of the contact person(s) responsible for corrective action: Arlo Washington Planned completion date for corrective action plan: January 1, 2025

CDFI ERP Program (COVID-19) – Assistance Listing No. 21.033 Recommendation: We recommend management develop procedures requiring employees to track their time and effort by grant. Another individual should periodically review and approve these time and effort records before the funding request is sent to the federal agency or charged to the federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Each employee will track their time spent on the grant through Paychex. Timesheets will be approved by Arlo Washington, President, each payroll period. Name(s) of the contact person(s) responsible for corrective action: Arlo Washington Planned completion date for corrective action plan: January 1, 2025

Finding 2023-02- Compliance Requirement: Cash Management HIV Alliance will prevent delayed reporting to funding agencies on underspent awards by reviewing, at least on a quarterly basis, current spending as compared to the budget for all contracts and grants with the agency directors. During this review the directors will draft and implement a plan to adjust spending to prevent the over or under spending of those contracts and grants. HIV Alliance currently maintains a schedule of contract dates and amounts. HIV Alliance will add notes regarding the requirements for reporting unexpended funds for each contract and grant to the tracking schedule. Any underspent contracts and grants will be reported to the Budget and Finance Committee and the funding agency in the timeline required.