Corrective Action Plans

Finding #2023-002 – Material Weakness and Other Noncompliance. Recommendation: Provide additional staff training to ensure internal control procedures over client eligibility and required documentation are followed. Planned corrective action: Client eligibility and documentation requirements do not pertain to cost reimbursement grants; these regulations exclusively apply to fee-for-service grants. The fee-for-service grant programs concluded on September 30, 2023. Consequently, starting from October 1, 2023, the business model shifted to cost reimbursement only. As a result, no corrective actions are needed for fee-for-service grants. Responsible officer: Drew Dutton, President and CEO. Estimated completion date: Completed October 1, 2023

A copy of the Davis-Bacon Act requirement has been placed in the office of the federal program director. The director will be responsible for filling out the appropriate paperwrok before approving any federal funds to be used on projects that are classified as construction. The requirements of the Davis-Bacon Act have also been shared with the Encumbrance Clerk and Treasurer for the purpose of checks and balances.

Finding 2023-007 – Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirement Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all construction projects using federal funding will meet the wage rate requirements. Anticipated Completion Date: March 2024

Finding 2023-006 – Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: X Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next ESSER reports due in FY24

The Tipton School District will immediately implement the following controls to assure that the district has adequate internal controls in place should any future expenditures of federal funds for Capital Projects be made. The district will review the Federal Procurement and contractor requirements prior to submitting documents to use Federal Funds for Capital Projects. The district will provide training to staff to ensure compliance with all Federal Program Procurement including compliance with the Davis-Bacon Act (prevailing wage rate) requirements, and reviewing weekly certified payroll reports from the contractor or subcontractor. The district will ensure that all items are posted at the work site to confirm compliance. This corrective action plan will go into effect by March 11, 2024.

Finding 2023-005 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Linda Williams Contact Phone Number: 219-764-6209 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The PTS Office of Grants and Assessments will collaborate with the PTS Finance Office to establish a system of internal controls and separation of duties to ensure a thorough review prior to the submission of the Annual ESSER Data Report. Anticipated Completion Date: April 2024

DOC will institute internal controls to review and monitor, on a quarterly basis, medical costs billed from the pharmaceutical vendor to ensure the billing is consistent with contract language. The review will be done by a Fiscal Management Specialist (FMS). The internal control will consist of the following: - Beginning with the December 2023 invoice, DOC will request fully executed procurement documents from the pharmaceutical contractor to verify acquisition costs. - The current contract language states that pharmaceuticals are billed at actual acquisition costs plus a dispensing fee. Therefore, the FMS will match the acquisition cost for the vendor for a sample of transactions to the invoices received from the vendor. - DOC will conduct this review on the pharmaceutical invoices for March, June, September, and December in each year continually. - DOC will document the review using an excel spreadsheet that has the universe of pharmacy orders by patient – matching the records and recording the date the review was done. All documents will be saved in an internal medical invoice folder. - Reviews will be completed by the last day of the month after the invoice is submitted. - Training on the new process will be done by March 31, 2024. Findings (or lack thereof) will be reported to DDAP by April 30th, July 31st, October 31st, and January 31st of each year via email. - If there are discrepancies, the vendor will be contacted immediately and a true-up will be requested in the next month’s invoices (either a credit or a debit depending on the discrepancy). DOC will continue to utilize PACE to complete full audits on reasonability of drug prices. DOC acknowledges, due to purchasing and distribution practices for the pharmaceutical vendor, Sublocade was not on prior reports. However, in the third and fourth quarter of 2023, Sublocade was added to the quarterly PACE audits for reasonability of drug prices. DOC has spoken with PACE and will now receive all quarterly audits and will be invited to all meetings between PACE and the contracted pharmaceutical vendor to discuss any findings. Anticipated Completion Date: 03/31/2024 Contact Names: Erica Benning, Director, Healthcare Services; Jodilynn Jacob-Byrd, Fiscal Management Specialist

DEP will ensure appropriate language as per 31 CFR Section 205.33 (a) of the Treasury-State Cash Management Improvement Act (CMIA) to be included in all Delegation Memorandum of Understandings (DMOU) and Letter of Commitments (LOC) for all future Capital Budget Projects to ensure the expenditure of federal monies is consistent with the progress of the project. Anticipated Completion Date: Completed Contact Names: Patrick Webb, Director, Bur. of Abandoned Mine Reclamation; Tim Golding, Exec. Assist., Office of Admin. and Management

Office of Income Maintenance (OIM) Bureau of Operations (BOO) BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators’, alternates’, pinners’, and card makers’ responsibilities. The BOO will ensure users in the EBT Card Tracking Database know their responsibilities and segregation of duties and will ensure there is coverage for card pinning until 5:00 pm each business day. Also, reminders to be sent to review the OIM EBT Procedural Manual periodically and when updates occur. This will occur by April 1, 2024. 2. All CAOs and district offices will be reminded to maintain adequate security of the EBT cards, card inventory, pinning devices, and ribbons. The EBT office will ensure all offices have two pinning devices and that they are in working order. This will occur by April 1, 2024. 3. OIM mandates annual training for EBT personnel to be completed at the beginning of each year. The training includes reviewing the procedures that safeguard access to the EBT systems. Area managers and staff assistants monitor completion of the training. Also included are the following: a. Review of roles and responsibilities and who may hold a role b. Card maker and pinner coverage for all business hours c. Proper security for EBT cards and associated items d. Timeframes for submitting changes e. Retention timeframes Anticipated Completion Dates: 1, 2 - 04/01/2024; 3 - Completed Contact Name: Jeanette Coulston, Staff Assistant to Director, Bureau of Operations OIM Bureau of Program Support (BPS)/EBT Project Office BPS will take the following actions to address the finding: 1. The EBT Project Office will make updates to the EBT Procedures Manual (Manual) and OIM EPPIC EBT Systems Application form (application) as needed. Notification of updates will be sent to CAO staff via email. This is expected to occur by April 1, 2024. 2. The EBT Program office will provide guidelines for the CAOs to follow when reviewing/updating their written internal procedures for EBT security of card mailings. This is expected to occur by April 1, 2024. 3. The EBT Project Officer will start retraining parties that are responsible for the completion of the EBT Headquarters Card Destruction log. This is expected to occur by April 1, 2024. Anticipated Completion Date: 04/01/2024 Contact Name: Tonya Holloway, Division Director OIM Bureau of Program Evaluation (BPE)/Division of Corrective Action (DCA) BPE will take the following actions to address the finding: The Bureau of Program Evaluation, Division of Corrective Action conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are completed on a 3-year rotation to ensure compliance in the execution of documented policies and procedures. BPE/DCA will adjust the review criteria to incorporate any procedural changes implemented in the Electronic Benefit Transfer Procedures Manual. The current rotation schedule spans FFY 2022- FFY 2024. The new 3-year schedule will begin October 2024. Anticipated Completion Date: October 2024 Contact Name: Amira S. Milikin, Division Director

Finding 2023-004 – Education Stabilization Fund Wage Rage Requirement Contact Person Responsible for Corrective Action: Administration and Head of Maintenance Contact Phone Number: 812-347-2407 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Superintendent will review with Grant Coordinator on any building projects where funds are allocated. Anticipated Completion Date: On going

Auditee Contact Person: Paula Powers Title of Contact Person: Food Service Coordinator Phone Number: 812 347-3905 Findings 2023-002-Child Nutrition Cluster-Eligibility Views or Responsible Official: We concur with the findings. Description of Corrective Action Plan: With future processing of free and reduced applications, the Food Authority will process the application. A second person will review and sign the application in order to maintain proper checks and balances. Anticipated Completion Date: March 2024

Finding 2023-001: Student Financial Assistance Cluster, Department of Education Programs Program Name: Federal Direct Student Loans CFDA Numbers: 84.268 Corrective Action Plan: The University will update written procedures to clearly identify a step to manually do enrollment testing following all conferral of degrees. For those regularly scheduled graduation periods and following the submission of both the degree and last of term enrollment files, we will randomly sample 10% of graduated students and manually verify their statuses. For degrees conferred outside of the regularly scheduled graduation periods, each record will be manually verified. This will ensure recorded graduation records will be verified within the National Student Clearinghouse to ensure alignment between degree history and enrollment history. The error was found to be a bug in the reporting software that happened in the current fiscal year. The University’s processes in previous years were correct as this error was not present. Completion Date: Estimated March 2024

FINDING 2023-006 Information on the federal program: Subject: Title I Grants to Local educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A210014, SA10A20014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Annual Report Card, High School Graduation Rate Audit Finding: Material Weakness Contact Persons Responsible for Corrective Action: Regin Johnson, Title I Director Chris Bajmakovich, Principal Calumet HS Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net cbajmakovich@lakeridgeschools.net Condition: An effective internal control system, which would include segregation of duties,was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Annual Report Card, High School Graduation compliance requirement. Context: One individual was involved in collecting the High School student documentation for withdrawal, reviewing the documentation, and removing the student from the cohort. Other review of knowledgeable individual was not documented to ensure all students that were removed from the graduation cohort, had the appropriate documentation to do so. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The high school principal shall review and approve withdrawal documentation collected by the registrar prior to the removal of the student from the graduation cohort. Anticipated Completion Date: Immediate

FINDING 2023-005 Information on the federal program: Subject: Title I Grants to Local Educational Agencies - Eligibility Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies CFDA Number: 84.010 Federal Award Numbers and Years or Other Identifying Numbers: S010A210014, SA10A20014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Regin Johnson, Title I Director Contact Phone Number and Email Address: (219) 838-1819 rjohnson@lakeridgeschools.net Condition: This finding addresses two issues. First, an effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. Second, The School Corporation has established a process of receiving and reviewing the listing of students from the Private Schools in order to be entered into the Title I application. However, the internal controls were determined not effective since the School Corporation only requested to receive eligible students listing and not enrolled students. Context: The School Corporation has not established a process of review of the Eligibility Summary in the Title I application for the student enrollment and poverty. Real time report October 1 count is used for the eligibility summary in the Title I application. Additionally, the examiner could not determine if the enrolled private school number was correct because the School Corporation did not request the information. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Title I Director will review and sign off on the Real Time October 1 report to ensure that the student enrollment and poverty numbers reconcile with what is submitted in the Eligibility Summary. Additionally, the Title I Director will solicit both eligible and total enrollment figures from private schools that wish to participate in Title I. Anticipated Completion Date: The Corrective Action will be implemented immediately and completed upon the filing of the next Real Time report and Eligibility Summary.

FINDING 2023-004 Information on the federal program: Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistance Listings Numbers: 10.553, 10.555, 10.559, 10.582 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Chris Akers, Treasurer Contact Phone Number and Email Address: (219) 838-1819 cakers@lakeridgeschools.net Condition: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to the monthly sponsor claim for reimbursement. Context: School Food Authority’s (SFA) and sponsors must submit monthly claims for reimbursement for meals and snacks served to eligible students within 60 days following the last day of the month covered by the claim. The Food Service Management Company employed Food Service Director prepared the monthly claim for reimbursement on the Indiana Department of Education Child Nutrition Program website based on meal count reports from the point-of-sale system. The School Corporation did not implement a system of internal control to ensure what was claimed for reimbursement agreed to the point-of-sale system meal count reports. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Before the monthly claim for reimbursement is submitted by the FSMC, the Treasurer will reconcile the claim with the meal count report generated by the point-of-sale system. Anticipated Completion Date: Immediate

Finding Number: 2023-004 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – 9/30/24) 211116-01 (7/1/20 – 9/30/22) 211303-01 (7/1/20 – 9/30/22) 221499-01 (7/1/21 – 9/30/23) 221769-01 (7/1/21 – 9/30/22) Compliance Requirement: Special Test Type of Finding: Material Weakness in Internal Control over Compliance, Other Matters Recommendation: We recommend that the Board enhance its procedures and internal controls to ensure that it retains documentation to support student withdrawals and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BCPS conducts regular training with the school-based staff that maintain this related student documentation. The training will include updates on collecting and maintaining written documentation to meet the requirements for removing a student form the cohort. Name(s) of the contact person(s) responsible for corrective action: Dr. Kim Ferguson, Executive Director of Student Support Services Planned completion date for corrective action plan: For immediate implementation and ongoing.

Finding 2023-004 Information on the federal program: Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Qualified Opinion Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions – Wage Rate Requirements compliance requirements. The School Corporation did not include Davis Bacon wage rate requirements in its contract with vendor which includes labor. The School Corporation did not obtain the weekly payroll reports certifications from a construction company and its subcontractors for a building project. Context: The School Corporation did not have an internal control designed to collect the weekly payroll reports certifications from a construction company and its subcontractors, as applicable, for building projects which included HVAC upgrades and replacements. Therefore, no review was performed by management to ensure that pay rates complied with the federal wage rate requirements. The vendor contract did not include a Davis-Bacon clause prescribing federal wage rate requirements required for construction contracts with labor installation costs. As of June 30, 2023, $566,328 was disbursed related to this capital project and charged to the ESSER III grant award (84.425U). The construction payments represented approximately 27.2% of the Education Stabilization Fund expenditures for the audit period. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. For any contracts related to projects with a cost of greater than $2,000 for the construction, alternation, or repair of public buildings or public works and which are federally funded, management will include a Davis Bacon wage rate requirement clause in the contract or request the vendor to sign a certificate or contract amendment affirming the contractor will comply with federal wage requirements. Management will designate a project manager to oversee the federally funded project and ensure the collection of the required weekly payroll wage report and document their review verifying prevailing wages are being paid to contractors. Responsible Party and Timeline for Completion: The Treasurer, Dawn Claussen, will oversee the corrective action plan which will be implemented by June 30, 2024.

FINDING 2023 - 004 Finding Subject: COVID-19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. During the audit period the School Corporation was required to submit two ESSER I reports, two ESSER II reports, and two ESSER III reports—a total of six reports. However, the School Corporation failed to submit all six required reports. We recommended that management of the School Corporation establish a proper system of internal controls and develop policies and procedures to ensure reports are submitted. Contact Person Responsible for Corrective Action: Steven Boyer Contact Phone Number and Email Address: 574-936-3115 sboyer@plymouth.k12.in.us Views of Responsible Officials: The Corporation concurs with the finding. Description of Corrective Action Plan: The transition in the Corporation’s Business Manager position resulted in a failure to properly identify and train the person responsible for submitting final expenditure reports for ESSER grants. The Business Manager will prepare the final expenditure reports, and the Grant Specialist will review and compare the report to the ledger to verify that it is correct. After the review, the Business Manager will submit the final expenditures reports. Additionally, the Business Manager and Grant Specialist have developed a shared calendar that includes all report due dates. Anticipated Completion Date: This corrective action plan was implemented beginning February 2024 and will be implemented moving forward.

Finding No. 2023-005: Inaccurate Reporting of Higher Education Emergency Relief Fund (HEERF) Quarterly Data CFDA Numbers: 84.425 Program: Higher Education Emergency Relief Fund Corrective Action: Institutional expenditure reporting was reviewed and revised reports were posted to the institution’s website. Implementation Date: March 6, 2024 Contact Person: Amanda Fijal

FINDING 2023-003 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program COVID-19 - National School Lunch Program Assistance Listings Numbers: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): SY22, SY23 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Eligibility, Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP), Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Finding: Material Weakness Condition and Context The School Corporation had not established effective internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. Eligibility The School Corporation's policy is to have the Treasurer review and initial paper applications processed by the individual school treasurers to ensure that the eligibility determination was correct. However, six of the ten applications tested lacked documentation of this review. In addition, there was no internal control in place over applications submitted online. INDIANA STATE BOARD OF ACCOUNTS 18 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) The Treasurer performed the verification of free and reduced price applications without a documented review or oversight process in place to ensure that applications selected for verification were in compliance with requirements related to the program. Special Tests and Provisions - Non-Profit School Food Service Accounts The School Corporation did not have an internal control in place to ensure that reimbursements for meals served were properly credited to the School Lunch fund. The lack of internal controls for Eligibility and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) was isolated to the second year of the audit period. The lack of internal controls over Special Tests and Provisions - School Food Accounts was systemic throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity 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). . . ." Cause A proper system of internal controls was not designed by management of the School Corporation, which would include segregation of key functions. Embedded within a properly designed and implemented internal control system should be internal controls consisting of policies and procedures. Policies reflect the School Corporation's management statements of what should be done to effect internal controls, and procedures should consist of actions that would implement these policies. Effect Without the proper design or implementation of the components of a system of internal controls, including policies and procedures that provide segregation of duties and additional oversight as needed, the internal control system cannot be capable of effectively preventing, or detecting and correcting, material noncompliance. Questioned Costs There were no questioned costs identified. INDIANA STATE BOARD OF ACCOUNTS 19 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Recommendation We recommended that management of the School Corporation 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. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.

Special Tests and Provisions Education Stabilization Fund: Assistance Listing No. 84.425 Recommendation: We recommend that for future construction contracts financed by federal education funds PLA verify that subcontractors comply with prevailing wage requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PLA will train operations and business office staff on the compliance requirements under Davis-Bacon to ensure construction contracts are entered into with qualified contractors and obtain and retain appropriate certified payroll documentation during the construction period. Name(s) of the contact person(s) responsible for corrective action: Carlo Hershberger, Director of Finance and Accounting; Javier Dimas, Vice-President of Operations; Martha Arellano, Procurement Manager and Buyer Planned completion date for corrective action plan: April 1, 2024 If the United States Department of Education has questions regarding this plan, please call Eva Spilker, Chief Financial Officer, at 410-598-3087.

FINDING 2023-005 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: During testing of reporting, we identified a control breakdown in the claim submission process. Although student meal data is summarized at the school level and reviewed by both the Food Services Bookkeeper and the Food Services Director, there is not a review of the actual claim submission prior to being submitted to the portal. Due to the breakdown in controls, we identified that the October 2022 revision claim overstated breakfasts served by 10 meals. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Food Services will input the monthly claims into the state reporting system. This will be checked by the bookkeeper prior to submission to ensure data was entered correctly. Responsible Party and Timeline for Completion: Beginning January 2024

FINDING 2023-004 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirements. Context: During testing of eligibility, we noted that a formal documented control for the review of online student applications was not in place. Management indicated that the free and reduced parameters are updated annually in the Titan system, however, there was no documented review that the updated parameters were reviewed. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will document a formal review of student applications for free/reduced lunch. Management will also document a review over the thresholds for free/reduced meals within the Titan system to ensure they accurately input into the system this will be done by way of signature on the state published eligibility guidelines. This will be kept for record keeping. Responsible Party and Timeline for Completion: Beginning July 2024

Federal Agency Name: Department of Agriculture & Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not maintain a reserve account or request the Department of Agriculture’s (USDA) permission prior to entering into new debt in compliance with their debt agreements. As of June 30, 2023, the Hospital should have USDA debt reserves at least equal to $417,954. Responsible Individuals: Eric Salmonson, CFO Corrective Action Plan: Management agrees with the finding. The Hospital has reviewed the internal controls and implemented improvements related to their USDA debt. They have also funded our USDA debt reserve account and worked with USDA to become compliant with all debt requirements. Anticipated Completion Date: March 5, 2024

Finding 2023-003 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: (suggestion: The School Corporation had not properly designed or implemented internal controls over eligibility.) Contact Person Responsible for Corrective Plan: Dr. Tracy Lorey, Monica Young, April Hopf Contact Phone Number and Email Address 812-482-1801 tlorey@gjcs.k12.in.us myoung@gjcs.k12.in.us ahopf@gjcs.k12.in.us Views of Responsible Officials: We agree with the Finding. Description of Corrective Action Plan: The corporation meets virtually each year with the software vendor to set up all free/reduced lunch applications, federal income guidelines and forms. A certified and signed copy of the income guidelines will be kept on file to show the match between the guidelines and point of sale. The applications that are flagged by the system will be reviewed for approval or denied and a copy will be maintained for The State Board of Accounts for audit. Anticipation Completion Date: February 2024