Corrective Action Plans

U.S. Department of Agriculture CFDA # 10.569 Food Distribution Cluster Finding Summary: Great Plains Food Bank does not have consistent and effective controls in place over inventory to properly track and record receipts and distributions due to changes in staff, facilities and inventory programs. Responsible Individuals: Melissa Sobolik, CEO and David Stachon, CFO Corrective Action Plan: The GPFB has taken steps to continue to learn more about our new inventory software, P2, and will continue to educate ourselves in the best use of this program. Also, we will do a quarterly catch-up inventory reconciliation within the program to avoid large year end adjustments. The Inventory Control Manager has a set schedule for audits including quarterly inventory in Bismarck, a twice a year full audit and inventory counts by program quarterly. Anticipated Completion Date: On going

Incorrect and Untimely Return of Title IV Funds Calculation (R2T4) Planned Corrective Action: The University understands and concurs with the incorrect and untimely return of some Title IV funds. In response, the University has taken three (3) immediate steps to address this deficiency in the future. First, the institution has added financial aid staff with significant expertise and experience in the administration of the R2T4 process to periodically review standard and modular students R2T4 to ensure accurate, timely and compliant returns and reporting. Second, the University has identified policy and procedure improvements that align with best practice approaches to R2T4 administration in support of Pell recalculations and accurate return of funds. Finally, the institution has identified professional development opportunities for all financial aid, and associated personnel, to improve theoretical and practical awareness and implementation of the return process i.e., conference/webinar participation, in-house training workshops and discussions, identified liaison/unit champion roles, etc. Person Responsible for Corrective Action Plan: Michael Mathis, Director of Financial Aid Anticipated Date of Completion: January 2024

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Cleary understands that GLBA requires universities and other institutions to create controls concerning the handling of data in conformance with best practices in cybersecurity. We realize that it is vital for us to be fully compliant to safeguard our institution's and our students' sensitive information, and we have put in place a robust set of activities and services. The GLBA requires us to implement administrative, technical, and physical safeguards to protect the security and confidentiality of non-public personal information (NPI). Some of these requirements have been addressed in the past fiscal year, and the rest are currently being implemented in this fiscal year. Person Responsible for Corrective Action Plan: Eric Riddering, Director of Information Technology Anticipated Date of Completion: October 2024

Finding 2023-001 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Federal Agency Name: Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly Project and Expenditure Reports were not reviewed and approved by a separate individual outside of the preparer. The reports submitted in fiscal year 2023 did not contain obligation and expenditure information for $10,000,000 in revenue replacement expenditures allocated to fiscal year 2023 eligible employee wages. Responsible Individuals: Stella Runde, Budget Director Corrective Action Planned: Moving forward, the Finance Director will review and approve the reports prior to being submitted by the Budget Director. Anticipated Completion Date: June 30, 2024

FINDING 2022 – 005: Repeat of Prior Year Finding 2021-003 Type of Finding: Material Weakness-Enrollment Reporting Name of Responsible Individual: Joyce Lubeck-Sonenberg, Acting Director of Financial Aid Criteria: An institution is required to update students’ changes in status on the National Student Loans Data System (NSLDS) website within 30 days of the date the institution becomes aware of the change in enrollment status for students that graduate, withdraw, or have an increase or decrease in attendance during the fiscal year (34 CFR 685.309). Condition: For certain students selected for testing who graduated or withdrew during the year, the University did not submit an appropriate and/or timely status change notification to the NSLDS website. A group of graduated students were erroneously reported as ‘withdrawn’ from the University. Corrective Action: Audit results identify several Wheeling University Enrollment Reports that were found to be incomplete, inaccurate, or not completed within an acceptable time frame as required by regulations. In response to finding 2022-005, Wheeling University has implemented several significant corrective actions towards improving Enrollment Reporting. The apparent cause of these findings was a lack of administrative capability, staff turnover, and a general lack of a systematic process for completing accurate Enrollment Reports to the National Student Clearing House (NSC) and National Student Loan Data System (NSLDS). Since these findings were first noted, the Wheeling University Registration Office and Financial Aid Office have added competent staff and have provided sufficient training and experience to ensure Enrollment Reports are completed within the regulatory guidelines. The Vice President of Enrollment has worked closely with the Financial Aid Office and the Registration Office to ensure there is a clear understanding of who reports to the National Student Clearing House and who is responsible for monitoring NSLDS. There are also weekly meetings between the Business Office, Registration, and Financial Aid to ensure all reporting is correct and completed in a timely manner. Anticipated Completion Date: A new process has been in place Since October 2023 and is ongoing.

2023-003 US Department of Education Student Financial Assistance Cluster - Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding, but we offer the following explanation: Identification of Errors and Corrections to New SIS: • Conversion to a new SIS (Jenzabar - Jl) was effective November 2022, and forced subsequent Fall 2022 NSC Enrollment Transmittal Files to be created in the new system mid-term. The concern of enrollment report timing was brought to the vendor multiple times before the transition. However, due to scheduling limitations on the vendor's end, the transition to the new system had to be completed mid-term. • In late May/early June we began end of term processing and reconciliations, and we identified that student status changes were not properly pulling the correct enrollment status information through the vendor's enrollment report creation process. • Support tickets were sent to the vendor immediately to address the problems with the system process that creates NSC Transmittal Files. • System configuration changes were made as recommended by the vendor to properly update enrollment status changes. • Through the investigation of these configuration changes, additional system errors were identified that were not allowing some enrolled students to be properly pulled to the enrollment files. • Support engagements continued with the vendor throughout July and August to identify and correct the system configuration to correctly pull enrolled students into the NSC Transmittal File. This was completed by the end of summer term, and the final summer enrollment file contained the correct number of students enrolled with the correct final enrollment status. • Internal validation reports were created and executed to ensure that correct student data was transmitted on the Fall first of Term reports. We believe this transmission contained the correct number of students and the correct status. These internal validation reports will be conducted prior to all NSC submissions. Creation of new/additional reports will be conducted as necessary. • We have been able to verify that the Fall 2023 subsequent term enrollment file did contain accurate status change information, and this issue is now resolved. • By correcting status change configurations, we have also identified that program begin dates converted from the old SIS to the new SIS were incorrectly mapped. • We are currently in the process of identifying the ID#s with incorrect program begin dates and making manual updates to the students' record in the new SIS environment. The vendor has not provided a clear path to programmatically correct this in bulk, so this record validation is being completed one-by-one manually. We project to have this completed for currently enrolled students by the final fall 2023 enrollment submission. Correcting previously submitted data: • We reached out to our Data Analyst, Elizabeth Fennessy, with the National Student Clearinghouse, to begin working on a corrective action for the missing status change data. • Elizabeth consulted with the NSC Audit Resource Team, and the following plan was recommended to MACC: • For students Less Than Half Time Spring 2023 or Withdrawn Spring 2023 that re-enrolled Summer 2023, these would be a manual update in NSLDS for Title IV students in these scenarios using NSLDS site 'Enrollment History Update.' • Later in Clearinghouse, the same update can be reflected using Clearinghouse site 'Student Look-Up' to bring the record current with updated enrollment reflected Spring 2023. By updating NSLDS first, that will avoid an NSLDS error "certification date out of sync" (error code 32). • MACC prepared reports to retrieve students meeting the criteria identified above. • These students' enrollment statuses for Spring 2023 and Summer 2023 have been manually updated in NSLDS Enrollment History Update and in NSC Student Look-up to bring these enrollment statuses up to date; this has been a long and time-consuming process. • We are also currently working on reports to identify students that were enrolled in spring 2023 but missed when the NSC Enrollment Transmittal File was created. We believe that students missed in Summer 2023 have been brought up to date through the submission of the corrected final Summer 2023 Enrollment File (to include students that were also enrolled in Spring 2023). Any student that was inadvertently excluded from the Spring 2023 and has not been brought up to date through subsequent corrected submissions, will be manually corrected through NSC Student Look-Up, and NSLDS Enrollment History Update if necessary. • We also reached out to l<athy Feith, Branch Chief, l<C School Participation Division, Federal Student Aid, U.S. Department of Education; she is aware of our issues. She recommended making enrollment changes directly in NSLDS for students who withdrew. Action taken in response to finding: The following is our Corrective Action Plan. • The Registrar will review data in J1 and submit enrollment records to NSC each month. o The Registrar will also work with the Director of Administrative Computing to ensure program information and other vital data are reported correctly. o MACC will continue to work with Jenzabar for a solution for reporting last dates of attendance for students who are withdrawn from all classes. • After the enrollment file is accepted by NSC, 20 randomly selected students will be verified for accuracy. • The selection will be made by the Director of FA and/or Registrar. • The selection will include students who have withdrawn from all classes and had an R2T4 calculation performed. • The Registrar, or designee, will review the data in NSC. • The Associate Director of Financial Aid, or designee, will review the data in NSLDS. • Discrepancies will be addressed between the Registrar and Financial Aid Offices immediately; and will utilize the Director of Administrative Computing to assist with configuration changes and data clean-up. • The records will be maintained in a designated Teams folder. Name(s) of the contact person(s) responsible for corrective action: Amy Hager and Amy See (Registrar). Planned completion date for corrective action plan: We expect the plan will be an ongoing effort to ensure compliance.

Management will be reviewing policies and procedures in the month of May every year. Additionally, the Director of Finance has been hired and joined Inner Voice effective October 16, 2023. The additional member of the finance department will allow for stronger internal controls and segregation of duties.

Inner Voice hired a Director of Finance with extensive experience in accounting and HR on October 16, 2023. The Director of Finance reports directly to the CFO.

The Organization continues to work with the contract financial team who plans to have the books closed in a timely manner going forward. The Organization is also actively working with their auditor to improve communication during the audit so a future break-down in communication does not occur. We expect the issue will be mitigated for the 2023 audit.

Federal Award Findings and Questioned Costs - Major Federal Awards Finding 2023-001 Material Weakness and Nonmaterial Noncompliance in Internal Control over application of sliding fee test. 2023-001 Recommendation: The Organization should ensure that controls and procedures are implemented to ensure the sliding fee application and assessed rate is reviewed by a secondary reviewer prior to billing. Action Taken: We concur with the recommendation and will establish procedures to ensure supporting documentation substantiating all patient household income and the number of residents who reside within their household is obtained and verified before services are provided. This process will indude the following: • Additional training for appropriate staff • Individual assessment of staff accuracy for training purposes • Reassignment of SFDS application audit function • Quarterly reporting to the Board of Directors on SFDS activities Date of Completion: April 30,2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Valerie Butt, Chief Financial Officer, at 757-618-0476. Sincerely, Valerie Butt Chief Financial Officer.

View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding. The Agency has done the following to correct the: • The Agency created a written procedure. This procedure requires that the Finance Director draw down funding in LOCCS for capital projects and that there are no more than 3 days before the funds are dispersed. The Executive Director will verify funds are being drawn down and expended according to the written procedure. This procedure took effect on January 29, 2024 after board approval.

Name of Contact Person: Terry Dudney, Chief Finance Officer Corrective Action Plan: Management will return the excess funds received and implement controls and procedures to ensure that federal funds are expended in a timely manner. Proposed Completion Date: As soon as possible.

2023-004 ESSER - Segregation of Duties – Grant Reporting Recommendation: We recommend that the District implement a review process over the reporting requirements related to the ESSER grants. Explanation of Disagreement with Audit Finding: There is no disagreement with this finding. Action Planned/Taken in Response to Finding: Lauren Lucius will prepare the ESSER claim and either Tonya Gebert or Rodney Huther will approve the claim before it is submitted. Name of the Contact Person Responsible for Corrective Action: Lauren Lucius Planned Completion Date for Corrective Action Plan: December 15, 2023

Condition: The University did not timely notify student or parent within 30 days of crediting the student’s account with FDL. Planned Corrective Action: When posting direct loans to the student’s account, we add a touchpoint to the student’s record. This automatically sends an email to the student. We will mail a notification to the parent in the case of a Parent PLUS loan. Contact person responsible for corrective action: Nicole Neal Anticipated Completion Date: 11/01/2023

Condition: Shawnee State University did not report student status changes timely and accurately for certain students who withdrew during the year. Planned Corrective Action: Shawnee State University will perform a comprehensive review of reporting procedures (including review of reporting process, personnel responsibilities, system modifications) and make revisions to workflow to prevent future occurrence of this finding. A review of activity prior to implementation of revised procedures will be conducted and any exceptions will be documented and corrected. Contact person responsible for corrective action: James Farmer, Chief Enrollment Officer and Greg Ballengee, Chief Financial Officer Anticipated Completion Date: 12/31/2023

Condition: The University did not return Title IV funds to the Department of Education within the required time frame for certain students who required a return of funds, and it did not initially identify all students who required a return of Title IV funds. Planned Corrective Action: Shawnee State University will perform a comprehensive review of financial aid procedures (including review of financial aid processing, personnel responsibilities, system modifications) and make revisions to workflow to prevent future occurrence of this finding. A review of activity prior to implementation of revised procedures will be conducted and any exceptions will be documented and corrected. Contact person responsible for corrective action: James Farmer, Chief Enrollment Officer and Greg Ballengee, Chief Financial Officer Anticipated Completion Date: 12/31/2023

Material Weakness in Internal Control and Material Noncompliance (Modified Opinion) 2023-002 (Previously component of 2022-002) FFATA Reporting U.S. Department of Health and Human Services Maternal, Infant, Early Childhood Home visiting Assistance Listing Numbers: 93.870 Recommendation: While the program did perform the annual SF425 reporting, we recommend the program ensure follow-through with the FFATA reporting requirement by entering the data collected from the subrecipients into the FSRF portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ECECD takes this matter seriously and has been committed to addressing and correcting it in FY23. ECECD implemented guidelines in FY23 that are accessible on our intranet that mandates all sub-recipients to complete and submit a FFATA report. Current existing FFATA reports have been submitted to the ASD Grants Management Division for further transmission to the appropriate Federal Reporting Agencies. ECECD is fully committed to ensuring compliance with FFATA reporting requirements for all our contracts. Additionally, to prevent any future lapses in FFATA reporting, the Chief Financial Officer (CFO) will develop a system where any contracts with subrecipients involving thirty thousand ($30,000.00) or more will be flagged for mandatory FFATA reporting. These proactive measures will help us maintain transparency and accuracy in our reporting, and ECECD is dedicated to its successful implementation. ECECD is fully committed to strengthening our processes to ensure full compliance with FFATA reporting requirements moving forward. Name(s) of the contact person(s) responsible for corrective action: Carmel Pacheco-Aragon, Chief Financial Officer; Inez Gonzales, Grants Manager; ECECD Program Managers. Planned completion date for corrective action plan: June 30, 2024

CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2023 Bowen Center respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Blue & Co., LLC 500 N. Meridian Street, Suite 200 Indianapolis, Indiana 46204 Audit period – Year Ended June 30, 2023 The finding from the 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS RELATED TO INTERNAL CONTROL OVER COMPLIANCE AND SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS REQUIRED BY THE UNIFORM GUIDANCE 2023-001 – Material weakness related to sliding fee discount application Recommendation: The auditor recommends that procedures and policies surrounding sliding fee discounts are reviewed and revised in order to strengthen internal controls to help ensure calculations and applications of sliding fee discounts are done correctly. In addition, the auditor recommends that all system settings surrounding sliding fee discounts are reviewed to make sure calculations are correctly performed. Planned Corrective Action: Management concurs with the recommendation. Policies and procedures regarding sliding fees will be reviewed and modified as necessary. In addition, sliding fee calculations will be automated when possible. * * * * * * * * * * * If there are any questions regarding this plan, please contact Jay Baumgartner, Chief Financial Officer at 574-269-0550.

Finding 2023-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Federal Assistance Listing Number: 14.871 Material Noncompliance – N. Special Tests and Provisions – Housing Quality Standards Inspections Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management there were documents that were unavailable for examination at the time of audit. Context: Of a sample size of sixteen (16) units, two (2) units did not have an annual HQS inspection performed. Our sample size is statistically valid. Known Questioned Costs: $8,640 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers Program and will implement internal control procedures that will ensure compliance with federal regulations. Sarah Parker, Executive Director, was designated to be responsible for implementing this corrective action by March 31, 2024.

Huntingdon Area School District submits the following corrective action plan in response to the finding listed in Section III of the Schedule of Findings and Questioned Costs for the year ended June 30, 2023. Finding 2023-001 Prevailing Wage Rates Condition: The Huntingdon Area School District does not have internal control procedures designed and implemented for the review of federal prevailing wage rate requirements. Views of Responsible Officials: The School District's Business Manager is the responsible official for the Education Stabilization Fund grants. The Business Manager stated that they agree with and understand the finding. Planned Corrective Action: Documented internal control procedures will be designed and implemented for the review of federal prevailing wage rate requirements. Person Responsible for Corrective Action Plan: Superintendent Anticipated Completion Date: April 30, 2024

Condition: Sinclair Community College did not report student status changes timely and accurately for certain students who withdrew and graduated during the year. Planned Corrective Action: Sinclair Community College will perform a comprehensive review of Enrollment Reporting to the National Student Loan Data System by way of the National Student Clearinghouse. This will include a review of enrollment reporting processing, personnel responsibilities, system modifications, and make all necessary revisions to workflows to prevent future occurrence of this finding. A review of activity prior to implementation of revised procedures will be conducted and any exceptions will be documented and corrected. Contact person responsible for corrective action: Dr. Tina L. Hummons, Registrar, Office of Registration & Student Records Anticipated Completion Date: 12/31/2023

Finding 2023-004 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Organization utilized net revenues and gross revenues in the lost revenue calculation causing errors in the lost revenue calculation which resulted in key line items being reported incorrectly in the Period 4 HHS Report. Corrective Action Plan: Management will correct the lost revenue calculation using budgeted net revenues to actual net revenues. The HHS report will be corrected on the next required report to HHS, if applicable. Management will enhance internal control procedures around the secondary review of the HHS Report to ensure all key line items are properly supported. Responsible Individuals: Justine Anderson, CFO Anticipated Completion Date: October 31, 2023

Finding 2023-003 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Organization selected option iii to calculate lost revenue using budgeted net revenues to actual net revenues. The Organization utilized net revenues for part of the calculation and then utilized gross revenues in later quarters. This inconsistency of net and gross revenues caused a miscalculation of the Organization’s total lost revenue. Corrective Action Plan: Management will correct the lost revenue calculation using budgeted net revenues to actual net revenues. Management will enhance internal control procedures around the secondary review of the lost revenue calculation. Responsible Individuals: Justine Anderson, CFO Anticipated Completion Date: October 31, 2023

Finding 2023-02 - Material Weakness in lhternal Control over ESSER Fund III The District concurs with the finding and the recommendation. The District will document its internal control policies and procedures for compliance monitoring to ensure federal expenditures did not exceed budgeted amounts. Tony Martinez, the District's Superintendent, is responsible for implementing the plan.

Management has implemented safeguards to ensure responsible business office employees are held accountable for following procedures to ensure timely and complete monthly and annual financial reporting. Currently, monthly account reconciliations are being prepared and monthly financial reports are being provided by management to the Board of Directors.