Corrective Action Plans

Finding 2023-001- Eligibility Condition During our audit, 8 out of 40 individual files selected for eligibility testing did not contain evidence that the Organization obtained or reviewed a lease to support the eligibility of the individual who received a direct assistance payment. Further, there was no evidence of alternative documentation of residence when a lease could not be obtained. Corrective Action Plan Corrective Action Planned: Catholic Charities Diocese of Allentown declined to administer the second round of ERAP funding. Significant leadership changes have been implemented in May 2023, including a new Managing Director. Catholic Charities is in the process of designing an enhanced training program to ensure all programs complete all documentation required to substantiate eligibility under each program administered, whether privately or publicly funded. Name(s) of Contact Person(s) Responsible for Corrective Action: Andrea Kochen Neagle, Managing Director and Susan Mazza, Finance Administrator Anticipated Completion Date: December 2023

Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers & Mainstream Vouchers Assistance Listing Number: 14.871 & 14.879 Noncompliance – N. Special Tests and Provisions – Housing Quality Standards Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussions with management, the Authority did not properly abate four (4) out of twenty-six (26) annual failed inspections selected for testing. Context: The Authority did not properly abate four (4) out of twenty-six (26) failed inspections selected for testing. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Our sample size is statistically valid. Known Questioned Costs: $12,804 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance with Notice PIH 2021-14(HA). Effect: The Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs are in material non-compliance with the with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor and has made arrangements to comply with the compliance requirements of the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs. Jeremy White, HCV Director, will be responsible to implement this corrective action by March 31, 2024.

Finding 2023-005 – Education Stabilization Fund - Activities Allowed or Unallowed, Allowable Costs- Cost Principles Contact Person Responsible for Corrective Action: Felicia Wolfington Contact Phone Number: (812) 936-4474 x232 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The school corporation’s management will establish a documented, primary and secondary review of all federal accounts payable claims. Anticipated Completion Date: 02/16/2024

Finding 2023-004 – Child Nutrition Cluster – Eligibility Contact Person Responsible for Corrective Action: Felicia Wolfington/Sasha Robison Contact Phone Number: (812) 936-4474 x232 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The school corporation’s management will establish a documented, secondary review of eligibility determinations to ensure they meet the grant agreement and eligibility compliance requirements. Anticipated Completion Date: 08/31/2024

Finding 2023-003 – Child Nutrition Cluster – Reporting Contact Person Responsible for Corrective Action: Felicia Wolfington/Sasha Robison Contact Phone Number: (812) 936-4474 x232 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The school corporation’s management will establish a documented, secondary review of the reporting to ensure they are meeting the grant agreement and cash management compliance requirements. Anticipated Completion Date: 02/16/2024

Finding 2023-002 – Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Felicia Wolfington/Sasha Robison Contact Phone Number: (812) 936-4474 x232 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The school corporation’s management will establish a documented, secondary review of all accounts payable claims to ensure the accuracy of the claims, and will ensure underlying support or details of the claims will be included. Anticipated Completion Date: 02/16/2024

The District agrees with the finding and the recommendations of the auditors. The District has taken a number of steps to improve internal controls and will finalize a comprehensive plan for robust internal controls reinstatement by January 10, 2024. Since the arrival of new Human Resources Leadership in the fall of 2022, steps have been taken to ensure that all employee contracts are kept on file in hard copy and digital. The missing files occurred during a transition period during the hire and rehire period of spring and summer 2022, before the arrival of new leadership. At this time, the Human Resources department ensures redundancy of storage of these contracts, with both paper copies and digital copies of all signed contracts kept in secure spaces. A staff member is charged to ensure these are all filed, and the Supervisor does an internal audit to ensure safekeeping. Going forward, the Human Resources Director will conduct quarterly checks, in May, August, November, and February to ensure all files are in place.

Audit Finding Reference: 2023-001 Management's View and Planned Corrective Action: Due to the extension of the federal funding for free school meals in the prior year, the District is aware of the fund balance greater than three (3) months of its average expenditures. We are looking to reserve the program fund balance to support the potential renovation that will take place over the summer of 2024 should Warrant Article 6 Renovate the Checkers Kitchen at Alvirne pass. This special warrant article is recommended by both the Hudson School Board and Budget Committee. This is allowable from the NH Department of Education's Office of Nutrition Programs and Services (ONPS). Name of Contact Person and Completion Date: Karen Atherton, Food Service Director Melissa Van Sickle, Finance Director Anticipated completion date: If supply issues are not a factor, December 31, 2024; otherwise, June 30, 2025.

Condition: Final Expenditure Reports due on November 29, 2022 for the ESSER II Section 23b Credit Recovery grant and the ESSER II Section 23b Before/After School grant were submitted on September 11, 2023. Planned Corrective Action: Finding has been corrected. Upon discovery of the oversight, the Final Expenditure Reports were reopened and completed on September 11, 2023. Further, the District acknowledges the lack of timeliness of submitting the Final Expenditure Reports, and has implemented procedures to ensure all reporting surrounding final expenditures is completed and submitted to granting authority in accordance with terms of the agreement going forward. Contact person responsible for corrective action: Erica Ingles, Finance Director and Jennifer Mudge, Supervisor of School Improvement and Grant Programs Anticipated Completion Date: 9/11/2023

2023-002 Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: WON should implement a process to complete time and effort certifications and reconcile those certifications to ensure the costs reported to the grantor are accurate. All additional amounts paid contain documentation that they are properly authorized. All employees should have timesheets to support the hours worked and charged to the grant. These timesheets should be formally approved by a supervisor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Women of Nations has updated its payroll policies and procedures to ensure that time and effort certifications are completed correctly and approved in a timely manner by supervisors. Name(s) of the contact person(s) responsible for corrective action: Charles Nelson Planned completion date for corrective action plan: June 1, 2023

Gramm Leach Bliley Act (GLBA) Compliance Planned Corrective Action: The college has implemented policies and procedures to address GLBA compliance and is taking steps to address all exceptions noted. Person Responsible for Corrective Action Plan: Jon Kokos, CFO Anticipated Date of Completion: June 30, 2024

Inaccurate Return of Title IV Funds (R2T4) Planned Corrective Action: The director is performing the R2T4 calculation, returning funds (if necessary), adjusting the student’s awards and bill in the appropriate software. The senior associate director is reviewing each student to be certain the correct funds are being reduced and/ or returned based on the calculation. Person Responsible for Corrective Action Plan: Karen Benfield, Director of Financial Aid Anticipated Date of Completion: This process is being implemented for the 2023-24 academic year.

Federal Supplemental Educational Opportunity Grant - Assistance List No. 84.007 Federal Work Study Program- Assistance Listing No. 84.033 Federal Pell Grant Program - Assistance Listing No. 84.063 Federal Direct Student Loans - Assistance Listing No. 84.268 Recommendation: We recommend the University 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. Action taken in response to finding: Ellucian, the producer of Banner, had a known defect that caused incorrect status change dates to be inserted in the Banner program which processes student enrollments. This defect was not known to me at the time, therefore, it was not something I was aware to be looking for when completing enrollment reporting. There were no errors which would have alerted me to the issue. See case PB006205. Known defect now seems to be corrected. Will review current processes in order to ensure the continuance of timely and accurate reporting, and to eliminate the possibility of future errors being at the fault of the University. Name(s) of the contact person(s) responsible for corrective action: Erin Moore and Dasha Smith Planned completion date for corrective action plan: 4/1/24

Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Jim Holifield Contact Phone Number: 219-531-3007 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Davis-Bacon wage rate requirement language has been added to all bid packets and quote solicitations. The Educational Support Coordinator and Deputy Treasurer will work with VCS Department Directors to monitor all federally-funded construction projects for compliance with said language. Anticipated Completion Date: February 1, 2024

Timely Reporting Condition: There was a lack of evidence of timely remittance of two PPG reports. There was also one instance of board listing report not submitted by required due date. Recommendation: We recommend documenting and retaining all submittal support when reports are submitted each year. CLA also recommends that the Center keep track of relevant due dates to insure timely submittal of reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: PPG reports were submitted on time whenever possible however there were instances where changes were requested and there were subsequent reports which made the submission date appear to be tardy. For future clarification, the staff will add date submitted on the bottom of those reports to be saved in our own database with additional dates for 2nd or 3rd submissions due to change requests. Name(s) of the contact person(s) responsible for corrective action: Angie Ellison Planned completion date for corrective action plan: Staff will add date submitted to the Quarterly reports already submitted for the 23/24 year and will include the submittal date to all future quarterly reports for ppg and all reports requested by managing entity. If the Oversight Agency has question"s regarding this plan, please call Angie Ellison at (863) 802-0777 .

Matching Calculation Condition: During review of yearly match calculation report, It was noted the match was not correctly reported. Recommendation: We recommend documenting via an approval form with written or electronic signatures designating who is preparing and who is reviewing match form. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Match reports are input into a data document that includes providers in 14 counties. For this reason, our managing entity was requested to send our version without the other counties. The wrong version was sent (quarter 3 instead of final year end version) therefore from this date forward we will keep each quarterly version in our database with added line items that list the preparer and tile approval w/date. Name(s) of the contact person(s) responsible for corrective action: Angie Ellison Immediate: Staff will go back to quarter 1 of 23/24 year and make these changes with copies in database as well as preparer and approval lines w/date. These documents will be prepared in this fashion from this date forward.

Lack of Review Condition: During review of employee timesheets and related grant reimbursement requests, and annual match report, there was a lack of evidence of review of these documents. Recommendation: We recommend documenting via an approval form with written or electronic signatures designating who is preparing and who is reviewing reimbursement forms and match reports. We also recommend that those approving timesheets document their approval via a signature. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned: While some of these documents (example: match) are not in our control, we will save them in a file for our use with the added lines that include preparer's name, approval line and signature Name(s) of the contact person(s) responsible for corrective action: Angie Ellison Planned completion date for corrective action Rian: All form revisions will begin March 1 2024

Finding Number: 2023-001 Planned Corrective Action: See Below Anticipated Completion Date: 01/22/2024 Responsible Contact Person: Patricia Eddy, Treasurer The District is aware of the requirement in Federal Program legislation to ensure the inclusion of the prevailing wage rate provision in agreements, as well as to obtain certified payroll reports to verify prevailing wages were paid. At the time the District entered into the agreement with West Roofing to install and renovate the HVAC system at Columbia High School, which was January 7, 2021, ESSER funds were not awarded to the District. The District planned on using its Permanent Improvement funds (a non -federal program sourced fund) to pay West Roofing. The District initially paid West Roofing from the Permanent Improvement fund for the installation/renovation of the HYAC at Columbia High School as per the initial contract. Once the ESSER funds were awarded, they allowed for previous expenses related to improving air quality to be included as part of reimbursement through ESSER funds. The prevailing wage was not met under the existing contract. The District has implemented the following Action Plan for Correction: 1. The Treasurer will ensure that all agreements intended to be sourced through Federal Funds will contain prevailing wage rate provisions prior to signing such agreements. 2. The Treasurer will ensure that invoices from contractors contain the necessary prevailing wage certified payroll reports prior to approving such invoices for payment from Federal Funds, 3. The Treasurer will educate all responsible parties in the District regarding prevailing wage documentation to ensure appropriate documentation is obtained prior to payment to the contractors and prior to requesting Federal Funds.

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.