Corrective Action Plans

Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.

U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Charter Schools – AL #84.282 Education Stabilization Fund – AL #84.425C, 84.425D & 84.425U 2023-001 Risk Assessment Process Related to Compliance Requirements (Repeat Finding 2022-001) Material Weakness Recommendation: The Auditor recommended additional resources be allocated to federal award compliance to review federal award provisions and requirements, evaluate risks of noncompliance, and respond to such risks through internal controls. The process should include methods to identify and communicate changes to federal award requirements to all key individuals within the Organization and to verify internal controls are implemented correctly and are operating effectively. Planned Corrective Action: As the organization has grown, compliance of federal programs has become decentralized. We agree that additional resources need to be added to ensure compliance with all state and federal awards. The Organization has added additional capacity to the Business Office to assume the compliance and reporting responsibilities. Michelle Krauter, the Director of Accounting & Finance, is responsible for ensuring fiscal compliance and will coordinate program compliance activities with the Heads of School at each campus and the Directors of Academic Accountability. Through the monitoring activities conducted by the Indiana Department of Education during 2023, staff gained a better understanding the compliance requirements and are implementing processes to ensure ongoing adherence to the requirements. Evaluation of these processes will continue through 2024. 43

Finding 2023.002 Response: The information reported on filing for Period 6 will be reviewed internally by others in the Finance department to ensure the expenses are reported accurately. Responsible Party: Terry Lutz, CFO at Scheurer Hospital Estimated Completion: 03/31/2024

Finding 2023.001 Response: Scheurer Hospital plans to save the documentation noting the overstated expenses along with the unused lost revenue in the audit file. In the event of a further audit, Scheurer Hospital will have the documentation to support the federal awards expended. Responsible Party: Terry Lutz, CFO at Scheurer Hospital Estimated Completion: 02/21/2024

The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Award Program Audit Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Catalog Numbers: 14.871 and 14.879 Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Section 8 Housing Choice Vouchers Program - No Mainstream Vouchers Program - Yes Material Weaknesses in Internal Control over Compliance for Eligibility for the Mainstream Vouchers Program Significant Deficiency in Internal Control over Compliance for Eligibility Section 8 Housing Choice Vouchers Program 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: There are approximately 5,295 units. Of a sample size of seventy-one (71) tenant files, the following was noted: • HUD 9886 Form was missing in 1 file • Annual HUD 50058 recertification form and related verification of income and assets was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: • Mainstream Vouchers $19,830 • Section 8 Housing Choice Vouchers Program $1,875 Cause: There is a significant deficiency in compliance for the eligibility type of compliance related to the maintenance of tenant files in the Section 8 Housing Choice Vouchers Program. There is a material weakness in compliance for the eligibility type of compliance related to the maintenance of tenant files in the Mainstream Vouchers Program. The Authority has not properly maintained tenant files in compliance with program requirements following the expiration of HUD waivers. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. The Mainstream 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 a corrective action plan that will 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. Following the expiration of the COVID-19 HUD regulatory waivers, the Authority experienced a large backlog of reexaminations along with higher than usual rates of staff turnover and other staff capacity challenges related to the pandemic. Authority management developed and implemented a plan to rapidly work through the backlog, and has made significant progress to bring the program into compliance. The audit resulted in one missing consent form (HUD 9886), and one re-examination (HUD 50058), which is noted as missing. While the consent form had expired and a new consent form was required during the audit period, the income information collected for the household was collected while the consent form was still valid. With regards to the re-examination noted as missing, this re-examination was performed late, having been completed just six days after the end of the audit period. The re-examination was initiated on time, and the delay in completing the re-examination was caused by the program participant’s delay in providing the required documents. Additionally, the Authority has been selected for participation in the Moving to Work program ('MTW'). Alternative re-examination schedules, including biennial re-examinations, are an approved MTW activity allowable through the MTW Operations Notice. The Authority has received HUD approval of a waiver that allows the use of an alternate re-examination schedule effective July 1, 2023. This re-examination schedule is in effect currently and will be in effect for the entire duration of the subsequent audit period. Based on the transition to biennial and triennial re-examinations, the Authority has already come into compliance with timely recertifications. Further, the Authority management is in the process of implementing enhanced Quality Control procedures, with staff to conduct ongoing internal audits over the course of the year. If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please call Aaron Pomeroy, Finance Director at 831-454-5908.

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Utility Allowance Schedule Type of Finding: Instance of Non‐Compliance and Material Weakness in Internal Control over Compliance Views of Responsible Officials: The Housing Authority fully complied with 24CFR 982.517(C)(1) of HUD regulations that states that "A PHA must review its schedule of utility allowances each year and must revise its allowance for a utility category if there has been a change of 10 percent or more in the utility rate since the last time the utility allowance schedule was revised. The PHA must maintain information supporting its annual review of utility allowances and any revisions made in its utility allowance schedule." Each year, the Housing Authority hires a consultant to analyze the Utility allowances for the Fairfield jurisdiction. Once that assessment is completed, Housing Authority staff and Management review it. The Housing Authority staff then meets with the Consultant to discuss any irregularities found or resolve questions emanating from its review. Once staff and Management are satisfied with the information, have clear documentation explaining the Consultant's conclusions, and memorialize any categories that have changed 10% or more, Management will finalize its review of the Utility Allowance Schedule. The Housing Authority will document Management’s approval of the utility allowance adjustments, if any. Responsible Individual(s): Tanya Tran, Housing Division Manager LaTanna Jones, Deputy Executive Director Anticipated Completion Date: June 1, 2024

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials: We concur. The Housing Authority addressed this issue when the City was informed in March 2023 there was not enough documentation prior to online grant reporting for the auditors to verify grant reports were reviewed prior to submission on other grants being audited. The Housing Authority has continuously maintained a check and balance approach for preparing and reviewing VMS reports before HUD submission. All reports are prepared by the Housing Authority and finance staff, then reviewed by either the Housing Authority Manager or the Deputy Executive Director before submission to HUD. The reviewer is now documenting their review prior to submitting the VMS reports. Responsible Individual(s): Tanya Tran, Housing Division Manager Anticipated Completion Date: June 30, 2023

Federal Agency: U.S. Department of Homeland Security Program/Cluster: Staffing for Adequate Fire & Emergency Response Federal Assistance Listing Number: 97.083 Pass‐through: N/A Award No. and Year: EMW‐2020‐FF‐00816, 2020 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials and Corrective Action Plan: The Fire Department has addressed this issue when the City was informed in March 2023 there was not enough documentation prior to online grant reporting for the auditors to verify grant reports were reviewed prior to submission on other grants being audited. The two (2) submissions in question were reviewed and verified by management but were not documented for the auditors to verify when the review was completed, prior to the City being notified in March 2023 to further document the review process. The City has implemented this recommendation. Responsible Individual(s): Taylor Armour, Administration Division Manager Anticipated Completion Date: June 30, 2023

Finding 2023-001: Section 232 Loan – Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Loan, ALN 14.129 Anticipated Completion Date: September 30, 2024 Recommendation: It was recommended management of Cheney Care Community review their internal controls over the financial reporting and close processes to determine whether additional controls over the preparation of the final trial balances and related schedules can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP. Action Taken: Cheney Care Community will review their internal controls over the financial reporting and close processes to determine whether additional controls need to be implemented going forward.

Due to turnover of the Organization's Finance and Administration manager, the Organization was unable to have the annual audit completed within the required timeframe, and subsequently were also late in submission of the FAC report. The Organization has internally hired a Staff Accountant and an Accounts Payable to assist with audit preparation. The Organization has externally contracted an accounting firm that has provide the Organization with a CPA to conduct audit preparation and other financial services, as requested. We can confirm that this is not a repeat finding but an isolated instance. The Organization will work on getting financial information timelier (i.e. submit the reporting package with the guidelines of Uniform Guidance).

FINDING 2023-005 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were complied, prepared and submitted by the Assistant Superintendent and reviewed by the Treasurer prior to submission. However, this review process was not effective and did not detect and allow correction of errors prior to submission. All six of the submitted reports were selected for testing. Four of the reports were not supported by the unit's records. The financial information provided did not agree to the data submitted in the reports; therefore, we could not determine the accuracy of the reports. The lack of controls was systematic throughout the audit period. The noncompliance was isolated to the four reports identified above. The auditors recommended that management of the School Corporation establish a proper system of internal controls and develop policies and procedures to ensure reports are supported by the ledgers or reports used to complete the report Contact Person Responsible for Corrective Action: Rolland Abraham Contact Phone Number and Email Address: 765-584-1401, rabraham@randolphcentral.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation is required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted includes, but is not limited to, current period expenditures, prior period expenditures, and expenditures per activity. The annual data reports will be complied/prepared by the Treasurer and the Assistant Superintendent to ensure the reports are supported by the corporation’s financial data. The JotForm will be reviewed by the Superintendent prior to submission. Anticipated Completion Date: 2/21/2024

FINDING 2023-003 Finding Subject: Special Education Cluster (IDEA) – Allowable Costs/Cost Principles Summary of Finding: The Individuals with Disabilities Act (IDEA) Special Education – Grants to States program provides grant to states, and through them to Local Educational Agencies (i.e. the School Corporation), to assist them in providing special education and related services to eligible children with disabilities ages 3-21. IDEA’s Special Education – Preschool Grants program provides grants to states, and through them to LEAs to assist them in providing special education and related services to children with disabilities ages three to five and, at the state’s discretion, to two-year-old children with disabilities who will turn three during the school year. To receive reimbursement for special education expenses paid, the School Corporation’s Treasurer completed a reimbursement request, and the Assistant Superintendent reviewed it. The documentation attached to the reimbursement request; however, did not have adequate detail to determine the payroll paid was in conformance with the applicable cost principles. Furthermore, payroll disbursements were posted by the Treasurer without a review to ensure the payee, amount, fund, and disbursement classification was accurate prior to disbursement. The auditors recommended that management of the School Corporation design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Contact Person Responsible for Corrective Action: Rolland Abraham Contact Phone Number and Email Address: 765-584-1401, rabraham@randolphcentral.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Treasurer will prepare a detailed payroll appropriation report each payroll. The Assistant Superintendent will review it to ensure the payee, amount, fund, and disbursement classification are accurate prior to disbursement. After approval, at the end of the month, the Treasurer will complete a reimbursement request and the Assistant Superintendent will review it for accuracy prior to submission. Anticipated Completion Date: 2/21/2024

Finding 2023-006: Voucher Management System Reporting NHA Corrective Action: In process. The fee accountant will now complete the VMS report monthly. The executive director will review these reports monthly. The executive director will conduct an annual review of VMS at the YE closing in June (done in July or August prior to FDS submission) and before HUD pulls VMS data for annual renewal funding (usually done in January). This will ensure that all VMS data is reviewed by both management and the fee accountants, increasing the likelihood that any error will be caught and corrected in a timely manner.

Finding 2023-005: Utility Allowance Review NHA Corrective Action: In process. The Authority hired a firm to complete the annual utility allowance reviews two years ago. Coordinating the review with the firm has yet to produce a review in time to meet the audit deadlines. The annual utility allowance review has been added to the Authority’s annual calendar so that the process will be completed each year by November 1. An annual documentation checklist has been created implementing the finding recommendation to track the annual utility allowance review including: • date of annual utility allowance review • records of rates as of the review date • records of calculations for rate changes • records of increases in utility allowance schedule

Finding 2023-004: Capital Fund Grant Admin NHA Corrective Action: The Authority has all documentation on paper for all payment vouchers, statements that monies were drawn down correctly, invoices, and records of payments. The updated annual online budget forms were not completed in the required Capital Funds timeline regulations. Plans are underway to update the 2023 online budgets within the next month. Ongoing Capital Funds Education continues to be prioritized. Improvements in internal processes will be implemented as knowledge is accumulated. When these online budgets are updated with the information from the paper tracking documentation and submitted for approval to the regional office, it will be clear that the $206,189.50 in Questioned Costs in this finding were accurately distributed. In order to prevent this situation from occurring in the future, the Authority will follow the finding recommendation to provide the following reports at monthly board meetings beginning with the April 2024 board meeting.: • status of grants including grant award • obligation and expenditure deadlines • funds obligated • funds advance, and • funds expended

Finding 2023-003: Allowable Activities NHA Corrective Action: In process. The Authority has initiated a new time study to review its allocation system and document the justification for it. Urlaub will use this information to verify the original 65/35 percentages or to determine more accurate percentages. The new percentages will be used for determining the correct Reallocation of administrative funds. The new percentages will be used to correct the percentages that will be used by Urlaub to redistribute the funding for fiscal year 2024. This information will be used to determine the relevance of the expense being allocated.

Finding Summary: Part of the Federal Funding Accountability and Transparency Act (FFATA) requires direct recipients of certain federal awards to report subaward information by the end of the month following the month in which the prime awardee obligates a subgrant award equal to $30,000 (or $25,000 for federal agencies that have not yet adopted amendments effective November 12, 2020). Required subaward information was not reported in the FFATA Subaward Reporting System (FSRS). Responsible Individuals: Erik Schoen, CEO Corrective Action Plan: Management agrees with this finding and will comply with this requirement going forward. Staff are currently creating a process in relation to this finding to accurately report needed information monthly. Anticipated Completion Date: June 30, 2024

CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2023 Finding 2023-001 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: 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Noncompliance 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 playground equipment. As of June 30, 2023, $75,190 was disbursed related to this capital project. The construction payments represented approximately 2.7% of the Education Stabilization Fund expenditures for the audit period. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements. The construction contracts did not include clauses for federal wage rate requirements. 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: Mary Ann Baines, Director of Financial Operations/Treasurer, will oversee the corrective action plan which will be implemented immediately and steps will be taken to collect on wage reports for work performed since July 1, 2023.

Finding 2023-003 – Education Stabilization Fund - Activities Allowed or Unallowed, Allowable Costs- Cost Principles Contact Person Responsible for Corrective Action: Jessica Cheesman Contact Phone Number: 765-468-6868 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Superintendent will sign off on all vouchers going forward and all vocuhers from 07/01/2023 to 12/31/2023 Anticipated Completion Date: 04/30/2024

Finding 2023-004 – Special Tests and Provisions – Wage Rate Requirement Contact Person Responsible for Corrective Action: Michelle Babcock Contact Phone Number: 317-392-2505 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We now require all federal contracts to provide the proper language for Davis Bacon wages. In addition, we require the payroll reports to ensure that the pay rates comply with the federal wage rate requirements. Anticipated Completion Date: July 2023

Condition: The billing submitted to the awarding agency for May and June 2023 cash management drawdown included expenses that weren’t incurred as of May and June 2023. Planned Corrective Action: The corrective action has been implemented to modify the order of our preventative internal controls. SFTRA has changed the order of review so the electronic drawdown is not completed by the Budget Office until the Accounting Office has reviewed and approved the draw. This step was previously completed after the drawdown was initiated. Additionally, during review by the Accounting Office, the general ledger line detail will be reviewed to ensure accuracy Contact person responsible for corrective action: Jeremy Baker, Director of Finance Anticipated Completion Date: 1/15/2024

FINDING 2023-002 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Findings: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. The free and reduced-price applications were completed online by the applicants, and the information was automatically uploaded into the School Corporation's nutrition program software system. The software system then calculated the student's eligibility for free and reduced-price meals based on the parameters in the system. There was no documented oversight, review, or approval process to ensure the parameters in the system were correct and that the eligibility determination made complied with the requirements of the programs. The lack of internal controls was a systematic issue throughout the audit period. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director and Business Manager have added the verification of every 30th Free/Reduce application that is submitted during the school year to their monthly checklists. Beginning with the 2024-25 school year, the Food Service Director will enter the eligibility parameters into the school nutrition software. Once entered the Food Service Director will provide a copy of the prices entered into the system to be reviewed and approved by the Business Manager or Superintendent. Anticipated Completion Date: January 2024/July 2024

FINDING 2023-001 Finding Subject: COVID-19 – Education Stabilization Fund – Equipment and Real Property Management Summary of Finding: 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 following compliance requirements: Equipment and Real Property Management. The School Corporation presented the equipment and real property records for the ESF grant equipment: however, the records failed to include a description (including serial number or other identification number), source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, location, use, and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR 200.313(d)(1)). Contact Person Responsible for Corrective Action: Jacob Heuchan Contact Phone Number and Email Address: (317)-878-2100; jheuchan@nhj.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager will work with the Technology Director and the respective departments to ensure the appropriate information is being entered into the Corporation’s equipment and real property records for items purchased through ESF/federal funds. A physical inventory of the property will be taken and the results reconciled with the property records at least once every two years. Anticipated Completion Date: Immediate.

Finding 2023-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital’s expenditures identified as eligible and claimed under the Provider Relief Fund program did not agree to the underlying detail listing. The current key financial personnel were unable to reconcile the differences between the support and the amounts reported. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will strengthen the control process for maintaining documentation of the final expenditure listing used to report under the federal program. Anticipated Completion Date: March 31, 2024

Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed/Allowable Costs Finding Summary: The Hospital’s expenditures identified as eligible and claimed under the Provider Relief Fund program did not agree to the underlying detail listing. The current key financial personnel were unable to reconcile the differences between the support and the amounts reported. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will strengthen the control process for maintaining documentation of the final expenditure listing used to claim the allowable costs under the federal program. Anticipated Completion Date: March 31, 2024