Corrective Action Plans

2022-002 - Policies and Procedures for Federal Awards Corrective action planned: The Medical Center is in the process of developing policies and procedures as relates to federal awards, and anticipates having written federal procurement policies and procedures in place within 60 days of issuance of this report. Anticipated completion date: March 31, 2023 Contact person responsible for corrective action: Patrick Banks, CFO

U.S. DEPARTMENT OF TREASURY 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: The Health Board should ensure that program managers are aware of the significant compliance requirements of an award and implement a system of internal control that supports compliance and documentation of compliance. Explanation of disagreement with audit finding: We respectfully disagree with the characterization of the finding as a material weakness in internal control. The sample size of 28 selections called for 3 specific source documents to be provided in association with each sample. Thus, 10 out of a total of 84 source documents requested were not immediately available. The eligibility forms in question are part of the process which initiates the determination of the validity of the request for assistance. Due to the sensitive nature of this program, these documents are not readily available electronically (in order to protect the privacy of the recipients). The Health Board?s Community Services Team, which includes Rapid Rehousing, Gender-Based Violence, and Emergency Housing, experienced significant turnover due to the pandemic. We have informed the auditor about the turnover challenges faced by this specific department and the difficulties in securing physical documentation. Action taken in response to finding: In September 2022, the Community Service Team began reporting to the Health Board?s Behavioral Health Officer. Under her direction, processes have been updated and documented along with the creation of a stronger review process. The health board remains committed to further strengthening our controls and processes where necessary. We will ensure that program managers are aware of the compliance requirements associated with the award and implement a robust system of internal control that supports compliance and proper documentation. Name(s) of the contact person(s) responsible for corrective action: Linda Zhang, CFO Planned completion date for corrective action plan: September 30, 2023 If the U.S. Department of Treasury has questions regarding this plan, please call Linda Zhang, CFO at (206) 324-9360.

FINDING 2022-001 Information on the federal program: Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Numbers: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: 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 requirement. Context: We noted that for one claim in a sample of four, the school lunch meal count was overclaimed for the month. We noted that in October 2020 the School Corporation had overclaimed lunches by 173 meals. We noted that the sponsor claim reimbursement form had been reviewed, however, the lack of an effective review allowed the error to go unnoticed. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Going forward, we will have multiple people verifying the data before submission to reimbursement for claims to make sure all meals submitted meet the criteria and eligibility of the Child Nutrition Cluster. Responsible Party and Timeline for Completion: The Food Service Director and the Corporation Treasurer are the responsible parties for this corrective action. This has already been implemented.

MATERIAL WEAKNESS 2022-002 Action Taken: We concur with the recommendation, and we are currently taking action to negotiate the contract with our primary vendor, which provides curriculum, instruction, technology, and other services, Pearson Virtual Schools (Connections Education LLC). The new contract will be effective July 2023. TECCA administration and Board representatives have consulted with and continue to engage with legal counsel to ensure that the new contract details expenses aligned with agreed-upon terms. For the current year (FY23), we are continuing to request appropriate detail information from the vendor, Pearson Virtual Schools.

FINDINGS - FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2022-001 - Internal control over financial reporting ? contract monitoring/compliance Action Taken: We concur with the recommendation, and we are currently taking action to negotiate the contract with our primary vendor, which provides curriculum, instruction, technology, and other services, Pearson Virtual Schools (Connections Education LLC). The new contract will be effective July 2023. TECCA administration and Board representatives have consulted with and continue to engage with legal counsel to ensure that the new contract details expenses aligned with agreed-upon terms. For the current year (FY23), we are continuing to request appropriate detail information from the vendor, Pearson Virtual Schools.

Finding Number: 2022-002 Condition: The University initiated certain returns of Title IV funds after the required timing and, for other students, did not initiate certain returns. The University performed certain return calculations using inappropriate inputs. There were three errors that attributed to this finding: 1.Of the 60 students tested, there were 29 students with discrepancies between the date utilized in return to Title IV calculations and the date required to be utilized based on Federal regulations resulting in $5,990 in questioned costs. 2.Of the 60 students tested there were 18 students identified where the University had returned the funds untimely (45 days if student attended, 30 days if never attended). 3.Of the 60 students tested, there were 4 identified where no return to Title IV calculation was performed and therefore no return of funds until students were selected for testing for the audit resulting in $1,715 in questioned costs. Views of Responsible Officials and Corrective Action Plan - The University agrees with the finding. Planned Corrective Action: The procedures used to monitor, calculate, report, and return Title IV funds are being updated in the following ways to address the errors found and the cause of the errors: ?All procedures will be tied to FSA Handbook and regulatory guidance with references linked as appropriate. This will clarify the procedures being used for the return to Title IV process. ?Procedures will include updated regulations related to module courses. This will address the errors that were caused in misinterpreting these new regulations. ?Methodology for dates being used for end of semester and date of determination will be clearly documented for each semester along with the actual dates used. For non- modular courses, the end of semester date will be the Friday of final exam week. (This will be verified via guidance received from the ask regs function of NASFAA.) This will clarify the required deadlines for each semester. ?A new report generated from our Data Warehouse system will be used to reconcile all required returns for a given semester have occurred. This will address students who were also missed in the prior year process. Contact person responsible for corrective action: Brian Bell, Director Student Account Services Anticipated Completion Date: 10/31/2022

Finding Number: 2022-001 Condition: The University did not report certain students' status to NSLDS in an accurate and timely manner during the fiscal year. There were three errors identified that attributed to this finding. 1. Of the 40 students tested, there was 15 students who withdrew/graduated whose status change was not reported accurately to the NSLDS. Student withdrew or graduated and was reported but with an incorrect effective date. 2.Of the 40 students tested, there were 7 students who withdrew/graduated whose status changes were not reported to the NSLDS within 60 days. 3.Of the 40 students tested, there were 6 students who withdrew/graduated whose status change were not reported to the NSLDS. Views of Responsible Officials and Corrective Action Plan - The University agrees with the finding. Planned Corrective Action: Following guidance provided via Plante Moran and the Dept, of Education (2020-2021 desk file review and NSLDS direct support), we will be implementing the following changes effective Fall 2022 to address correct enrollment status change reporting by: ? Adopt the use of the published academic semester end date for enrollment reporting vs using the long-standing use of the SAP/SLCM 100 Date or end of a semester payment period. It was learned that published end of an academic semester, per the Academic Calendar, is expected to be reported for use in applicable enrollment compliance timing calculations. ? Registrars will update NSLDS with the actual status effective date when learned for all unofficial withdrawal or graduated statuses. This date will be the earliest date at which Registrars retroactively learns was the actual last date of attendance that created an enrollment status change. Our past practices did not update such students but used the end of the previous semester date (SAP/SLCM 100 Date) if a student was shown to be enrolled in the next upcoming semester. This corrective action will occur for all cases even if the student is not required to have a R2T4 initiated, due to having attended at least 60% of the semester. Students who officially withdraw, in part or total, during a given semester are found in our monthly enrollment reporting as last date of attendances are supplied at the time of formal withdrawal. ?Registrars will enhance or develop (if not already in place), in conjunction with SASUB, necessary control reports to ensure accuracy of identifying students who are unofficial withdrawals at the end of an academic semester and adjust staffing resources as necessary to account for critical time periods such as the period between CMU?s Fall and Spring semesters when the university is closed. This will be necessary due to using the published last date of the semester instead of the end of the payment period date that was used in prior years. ?Planned timeline to complete corrective actions is February 2023 to account for end of Fall 2022 grading processes and manual updating of NSLDS as necessary for identified unofficial withdrawals. ?Contact person responsible for corrective action: Keith Malkowski, Registrar ?Anticipated Completion Date: February 2023 following end of semester grading and subsequent student record updating per our Date of Determination process.

Finding 2022-001 Lack of Internal Controls over Reporting Federal Agency: U.S. Department of Agriculture (passed through the State of Alaska) Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553/10.555/10.582 Award Year: 2022 Type of Finding Material weakness in internal control over compliance and noncompliance. Name of Contact Person: Dennis Niedermeyer Corrective Action Plan: The District will make changes in personnel to provide for the accurate entry and reporting of meal counts into the state?s reporting and claims system. The NSBSD will hired an experienced and qualified food service administrator who will review, monitor and verify compliance with accurate reporting of meal counts. Proposed Completion Date: October 28, 2022.

The organization moved offices and storage facilities, and in the process, evidence of pay rate in personnel file of was misplaced. Managers will be retrained regarding the required paperwork necessary to retain for all employees. In addition, moving forward, our payroll company has agreed to advise us on the privacy and records retention landscape as well as provide us with a solution for federal, state, and local HR compliance.

CORRECTIVE ACTION PLAN 2 CFR ? 200.511(c) JUNE 30, 2022 Finding Number: 2022-001 Planned Corrective Action: In the summer of 2022, during a Monitoring Review performed by ODE of ESSER II funds, the District became aware of the specific requirements/documentation necessary for contracts let with federal ESSER funds. School Districts are usually not required to pay prevailing wages (state/local funds). The District had not used federal funds for construction in the past and was unaware of the requirement. Due to using an architect firm for the HVAC and window projects that were familiar with the requirements, the District had paid prevailing wage and had the required Davis-Bacon documentation for two of the three projects spent out of ESSER funds. The remaining project was in the amount of $46,870 for Locker Room Floor Renovations at the High School. The District was not aware of the Davis-Bacon requirements when the Business Manager originally contacted Kiefer in 2020 about the rubber flooring (no guidance was available). Due to COVID and delays in materials, the project was pushed back and this requirement was not reconsidered. District Administration has been made aware of the requirements using Federal ESSER funds going forward. In addition, the District policy (DJF) regarding purchasing procedures, that did not specifically include Davis-Bacon language, was updated to include Davis-Bacon requirements (Board approved 9/27/22). Further, the District intends to closely follow internal controls pertaining to federal grant management in order to prevent future issues as described in Finding 2022-001. Anticipated Completion Date: 09/27/22 Responsible Contact Person: Julie Taylor, Treasurer

2022-042 Oregon Health Authority Ensure expenditures of federal funds are for allowed activities Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services Federal Award Numbers and Years: 1B09SM083823, 2021 Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: $525,272 (known) Criteria: 42 USC 300x-5(a)(3) Mental Health Block Grant (MHBG) funds may not be expended on the purchase, construction, or permanent improvement of any building or other facility other than minor remodeling. Substance Abuse and Mental Health Services Administration?s (SAMHSA) standard funding restriction guidance defines minor alterations and renovations as the lesser of 25% of the budget period or $150 thousand. Additionally, all minor alterations and renovations must be approved by SAMHSA. During our testing of MHBG subrecipient contracts entered into during state fiscal year 2022, we noted one contract included payment for the remodeling of an existing building owned by the subrecipient. A payment of $525,272 was processed in December 2021 for the remodeling expenses as specified in the contract's payment provisions. However, this amount exceeds SAMHSA's threshold for minor alterations and renovations and is not allowed under the MHBG. We recommend department management ensure controls are properly designed and implemented to record only allowable expenditures to the MHBG. We further recommend department management seek SAMHSA approval for minor alterations and renovations. MANAGEMENT RESPONSE: We agree with this recommendation. OHA intended to have an interagency agreement with ODHS to co-fund an improvement to a much-needed treatment facility for children. OHA submitted the payment per our agreement with the vendor with the expectation that ODHS would fund the non-SAMHSA allowable expenses. The vendor used the funds for minor safety related renovations as one would expect them to prioritize before programmatic costs. But unfortunately, the ODHS payment was never made to OHA which prevented any additional funds from being sent to the vendor. Then, pandemic constraints along with a lack of funding prevented the vendor from being able to finalize their plan in the initial time frame. OHA sought a legal review, and the recommendation was made to cleave the contract from ODHS and allow the vendor additional time to finish their work. Upon cleaving the contract, the elements that OHA knows to be unallowable for SAMHSA funding were left in the contract because the contractor had already performed the work. OHA is awaiting a final review of expenditure reports and will request SAMHSA approval if warranted or adjust funding codes as needed to align with SAMHSA allowable charges. Anticipated Completion Date: September 30, 2023 Contact: Sarah Adelhart, Interim Manager

2022-041 Oregon Health Authority Ensure expenditures of federal funds are recorded to the appropriate program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services (COVID-19) 93.959 Block Grants for Prevention and Treatment of Substance Abuse (COVID-19) Federal Award Numbers and Years: 93.958 ? 1B09SM083994, 1B09SM085378 (COVID-19); 93.959 ? 1B08TI083513, 1B08TI083963 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: 93.958 - $2,268,421 (known COVID-19) Criteria: 2 CFR 200.303; 42 USC 300x-1 The department was required to submit a spending plan documenting the intended use of the awarded COVID-19 funding allocations under the Mental Health Block Grant (MHBG) and Substance Abuse Block Grant (SABG). The expenditure of COVID-19 funding should align with each block grant?s approved spending plan. Federal regulations also require recipients of federal awards establish and maintain internal controls designed to reasonably ensure compliance with federal statutes, regulations, and terms and conditions of the Federal award. Our testing of state fiscal year 2022 MHBG COVID-19 expenditures identified $10.4 million in workforce development incentive payments inappropriately recorded under the MHBG. Further inquiry into the payments revealed the department determined during state fiscal year 2023 these expenditures were not included in the MHBG COVID-19 spending plans and were not allowable activities under the MHBG. The department determined incentive payments totaling $8.1 million in COVID-19 expenditures should have been recorded under the SABG in accordance with the SABG COVID-19 spending plans. The department subsequently moved the $8.1 million of the combined $10.4 million total COVID-19 incentive payment expenditures to the SABG; however, the remaining $2.3 million in incentive payment expenditures were left in the MHBG as a funding source had yet to be determined. An adjustment to the Schedule of Expenditures of Federal Awards (SEFA) was required to move the $8.1 million in COVID-19 spending from the MHBG to SABG. The remaining $2.3 million is considered questioned costs under the MHBG. We recommend department management ensure controls are properly designed and implemented to record only allowable expenditures to the appropriate federal programs. MANAGEMENT RESPONSE: We agree with this recommendation. The identified expenditures were initially charged to the MHBG in error, and when the error was found by OHA staff, the funding source was corrected to SAPT for the authorized $8.1 million prior to the SOS audit beginning. There was still $2.3 million remaining coded to MHBG which after extensive review and leadership decision, has now been re-coded appropriately. OHA?s existing internal controls identified this issue initially, no additional corrective action is needed. Anticipated Completion Date: July 5, 2023 Contact: Sarah Adelhart, Interim Manager

2022-039 Department of Human Services Improve documentation of required income and benefit verifications Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Material Weakness Prior Year Finding: 2021-011 Questioned Costs: N/A Criteria: 45 CFR 205.55 Federal regulations require each state to participate in the Income Eligibility and Verification System (IEVS), which for Oregon, includes using income and benefit screens accessible through Oregon Employment Department, Internal Revenue Service, and Social Security Administration, when making Temporary Assistance for Needy Families (TANF) eligibility determinations. The department?s current procedure instructs caseworkers to narrate ?IEVS checked? in the case management system, Oregon Eligibility (ONE), after reviewing all appropriate IEVS screens at the time of eligibility determination. The department submitted change requests to the eligibility system?s service provider that would prohibit ONE from paying benefits until all IEVS screens are checked; however, the system change has not yet been completed. From a population of 105,267 TANF benefit payments recorded in ONE we randomly selected a sample of 40 and two additional individually significant payments for testing. We found in 16 cases, there was no narration of the IEVS check by caseworkers, in either ONE or the former narrative system. We verified these clients did meet the TANF eligibility criteria related to IEVS screens, however, by not providing assurance of verification of the use of IEVS screens, the department increases the risk of providing benefits to TANF ineligible applicants. We recommend department management ensure verification of income and benefits with IEVS screens is clearly documented in client case files when determining client eligibility. MANAGEMENT RESPONSE: We agree with this recommendation. The Department is implementing a new tool, Note Buddy, to assist workers with case notes when determining eligibility. Note Buddy will include a field that allows staff to select whether IEVS was checked. Staff will be encouraged, not mandated, to use Note Buddy. The Department will form a small workgroup to discuss options for revising and lowering the level of effort for the Change Request (CR) previously submitted. The Department will re-submit the CR for changes to ONE. Anticipated Completion Date: September 30, 2023 Contact: Annette Palmer, TANF Program Manager

2022-038 Department of Human Services Ensure work participation rate calculation uses verified and accurate data Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Special Test and Provisions Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: 2021-010, 2020-014, 2019-009 Questioned Costs: N/A Criteria: 45 CFR 261.61-62, 65 Federal regulations require each state maintain adequate documentation, verification, and internal control procedures to ensure the accuracy of data used in calculating work participation rates. Each state must have procedures to count and verify reported hours of work and must comply with its Work Verification Plan as approved by the U.S. Department of Health and Human Services (DHHS). Oregon?s Work Verification Plan outlines a system of controls for how reported hours will be verified and documented, and for reviews and monitoring procedures to identify errors. Work participation hours are reported via the quarterly Temporary Assistance for Needy Families (TANF) ACF-199 data reports and for benefits paid with designated state funds called maintenance of effort (MOE), the ACF-209 reports. As stated in a separate finding, titled `Ensure performance data reports are complete and accurate,? we determined the data reports are not complete or accurate. However, we found the department did correct a previous issue in which work participation hours on the ACF-199 report were left blank. Although reports were known to be incomplete, we reviewed the reporting periods October 1, 2021, through June 30, 2022, to test for compliance of the Work Verification Plan. We reviewed 20 randomly selected ACF-199 cases from a population of 16,249, and 20 randomly selected ACF-209 cases from a population of 146,324 of participating clients for verification of work activity participation. We found: Five of 20 ACF-199 cases with reported participation hours did not agree with hours in the system of record TRACS. 14 of 20 ACF-199 cases lacked support for the reported hours. 9 of 20 ACF-209 cases lacked support for the reported hours. These inaccurate or unverified hours were reported to DHHS for use in calculating the work participation rate. If the state fails to follow the approved Work Verification Plan, DHHS may penalize the state. We recommend TANF program management ensure the work participation rate is calculated appropriately using verified and accurate participation data in adherence to the department?s Work Verification Plan. We also recommend program management review the system of controls and identify where improvements are needed to ensure compliance with the work verification plan. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will develop training specific to error trends based on Quality Control audits of the JOBS program, skill enhancement/best practices on collecting and documenting accurate attendance, and technical training on the Department?s attendance documentation system, TRACS. The training will be instructor led and offered at minimum on a quarterly basis. The Department will review and edit tools, resources, and attendance logs to ensure compliance with the work verification plan. Updates made will be communicated to staff working with families receiving TANF. The Department will also form a workgroup to review the attendance documentation and case management system known as the Transition Referral and Client Self-Sufficiency (TRACS) system. The workgroup will make recommendations to developer, which will include system enhancements and edits to improve the process for staff. Anticipated Completion Date: April 30, 2024 Contact: Annette Palmer, TANF Program Manager

2022-037 Department of Human Services Improve accuracy of cases reported as noncooperating with child support Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Special Tests and Provisions Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 45 CFR 264.30-31 Federal regulations require the department to refer all appropriate individuals in the family of a child to the child support enforcement agency. If the department determines referred individuals are not cooperating, without good cause, in establishing, modifying, or enforcing a support order with respect to the child, then the department must reduce or deny assistance in the Temporary Assistance for Needy Families (TANF) program. The department faces reduced State family assistance grant payments for failure to enforce penalties against noncompliant individuals. In March 2020, the department established good cause exemptions due to Covid for all individuals. Noncooperation sanctions were reinstated in April 2021, by which time the department had moved its case management system to Oregon Eligibility (ONE). When a caseworker enters a child support noncooperation code in ONE, the system should automatically reduce TANF benefits. The population of cases identified in ONE as not cooperating with child support is obtained from the quarterly performance data reports compiled by a service provider. As stated in a separate finding, titled `Ensure performance data reports are complete and accurate,? we determined the data reports are not complete or accurate, therefore, the population of cases not cooperating with child support is also incomplete. However, we tested some cases in the reports to verify ONE was appropriately reducing benefits. The quarterly performance data reports for periods October 1, 2021, through June 30, 2022, consisted of 133 unique cases identified as not cooperating with child support. We randomly selected 14 cases and could not find support in ONE for noncooperation. The department identified one case entered in ONE incorrectly by a caseworker and the remaining cases had various nuances causing the performance data reports to retrieve the information incorrectly. All 14 cases were either cooperating with or not applicable to child support. The department also identified at least eight defects in child support data retrieval it reported to the service provider. We are unable to determine if ONE is correctly reducing TANF benefits when a case is not cooperating with child support. We recommend department management ensure noncooperative child support cases from ONE are completely and accurately reported in its performance data reports. MANAGEMENT RESPONSE: We agree with this recommendation. The Department has logged defects to correct Federal reporting requirements. The ONE system approving eligibility without a cooperation record was addressed through a defect and system build which corrected the issue on May 10, 2023. The Department has logged a defect to correct historic records where referrals were not sent; currently awaiting input from Division of Child Support. The system defect fix for issues identified related to incorrect values of child support cooperation status in ACF reports is currently in the development and testing cycle. Once the fix is deployed, future submissions will have correct data for this element. The reports will be resubmitted to ACF at the end of the current fiscal year (for months October 2022 ? Sept 2023) to correct previous data. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager

2022-036 Department of Human Services Ensure performance data reports are complete and accurate Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.558 Temporary Assistance for Needy Families Federal Award Numbers and Years: 2021G996115, 2021; 2022G996115, 2022 Compliance Requirement: Reporting Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: 2021-009, 2020-013, 2019-008 Questioned Costs: N/A Criteria: 45 CFR 265.7(a) and (b) and (f) Federal regulations require the department to collect monthly and report quarterly certain financial and non-financial data elements for services paid with Temporary Assistance for Needy Families (TANF) federal funding in the ACF-199 TANF data report. Federal regulations also require the department to report data quarterly for TANF eligible clients whose benefits are paid with designated state funds called maintenance of effort (MOE) in the ACF-209 SSP-MOE data report. Both data reports should be supported by applicable performance records. During fiscal year 2021, the department transitioned key aspects of the TANF program to Oregon Eligibility (ONE) for case management, while TANF child welfare payments continued to be recorded in OR-Kids the child welfare system. The department contracts with a service provider to extract data from ONE and OR-Kids to populate the data reports. Program staff currently work with the service provider to obtain comprehensible data reports prior to submission to review them for errors and when found, each issue is logged as a defect for the service provider to correct. The department and the U.S. Administration for Children and Families identified data reports submitted for state fiscal year 2022 were incorrect. The federal quarterly report ended September 30, 2021, was revised and resubmitted but still had likely errors according to program staff. Quarterly reports ended December 31, 2021 (Q1), March 31, 2022 (Q2), and June 30, 2022 (Q3), were corrected and resubmitted in February 2023. Data reports are comprised of individual component reports identified by ?T? for ACF-199 TANF and ?M? for ACF-209 MOE. We reviewed the resubmitted Q1, Q2, and Q3 reports and found: The Q1 TANF T2 and MOE M2 reports corrected a prior known defect. The fields identifying work participation have populated associated fields with job type and hours. The Q3 T6 report showing number of applications, number and types of families, and amount of assistance, reported $4.5 million more than supported by accounting records. The April 2022 T1 report contained 4,035 case numbers not found in the underlying system records, and 1,081 from system records not reported in the T1 report. OR-Kids cases in the Q1, Q2, and Q3 T1 24 of 45 fields left blank. In 10 of 21,171 cases recorded as having surpassed the federal funding limit of 60 months in the Q1, Q2, and Q3 T2 reports, we found three where the T2 reports did not agree to support in ONE. As the performance data reports are known to be incomplete and inaccurate, we are unable to test them for compliance with federal reporting requirements. To date, the implementation of ONE has not resolved findings related to performance data reporting, which have been ongoing since fiscal year 2010. Though the department has yet to receive a Service Organization Control (SOC) report from the service organization administering ONE and compiling data reports the department is in the process of contracting for a SOC report. Without an annual SOC report, the department does not have assurance controls are functioning as intended at the service organization for the TANF program. We recommend department management continue to review ACF-199 and ACF-209 reports prior to submission and monitor known compilation defects to ensure performance data reports submitted are complete and accurate. We also recommend department management obtain an annual SOC report over the service organization?s internal controls for the ONE application. MANAGEMENT RESPONSE: We agree with this recommendation. The Department continues to review ACF-199 and ACF-209 reports prior to submission to identify and resolve defects. The Department continues to monitor defects, sync up reports design with federal instructions, and progress towards complete and accurate reporting. The ACF 199 report issue regarding OR-Kids cases with 24 of 45 fields left blank is currently under development; mapping has been identified to rectify the missing data and once fixed, the future submissions will be corrected. The reports will be resubmitted to ACF at the end of the current fiscal year (for months October 2022 ? Sept 2023) to correct previous data. The issue regarding discrepant case counts between ACF 199 report and OR Kids data extract is under analysis. Child Welfare, TANF, and our technical team will develop a plan for rectifying and reconciling case numbers. The Department?s, Oregon Eligibility Partnership, has contracted for a SOC Type 2 audit, through contract 178884. The first audit review will be utilized to make sure all the reporting requirements and functional areas are in place. This means, the first formal audit finding, based on recommendation from the vendors, will occur in FFY25. Additional internal and external audits are happening on the system. Anticipated Completion Date: December 31, 2023 Contact: Annette Palmer, TANF Program Manager

2022-053 Oregon Health Authority Improve financial reporting accuracy Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541, 2020 (COVID-19); 6 NU50CK000541, 2021 (COVID-19) Compliance Requirements: Reporting Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: 2021-022 Questioned Costs: N/A Criteria: 2 CFR 200.328 In response to the COVID-19 pandemic, the Centers for Disease Control (CDC) awarded states substantial funds for the purpose of addressing the pandemic at the state level. Among other requirements, states are required to submit monthly financial reports to the CDC providing totals spent on travel, payroll, equipment, and other categories. During the fiscal year 2021 audit, we reported a material weakness relating to the accuracy of the amounts reported to the CDC. The same issue persisted throughout fiscal year 2022. As of June 30, 2022, the department had not taken the necessary actions to implement the prior recommendations and had not fully corrected the reports submitted in fiscal years 2021 and 2022. However, as of March 2023, the department had implemented the appropriate corrective actions and the previously inaccurate reports have been updated, including the reports for fiscal year 2022. Audit standards require that we report on the status as of June 30, 2022. We recommend department management maintain the necessary internal controls to ensure the monthly financial reports are accurate and agree to the accounting records. MANAGEMENT RESPONSE: We agree with this recommendation. As you note in your audit letter, our financial reporting accuracy had been remedied for all historical and current reports by March 2023. Unfortunately, these improvements were not in place by June 30, 2022 and, for that reason, a finding was noted. Corrective action plan: ? All monthly financial reporting has been assigned to our Fiscal Analyst ? The Fiscal Analyst submits monthly financial reports and the query used to generate the reports to the Office of Financial Services (OFS) for review and approval ? The Fiscal Analyst revises monthly financial reports based on OFS feedback ? Following OFS approval, monthly financial reports are entered into CAMP by an ELC administrative staff member and verified by a second team member Anticipated Completion Date: March 31, 2023 Contact: Merry Carlson, ELC Contracts Manager

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Philip McKelvey Contact Phone Number: 219-759-2531 Views of Responsible Official: we concur with the finding. Description of Corrective Action Plan: Reimbursement reports and claims will be signed off on between the submitter and the Food Service Consultant or Kitchen Manager(s) in order to ensure accuracy. Anticipated Completion Date: January 23, 2023.

FINDING:2022-004 Contact Person Responsible for Corrective Action: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 Views of Responsible Official: We concur with the findings Description of Corrective Action Plan: The Corporation Treasure and I discussed this matter and we will be more mindful in the future to get the reimbursement claims receipted in a timely manner. Anticipated Completion Date: February 2023

Finding Number: 2022-004 Condition: During testing of the grant, we noted the School District utilized funds from the Education Stabilization Funds ( ESF) for minor remodeling and renovations of the school buildings. Per the 2022 Compliance Supplement, recipients and subrecipients that use ESF for minor remodeling, renovation, or construction contracts that are over $ 2,000 and use laborers and mechanics, must meet Davis Bacon prevailing wage requirements. The School District expended approximately $ 360,000in ESSER funds that related to repairs and renovations for an indoor air purification system; however, the School District received the certified payroll reports from the contractor prior to being requested by the auditor. Planned Corrective Action: The School District will implement procedures such completing a review of contracts to make sure they include the Davis Bacon prevailing wage rate and review any certified payroll reports from the contractors. Annually for projects subject to Davis Bacon, the district will review certified payrolls of the contractors subject to the legislation. Contact person responsible for corrective action: Nikki Nash, Super intendent and Blair Brindley, Director of Business Operations. Anticipated Completion Date: 6/30/2023

Finding Number: 2022-003 Condition: During payroll expenditure testing of salaried employees, it was identified that, for employees who spend time in multiple cost objectives, appropriate controls were not in place to perform a timely reconciliation between the time charged to Title I based on budget estimates and the actual time expended on Title I activities. Ultimately a reconciliation was performed and approximately $ 99,000 was overcharged to Title I and subsequently reclassified as a non- grant expenditure. However, the School District requested and received reimbursement for this amount during the year- end June 30,2022. Planned Corrective Action: The School District will implement procedures to complete a review and reconciliation process to support the amount charged to Title I based on budget estimates is reasonable when compared to actual time expended on federal and state grants, specifically Title I Reconciliation will occur more than once a year to be able to align grant budgets, as needed. Contact person responsible for corrective action: Jennifer Graber, Director of Curriculum and Instruction and Blair Brindley, Director of Business Operations Anticipated Completion Date: 6/30/2023

FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Pruitt Contact Phone number: 765-342-1001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Morgan County Commissioners adopted Ordinance No. 2023-10 which establishes internal control procedures related to the expenditure of ARPA funds. This ordinance also requires reports to be reviewed by the Auditor?s office prior to submission and a printed copy with the County Administrator?s signature and the County Auditor or Deputy Auditor?s signature shall be retained. This ordinance took effect upon passage on April 17, 2023. Anticipated Completion Date: Has already been corrected.

2022-001 Policies and Procedures for Federal Awards Corrective action planned: Create a written policy and procedure on the tracking and usage of federal awards and have it uploaded into our policy and procedure software. Anticipated completion date: February 28th, 2023 Contact person responsible for corrective action: Corey Furin, CFO

The county will review and update our procurement policies and provide additional training and education to all departments to ensure the minimum requirements of 2 CFR 200 and the procurement policies established by the Oconto County Board are being followed. Planned completion date for corrective action: December 31, 2023 Name of the contact person responsible for corrective action: Lisa Sherman, Finance Director

FINDING 2022-002 Contact Person Responsible for Corrective Action: Tamara L. Asdell Contact Phone Number: 812-726-4440 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan The food service director will prepare and sign the monthly reimbursement claim then have the claim reviewed by another cafeteria worker or the corporation treasurer who will then sign off on the claim to be submitted. Anticipated Completion Date. Immediately