Corrective Action Plans

FINDING 2022-005 Contact Person Responsible for Corrective Action: Rachel Oesterreich Contact Phone Number: 574-772-9105 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: When the Auditor completes quarterly/yearly reports for the ARPA Funds to the U.S. Department of the Treasury (Treasury), another individual will review and sign stating that the information submitted matches the funding that has been approved by the Board of Commissioners and Starke County Council. Anticipated Completion Date: December 31, 2023 Rachel Oesterreich Starke County Auditor

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Montgomery County, operating as Council House, respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2021 through September 30, 2022 The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number in the schedule. FINDING No. 2022-002: Section 8 Housing Assistance Payments Program, CFDA 14.195 Recommendation: The Project should implement procedures to ensure that rent increases are submitted for approval in a timely manner and that all approved gross rent changes are applied and captured in the period of approval. Action Taken: In 2023, Compliance will be beginning to monitor rent increases to ensure they are submitted timely. Compliance will also be monitoring approved gross rent changes to ensure that new rents are applied timely. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

FINDING 2022-002 Subject: Medicaid ? Eligibility, Other Matters Federal Agency: US Department of Health and Human Services Federal Program: Medicaid Assistance Listing Number: 93.778 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility 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 eligibility compliance requirements that are performed by the Special Education Cooperative on behalf of the School Corporation. Context: The School Corporation participates in a Special Education Co-op. In 2015, the Co-op provided an avenue, through a third-party company, for the member school districts to obtain reimbursement for Medicaid services. It was discovered in 2021 that the annual parental disclosure statements had not been completed for Medicaid eligibility compliance. Due to this oversight, each member school had to void transactions through the third-party company and pay back the amount of these transactions for the period August 9, 2015 through April 23, 2021. The School Corporation?s amount owed was $82,291 for the period identified during 2015-2021. The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. The amount related to this period July 1, 2020 through June 30, 2022 was indeterminable. The full amount was paid back prior to June 30, 2021. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. Responsible Party and Timeline for Completion: The School Corporation completed a Voluntary Self-Disclosure of Provider of Overpayments Packet through the Indiana Family & Social Services Administration?s Office of Medicaid Policy and Planning Office to reimburse the amounts owed. There were two checks issued in response to this corrective action plan. Check number 22425 in the amount of $13,642.04 on May 27, 2021, and check number 22469 in the amount of $68,648.67 on June 15, 2021. The two payments totaled $82,290.71, and fulfilled our requirement per the corrective action plan.

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 four claims in a sample of four, the Food Services Director prepared the reimbursement claim without a secondary, documented review to ensure the accuracy of the reimbursement claim. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation?s management will review and formulate procedures to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Responsible Party and Timeline for Completion: The School Corporation?s management will ensure the Food Service Department implements a secondary document review to ensure accuracy prior to submitting the reimbursement claim. This action will begin immediately with the March of 2023 claim submission.

U.S. Department of Agriculture 2022-002 Child Nutrition Cluster ? Assistance Listing No. 10.553 & 10.555 Recommendation: We recommend that Management review the Uniform Guidance and ensure the procurement policy is updated to be compliant then officially approved by the board as soon as reasonably possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The school intends to assign someone the task of updating the procurement policy so it is compliant with the Uniform Guidance during fiscal year 2023. Names of the contact persons responsible for corrective action: Cam Stottler, Executive Director Planned completion date for corrective action plan: June 30, 2023

The Cornbelt Educational Cooperative Business Manager, Pamela Selken, is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough personnel to provide an ideal environment for the internal controls. We are aware of the weakness in internal controls and will continue to develop policies and procedures and provide compensating controls to reduce the risk. We will also communicate this concern with our Board of Directors. The Cornbelt Educational Cooperative did adopt an Internal Controls and Procedures policy on March 13th, 2018 that does address many of these issues, and would ask for consideration reflecting this implementation. This finding will be an ongoing process, requiring continued analysis of processes and procedures in order to minimize the risk.

FINDING 2022-005 Contact Person Responsible for Corrective Action: Kyle Zahn Contact Phone Number: 765-883-5576 ext. 5112 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The school?s leadership team will review the Federal Wage Rate requirements during the next director?s meeting. All future projects being funded by federal funds will require weekly payroll submissions to be reviewed by the school employee who is overseeing the project. Anticipated Completion Date: February 2023?

FINDING 2022-004 Contact Person Responsible for Corrective Action: Kyle Zahn Contact Phone Number: 765-883-5576 ext. 5112 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As ESSER reports and reimbursements are completed the supporting documents will be kept with the reports. Prior to submission, reports completed and documentation compiled by the Director of Finance will be reviewed by the Director of Exceptional Learners and Testing and vice versa. Anticipated Completion Date: February 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Kyle Zahn Contact Phone Number: 765-883-5576 ext. 5112 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Finance will conduct an internal audit of capital assets purchased and sold from 6/30/2022 to the current date in order to update the corporation?s capital assets records. New staff will also be trained on tracking capital assets transactions and completing the necessary documentation for future capital assets transactions. It is noted, a number of construction projects are scheduled in the near future which will result in capital assets being added. As such, after the completion of these projects, leadership will consider having the school?s contracted third-party capital assets consultant conduct an onsite inquiry visit to ensure the school?s records are accurate. Anticipated Completion Date: April 2023

Views of Responsible Officials, Corrective Action Plans, and Contact Information Pupil Services and Attendance will continue to provide policy guidance: 1. Provide ongoing reminders every other month through the Schoology communication platform regarding accurate enrollment, withdrawal codes and the MYPLN Essential Tips training to support with the withdrawal process, codes, and documentation. 2. Pupil Services and Attendance will continue to post resource tools such as the Certify Rules (this automated data validation tool allows users to efficiently identify data errors or omissions to improve the quality of student data in MiSiS) to support accurate enrollment and withdrawal procedures. 3. Pupil Services and Attendance will communicate with Local District Administration on disseminating information to school-site designees with audit findings to participate in the MYPLN training on accurate enrollment and withdrawal codes during school year 2023-24. 4. Pupil Services and Attendance will communicate with Office of Organizational Excellence to support in messaging the availability of the MYPLN training to support with the withdrawal process, codes, and documentation. 5. Will obtain written acknowledgement for completion of the MYPLN Essential Tips training to support with the withdrawal process, codes, and documentation from the schools identified with audit findings. Name: Elsy Rosado Title: Director, Pupil Services and Attendance Telephone: (213) 241-3844

Views of Responsible Officials, Planned Corrective Actions, and Contact Information Division of Adult and Career Education (DACE) will review the current process and implement the following: 1. Directive will be provided to DACE principals to stop enrolling 16?17-year-old students. 2. Instructions will be given to DACE Accelerated College and Career Transitions (ACCT) Advisors not to enroll students between ages 16-17 moving forward. 3. The District will utilize unrestricted funds for students under the age of 18 that are enrolled in the Workforce Innovation and Opportunity Act (WIOA) program. 4. DACE will continue to serve the existing 16?17-year-old ACCT student population through the end of the school year 2022-23 and use unrestricted funding sources other than WIOA. 5. During school year 2022-23 and henceforth, DACE will not report or claim any student outcomes other than those earned by students who are of 18 years of age and older. 6. DACE will amend the ACCT intake and enrollment policies and procedures in the DACE Counseling Handbook. Name: Megan Carroll Title: Program and Policy Development Coordinator Contact Information: mmc78271@lausd.net or (213) 241-3781 Name: Alejandra Salcedo Title: Federal Grants Specialist Contact Information: axs60041@lausd.net or (213) 241-3812

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, equipment, and restricted purpose requirements. Name, address, and telephone of District contact person: Joe Vetter, 2320 Borst Avenue Centralia Washington 98531 ? (360)-330-7600 Corrective action the auditee plans to take in response to the finding: Going forward, the District will update Departments on procurement requirements to ensure that prevailing wage is included in contracts for public works projects that use Federal dollars. We will also ensure that Vendors who are completing public works projects for the District are sending their certified payroll into the District for projects over $2,000. Anticipated date to complete the corrective action: 5/24/2023

Corrective Action Plan Finding 2022-01 Federal Agency Name: U.S. Department of Education Program Name: COVID-19 Elementary and Secondary School Emergency Relief (ESSER) Assistance Listing Number: 84.425D, 84.425U Finding Summary: The Davis-Bacon and Related Acts apply to contractor and subcontractors performing on federally funded or assisted contracts in excess of $2,000 for the construction, alteration, or repair (including painting and decorating) of public buildings or public works. Davis- Bacon Act and Related Act contractors and subcontractors must pay their laborers and mechanics employed under the contract no less than the locally prevailing wages and fringe benefits for the corresponding work on similar projects in the area. The District entered into an HVAC replacement project and roof repair project with federal funds, but did not monitor contractor and subcontractor payroll to ensure prevailing wage rates were paid. Responsible Individuals: Jenny Smith Corrective Action Plan: Prior to finalizing any construction, alteration, or repair projects utilizing federal funds with a planned expenditure in excess of $2,000, PISD will research the latest local wage determination rates. PISD will share these wage determination rates with the contractor/subcontractor, and will be ensured through the contract that the contractor/subcontractor will comply with the Davis-Bacon and Related Acts. PISD will notify the contractor/subcontractor of the necessity of receiving certified payrolls as needed, so that PISD may monitor requirements throughout the project. Anticipated Completion Date: December 1, 2022

US Department of Health and Human Services HIV CARE Formula Grants Passed-through State of Hawaii Department of Health 1250 Punchbowl Street Honolulu, HI 96813 Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2022 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745 Fort Street, Suite 2100, Honolulu HI 96813 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Material Weakness Finding 2022-001 Eligibility U.S. Department of Health and Human Services HIV CARE Formula Grants CFDA No. 93.917 Condition During the in-take and re-assessment process for the Ryan White HIV/AIDS Part B (RWB) program, case managers are responsible for (1) ensuring that all required forms and documents are received from clients, (2) reviewing those forms and documents for completeness and accuracy to verify that RWB program eligibility requirements are met; and (3) inputting the client?s information into e2 Hawaii, HHHRC?s system to monitor and track all RWB program clients. Effective April 1, 2022, HHHRC updated their policies and procedures, requiring a manager or knowledgeable employee other than the case manager to sign off on the certification forms to document their review of eligibility determinations for completeness and accuracy. We selected a sample of 60 clients receiving assistance under the RWB program as part of our eligibility testing. Within the 60 files, we examined 61 annual or semi-annual certification forms dated prior to April 1, 2022, and 32 annual or semi-annual certification forms dated April 1, 2022 or later. Of the 61 certification forms dated prior to April 1, 2022, we noted 59 certification forms did not contain evidence of a review performed by a manager or a knowledgeable employee other than the case manager. Of the 32 certification forms dated April 1, 2022 or later, we noted 6 certification forms were not signed off by a manager or knowledgeable employee other than the case manager. Criteria The Uniform Guidance, as prescribed in 2 CFR section 200.305, requires that non-federal entities receiving federal awards establish and maintain internal control over federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Internal controls over compliance with RWB eligibility requirements should include formal policies and procedures to ensure that data used to determine eligibility are complete and accurate in compliance with RWB program requirements. Eligibility determination procedures should be performed by case managers and reviewed by a manager or knowledgeable employee. Cause HHHRC implemented a formal policy requiring a manager or knowledgeable employee other than the case manager to sign off on the annual and semi-annual certification forms for each client. This formal policy was implemented on April 1, 2022. As such, the certification forms that were prepared prior to this date were not reviewed in accordance with this policy. Effect Without appropriate internal controls, noncompliance with RWB eligibility requirements may occur. Refer to Finding 2022-002 for instances of noncompliance identified in the current year. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediate previous audit as Finding 2021-001. Recommendation We again recommend that HHHRC adhere to established policies and procedures to ensure that eligibility determinations performed by case managers during the in-take and re-assessment process are reviewed by a manager or knowledgeable employee other than the case manager for completeness and accuracy. Views of Responsible Officials and Planned Corrective Action HHHRC has implemented a formal policy and review process by a manager or higher level within the organization for every certification form within 1 week of completing the form. As noted earlier in the audit, HHHRC has made significant progress on this compliance measure with certifications dated after April 1, 2022 having significantly higher review rates (26/32 had review compared to 2/60 prior to April 1, 2022). Additionally, HHHRC has added an additional policy of the HIV Director or Clinical Deputy Director will review twice annually a random selection of at least 20 certification forms to ensure there was manager review documentation and this internal control will hopefully identify any deficiencies in this practice.

2022-001 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 1,436 tenants, 43 tenant files were tested and the following deficiencies were noted: ? 13 files had incorrect utility allowance calculations, ? 12 files had an incorrect income calculation, ? 2 files utilized incorrect payment standard, and ? 1 file was missing the 214 declaration for all tenants in household. Auditor Recommendations: The Authority should consider reevaluating their established procedures and controls in place to ensure full compliance in regards to eligibility. The Authority needs to consider the impact to the rest of the population of tenant files that were not selected as part of the auditor?s sample. Action Taken: This audit provides an opportunity for the Lakeland Housing Authority staff in correcting problems identified during the audit, we are implementing new procedures and increasing staff proficiency. The plan is as follows: ? The department under the supervision of Carlos Pizarro has hired an additional Quality Control and Compliance Specialist Courtney Mitchell, from now until done she will be leading with the assistance of the program's Assistant Manager Alondra Baez a full 100% file audit, ? The current staff will be re-trained on income calculation, file management, fair housing, occupancy, inspections, SEMAP, etc? ? The staff will continue to use a quality control sheet while processing all recertifications or changes, ? The HCV program issued a task order to one of the consultants to help us monitor the progress of our internal file audit.

2022-002 Eligibility Public and Indian Housing Program ? AL No. 14.850 Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 257 tenants, 30 tenant files were tested and the following deficiencies were noted: ? 5 files had incorrect income calculations, and ? 1 file was completed but not entered into the system. Auditor Recommendations: The Authority should consider reevaluating their established procedures and controls in place to ensure full compliance in regards to eligibility. The Authority needs to consider the impact to the rest of the population of tenant files that were not selected as part of the auditor?s sample. Action Taken: This audit provides an opportunity for the Lakeland Housing Authority staff to correct problems identified during the audit, we are implementing new procedures and increasing staff proficiency. The plan is as follows: ? The department under the supervision of Carlos Pizarro has entered into a contract with a company named Preferred Compliance, we will be asking them to do a 100% review on all the public housing files, they are already reviewing all the files including admissions for the Low-Income Housing Tax Credits, ? The current staff will be re-trained on income calculation, file management, fair housing, occupancy, inspections, etc? ? The staff will continue to use a quality control sheet while processing all recertifications or changes,

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: Community Facilities Loans and Grants CFDA #10.766 Finding Summary: Eide Bailly LLP prepared our draft of the schedule of expenditures of federal awards (SEF) Responsible Individuals: Mandy Robinson, Administrator and Carol Schoch, Business Office Manager Corrective Action Plan: Management will review the Health Center's internal financial reporting process to enable staff to draft as much of the Schedule as possible. Anticipated Completion Date: June 2023

Finding Number: 2022-001 Planned Corrective Action: The District acknowledges it did not obtain certified payroll information from Panzica Construction until December 2022 which was after the Auditor raised the issue with the District. The District will work to ensure compliance with grant terms, in this instance, by assigning compliance responsibility to the Cost Center Manager who negotiates, monitors, and receives invoices, and authorizes payments. Standard prevailing wage contract language will be developed in consultation with General Counsel?s Office with the language inserted into future contracts, as appropriate. Anticipated Completion Date: 06/30/23 Responsible Contact Person: Nathan J. Mortimer, Interim CFO

Parkston School District Business Manager, Craig Bruening, is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff members employed in the district's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough personnel to provide an ideal environment for the internal controls. Parkston School District adopted an Internal Controls and Procedures policy in January 2019 that we are following. We are aware of the weakness in internal controls and will adhere to policies and procedures we have in place while providing compensating controls to reduce the risk. This will be an ongoing process.

View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. After contracting a third-party entity to review 10% of our files in Oct 2022, findings of said review led to the recommendation to retrain staff. 2. All Managers and assistant Managers received HCV & PH Rent Calculation Training In June 2023. 3. We are also currently working with our TA from HUD, Ms. Valerie Jackson. Ms. Jackson has identified, and is about to roll out training for our staff, to uniform and streamline our tenant files.

View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. After contracting a third-party entity to review 10% of our files in Oct 2022, findings of said review led to the recommendation to retrain staff. 2. All Managers and assistant Managers received HCV & PH Rent Calculation Training In June 2023. 3. We are also currently working with our TA from HUD, Ms. Valerie Jackson. Ms. Jackson has identified, and is about to roll out training for our staff, to uniform and streamline our tenant files.

FINDING 2022-004 ? ELEMENTARY AND SECONDARY SCHOOL EMERGENCY RELIEF FUND DAVIS-BACON PREVAILING WAGE REQUIREMENTS Contact Person Responsible for Corrective Action: Lisa Baker, Business Manager Contact Person's Phone Number: 765-664-0624 Views of Responsible Official: There is no disagreement with the audit finding. Description of Correction Action Plan: When the school district is awarded federal funds that will be used for construction, alteration, or repair projects in excess of $2,000, the superintendent and/or business manager will notify the contractors that the project is being funded by federal funds and the requirements as outlined by the Davis-Bacon Act. In addition, the superintendent and/or the business manager will ensure that the contractors provide weekly payroll report certifications and will review the documents to ensure compliance with the wage rate requirements. Anticipated Completion Date: March 24, 2023

FINDING 2022-003 ? ELEMENTARY AND SECONDARY SCHOOL EMERGENCY RELIEF FUND REPORTING Contact Person Responsible for Corrective Action: Lisa Baker, Business Manager Contact Person's Phone Number: 765-664-0624 Views of Responsible Official: There is no disagreement with the audit finding. Description of Correction Action Plan: The recipients of the ESSER Data Reporting notice from the Indiana Department of Education, which include the director of curriculum and assessment and the business manager, will work together to ensure the data reports are properly completed, approved, and submitted by the due date. The director of curriculum and assessment will complete the reports and present them to the business manager who will review and approve the reports. The director of curriculum and assessment will submit the reports and make record of the date and time submitted. Anticipated Completion Date: March 24, 2023

Corrective Action Plan and Views of Responsible Officials The district did not remain aware of all of the reporting criteria related to the COVID testing audit requirements. These requirements have been noted, and our records relating to the safe return to school have been reviewed. The district fiscal team has been transitioned at the CBO and Director of Fiscal level. We will continue our work to maintain a thorough backup for all grant funds.

Program Name: Education Stabilization Fund ? Assistance Listing 84.425D & 84.425U Condition: All construction contracts in excess of $2,000 awarded by non-Federal entities must include a provision for compliance with the Davis-Bacon Act as supplemented by the Department of Labor regulations. This includes a requirement for the contractor to submit to the non-Federal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). Corrective Action Plan: Management will work with contractors to get provisions included in construction contracts in progress and ensure new contracts have required provisions and obtain certified payrolls. Person Responsible for Corrective Action: David Jones, Business Manager Anticipated Completion Date ? FY2023