Corrective Action Plans

2022 ?001 ? Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization is a community based non-profit and considers supporting local businesses, including a bank, a worthwhile business practice. The Organization is currently in the process of reviewing its banking relationships, and looking at other scenarios which would involve transferring funds to another institution. Proposed Completion Date: No later than December 31, 2023

Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards Finding Number: 2022-001 ? Internal Control over Financial Close and Reporting Responsible Persons: Business Manager, Angelita Clitso Anticipated Completion Date: July 2023 Planned Corrective Action: The school has had turnover in the Business Office and in administrative positions. The business office will correct and reconcile all accounts timely.

The current year presented some challenges with significant new grant funding and resulting growth, as well as employee turnover. At the end of the fiscal year, the Organization increased the responsibilities of its outsourced accountant to assist and improve controls. We have and will continue to improve our controls over the year-end financial close process.

Finding: 2022-6 Name of contact person: Dyani Lynch, Supervisor Crisis & Medicaid Transportation Dept. Corrective Action: The Crisis Department will do a monthly review of Crisis and LIEAP policies to stay on top of any changes that may occur between fiscal years and to ensure we are implementing correct procedures. We will also perform self-audits monthly. We will randomly pull two applications from each caseworker to ensure that we are improving on where we?ve made errors and that we are correctly documenting/processing applications. Based on any findings/questions we have during these self-audits, we will contact our state representative for clarifications. Proposed Completion Date: March 31, 2023

Finding: 2022-5 Name of contact person: Renae Alston Corrective Action: Employees will be provided a refresher training on documentation of time sheets. Supervisors will be provided training on the review and reconciliation of data between the timesheet and the daysheet. Proposed Completion Date: March 31, 2023

Finding: 2022-4 Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The County added a Quality Control position effective January 1, 2021 to assist with conducting second party reviews and training. During Fiscal Year 2021 an experienced supervisor was hired for adult Medicaid with extensive knowledge of long-term care and SA policy. This has led to internal process changes for the department. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will implement effective processes to ensure that the Special Tests and Provisions ? Annual Report Card, High School Graduation Rate data is solicited and maintained for audit purposes. Description of Corrective Action Plan: The School Corporation will work to develop a more defined process that ensures compliance with procedures that were established, but have not always followed, to ensure that the Special Tests and Provisions ? Annual Report Card, High School Graduation Rate compliance requirement is met. Specific employees will be placed in charge of obtaining documentation from students leaving the district and others will be asked to review and approve the documentation. If documentation is not successfully garnered from parents, schools will maintain records indicating the school?s efforts to solicit the correct documentation from parents. Anticipated Completion Date: Immediately.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will work with non-public schools to make sure that their enrollment is properly reported. Description of Corrective Action Plan: School Corporation personnel will work with non-public school representatives to secure accurate enrollment information and maintain the proper documentation for audit purposes. Additionally, enrollment data entered on the Title I application portal will be reviewed prior to submission to ensure that data entered agrees with supporting documentation. Anticipated Completion Date: During submission of the 23-24 Title I application.

2022-005 Procurement Policy Recommendation: The City should be familiar with compliance requirements outlined by Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City approved a procurement policy in 2023 that follows the related requirements outlined in Uniform Guidance. Name(s) of the contact person(s) responsible for corrective action: Sandi Frion, Administrator. Planned completion date for corrective action plan: The activities outlined above will be completed by September 30, 2023.

2022-004 Investment Financial Reporting under Generally Accepted Accounting Principles (GAAP) Recommendation: The City should continue to evaluate its internal staff and expertise to determine if an internal control policy over the investment related disclosures is beneficial. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will continue to rely upon the audit firm to prepare the investment related footnote disclosures in accordance with GAAP. Management will review, approve, and accept responsibility for these investment related footnote disclosures prior to issuance. Name(s) of the contact person(s) responsible for corrective action: Sandi Frion, Administrator. Planned completion date for corrective action plan: The activities outlined above will be completed by September 30, 2023.

2022-003 Annual Financial Reporting under Generally Accepted Accounting Principles (GAAP) Recommendation: The City should continue to evaluate its internal staff and expertise to determine if an internal control policy over the annual financial reporting is beneficial. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will continue to rely upon the audit firm to prepare the annual financial statements and related footnote disclosures in accordance with GAAP. Management will review, approve and accept responsibility for these financial statements and related footnote disclosures prior to issuance. Name(s) of the contact person(s) responsible for corrective action: Sandi Frion, Administrator. Planned completion date for corrective action plan: The activities outlined above will be completed by September 30, 2023.

MATERIAL WEAKNESSES 2022-001 Limited Segregation of Duties Recommendation: The City should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will continue to work to achieve segregation of duties whenever cost effective. Name(s) of the contact person(s) responsible for corrective action: Sandi Frion, Administrator. Planned completion date for corrective action plan: The activities outlined above will be completed by September 30, 2023.

Housing Choice Voucher Program ? Assistance Listing No. 14.871 We recommend that the City review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA staff will review its current procedures for completing rent reasonableness requirements. As noted above, they will pursue options available under their contract with McCright, data feeds that could work within their existing software, and any other options in use at peer agencies to determine the best specific path forward to ensuring compliance with rent reasonableness requirements. PHA Supervisory Staff have also requested more detailed information on the audit results to help them further analyze the specific rent reasonableness cases where documentation and performance errors were made which led to this finding. This will help supervisory staff conduct a more thorough review and consider additional procedural changes. Also, as noted above the Finance Department suggests the PHA engage its software vendor or a peer agency to review functionality in the software to determine whether additional features could be employed in the software to prevent a HAP payment on a unit where rent reasonableness has not been completed yet. Name(s) of the contact person(s) responsible for corrective action: Steve Schaer Planned completion date for corrective action plan: 3/31/2024

Housing Choice Voucher Program ? Assistance Listing No. 14.871 Recommendation: We recommend that the City review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA staff noted that the current process of finding comparable data for rent reasonableness comparisons is challenging and obtaining accurate, up-todate data has been a struggle. As part of the RFP process for inspection services, staff noted that McCright offers a process that can assist in accessing data and making the rent reasonableness comparisons PHA staff will also pursue options available under its contract with McCright, data feeds that could work within its existing software, and any other options in use at peer agencies to determine the best specific path forward to ensuring compliance with rent reasonableness requirements. PHA Supervisory Staff have also requested more detailed information on the audit results to help them further analyze the specific rent reasonableness cases where documentation and performance errors were made which led to this finding. This will help supervisory staff conduct a more thorough review and consider additional procedural changes. Name(s) of the contact person(s) responsible for corrective action: Steve Schaer Planned completion date for corrective action plan: 3/31/2024

Housing Choice Voucher Program ? Assistance Listing No. 14.871 Recommendation: We recommend that the City review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of HQS enforcement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PHA is currently finalizing a contract with a 3rd party contractor to perform the required HQS inspections. They anticipate that outsourcing the inspection work will lessen the workload on PHA staff to allow program staff to focus their efforts on improving overall program compliance, including HQS enforcement procedures. As the contract arrangement is rolled out staff will review procedures between inspectors and PHA staff to ensure proper communication and clear procedures are in place as they relate to enforcement actions. PHA staff also will implement a new standard procedure in which the Housing Coordinator will check a list of units with failed or incomplete inspection records against the payment batch report prior to sending the batch to Finance to issue the HAP payments. PHA Supervisory Staff have also requested more detailed information on the audit results to help them further analyze the 3 specific cases where customers were issued HAP payments despite a failed inspection. This will help supervisory staff conduct a more thorough review and consider additional procedural changes. Additionally, the Finance Department suggests the PHA engage its software vendor or a peer agency to review functionality in the software to determine whether additional features could be employed in the software to prevent a HAP payment on a unit with a failed inspection, for example. Name(s) of the contact person(s) responsible for corrective action: Steve Schaer Planned completion date for corrective action plan: 3/31/2024

Finding 2022-002 Department of Transportation Airport Improvement Program, CFDA #20.106 AIP3-46-0050-57, AIP3-46-0050-61 Finding Summary: Federal share of expenditures reported within SF-425 annual report for grants #57 and #61 did not reconcile to supporting client records. Responsible Individuals: Dan Letellier, Executive Director Corrective Action Plan: Management will ensure correct support documentation is provided to 3rd party account for correct submission of FAA Forms 5100-126 and 127. Director will also verify that annual report form SF-425 is completed either by the Airport or the State of South Dakota DOT as it has been in the past. Anticipated Completion Date: Ongoing

Reference Number: 2022-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspections) Classification of Finding: Material Weakness in Internal Control over Compliance Material Noncompliance Authority?s Response & Actions Taken The Authority has made considerable progress in addressing the backlog of annual inspections. Since outsourcing the programmatic functions of the HCV program to a third-party contractor. The Authority acknowledges that more progress in this area is required and continues to work diligently with the third-party HCV contractor to ensure this occurs. The Authority will continue to reinforce its current oversight process to ensure HQS inspections are performed in accordance with HUD requirements. The Authority adopted a series of HUD waivers following the COVID-19 pandemic, one of which HQS-5, under Notice PIH 2021-14, allowing the Authority to waive the completion of HQS Inspections through December 31, 2021. The Authority resumed the completion of HQS Inspections and was required by HUD to complete all delayed inspections by December 31, 2022. During fiscal year 2022, the Authority had inspections not completed in a timely manner, however, was not out of compliance as waivers were in place. The Authority is committed to ensuring all units under contract are beyond safe, sanitary, and decent in accordance with HQS requirements and the Authority's Administrative Plan. The Authority uses the Emphasys Elite software to check against HUD's PIH Information Center (PIC) system to identify units with outstanding Housing Quality Standards (HQS) Inspections. The Authority has scheduled HQS Inspections for the units identified to be out of compliance. Some key strategies and controls in place are as follows: ? Review the report of outstanding HQS Inspections on a weekly basis. ? Schedule outstanding HQS Inspections in order of aging date. ? Conduct HQS Inspections prior to anniversary date of previously completed inspection. ? Running a monthly report of failed inspections and comparing them with future scheduled inspections to ensure a timely scheduling of the second inspection. ? Running a monthly report to identify units with two failed inspections to ensure all have been abated correctly. ? Implement weekly monitoring to ensure all units are properly abated and lifted timely when units pass inspections and contracts are properly terminated after being in abatement for 180 days without a cure. The Authority will continue to execute these sound procedures to prevent further findings related to inspections. The Authority has implemented a robust internal audit program starting fiscal year 2021- 22 and will continue to select annually a statistically significant random sample of actions completed by the HCV contractor to ensure that all actions are in compliance and files contain all required documentation. Although the HCV program subscribes to a quality control process, the Authority's internal audit program provides a method to reasonably understand the condition of the program as the Authority fully understands its responsibility to ensure the program complies to all applicable laws and regulations governing HCV operations. The HCV program is a part of our continuous monitoring process. Anticipated Implementation Date September 30, 2023 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractor Kendra Crawford, Director of Housing Operations

Reference Number: 2022-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Public and Indian Housing Federal Catalog Number: 14.850 Federal Grant Number: Not Applicable Category of Finding: Eligibility Classification of Finding: Material Weakness in Internal Control over Compliance Material Noncompliance Authority?s Response & Actions Taken No corrective action is required for this finding because the Authority?s Sunnydale-Velasco, Potrero Annex and Terrace public housing properties, all part of HOPE SF initiative, have been transferred out of the Low Rent Public Housing Program (LRPH). In 2020, the Authority began the accelerated conversion project (HQS conversion), a major undertaking to transform existing public housing sites owned by the Authority, Sunnydale-Velasco (Sunnydale) and Potrero Hill ? including Potrero Annex and Terrace. The conversion transferred the ownership of the public housing units to SFHA Housing Corporation, a blended component unit. To comply with guidelines from the U.S. Department of Housing and Urban Development (HUD), the public housing department has reviewed and updated the tenant files for each phase of the HQS conversion to ensure completeness and accuracy and compliance of the documents with the HCV program for intake requirements. The Authority has completed the accelerated conversion and the transition of the public housing tenant files to the HCV program on September 30, 2022. The public housing units were brought up to Section 8 physical standards (Housing Quality Standards, HQS) and assigned Project-Based Vouchers (PBV) Housing Assistance Payments (HAP) contracts through the Housing Choice Voucher (HCV) program. SFHA Housing Corporation will operate the properties as Project-Based Section 8, until the time that the units will be disposed to the developers for redevelopment, pursuant to their redevelopment schedule and agreement. Anticipated Implementation Date September 30, 2022 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action Kendra Crawford, Director of Housing Operations

Finding 2022-001 Finding Summary: Soldier Hollow Charter School is required to submit annual financial statements and the proposed budget to the USDA. These items were not provided to the USDA by June 30, 2022. Responsible Individuals: Jamie Bennion, Director and Rich Eccles, Business Manager Corrective Action Plan: Management will provide a copy of the audited financial statements and copy of the proposed budget to USDA annually. Anticipated Completion Date: Ongoing Anticipated Completion Date: Management will ensure all necessary corrective action plan items are in place by the end of 2022.

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, and restricted purpose requirements. Name, address, and telephone of District contact person: Joanne Klein 516 176th Street E. Spanaway, WA 98387-8399 Corrective action the auditee plans to take in response to the finding: The District does not concur with the finding or questioned costs. The district had every intention to provide these iPads to the preschool students who were not in the district technology plan. However, the pandemic caused many distribution delays. The decision was made to provide these students with older surplus iPads. Since the iPads shipment was expected after the students returned to school. The District will work with the FCC to resolve this finding. District does not have any other Emergency Connectivity Grants. Anticipated date to complete the corrective action: 11/1/2023

Finding Number: 2022-004 Condition: The schedule of expenditures of federal awards (SEFA) was not complete and accurate. Planned Corrective Action: Additional training for those individuals responsible for grant accounting has and will continue to be conducted, in addition to creating additional policies and procedures in FY23. Contact person responsible for corrective action: Kristen St. Peter Anticipated Completion Date: June 2023 Management Response: Management concurs with the finding and additional training for those individuals responsible for grant accounting has and will continue to be conducted as well as incorporating additional levels of review to ensure the SEFA is completed accurately and timely.

Finding Number: 2022-003 Condition: The Corporation did not follow the reporting requirements outlined in the HHS June 11, 2021, post-payment notice. Planned Corrective Action: Calculations related to lost revenue have been corrected in the March 2023 submissions and have been resolved. Contact person responsible for corrective action: Kristen St. Peter Anticipated Completion Date: March 31, 2023 Management Response: A misinterpretation of the guidance has been corrected and the submissions in FY23 are now in compliance with the reporting requirements.

Sharon Armijo Clerk ? PO Box 197 (575) 533-6400 Joyce Laney Treasurer ? PO Box 407 (575) 533-6384 Lillie Laney Assessor ? PO Box 416 (575) 533-6577 Keith Hughes Sheriff ? PO Box 467 (575) 533-6222 Lucinda Howell Probate Judge 100 Main St. Reserve, New Mexico 87830 Buster F. Green Commissioner District No. 1 Audrey H. McQueen Commissioner District No. 2 Haydn Forward Commissioner District No. 3 Commission Office PO Box 507 ? (575) 533-6423 FAX (575) 533-6433 Loren Cushman County Manager 2022-001 (2018-003) Procurement of Goods and Services (Significant Deficiency) Condition ? During our test work of a sample of 35 transactions we noted the following: County not following disbursements policy and procedures: ? No PO, PO not attached (6 of 35) P cards (6 of 20) ? 1 month ? no documentation of commission review of monthly check register ? Invoice referenced but not attached ? Taxes paid on goods (6 instances) ? 2 instances with no supporting documents Procurement ? (under $20,000) ? 1 No PO ? 1 No supporting documents Procurement ? (> $20,000 & <$60,000) ? 3 instances of only 1 quote ? 2 No supporting documents The County continues to have documentation retention or application issues, no progress from prior year. Corrective Action Plan ? Staff has been proactive in ensuring that purchase orders and invoices are attached to checks and has created a filing system for processed checks. Staff has been proactive in confirming receipts of goods/services, requesting receipts from purchasers, and generally following the NM Procurement Code and County Procurement Policy. Checks are currently being backed up electronically along with purchase orders and other supporting documentation of purchase receipt and justification. Staff has been proactive in obtaining NTTC forms for businesses and utilizing vendors with current state contracts. Staff has created a binder for documenting monthly review of purchases by Commission including maintain original signatures of Commission members. In instances where procurement has found it impossible to obtain three quotations, staff has maintained adequate documentation of best efforts made to obtain said quotes and has conversed with legal to determine that best efforts is adequate in these instances. Responsible Position: Chief Procurement Officer/Accounts Payable Timeline for Correction: Completed Catron County Corrective Action Plan (continued) 2022-002 (2018-006) Local Government Budget Management System (LGBMS) Reporting Incomplete (Other Non-Compliance Repeated with modification. Condition ? The County did not include all budget expenditures in the LGBMS system. The County reported total budgeted expenditures for their original budget in LGBMS of $10,965,065. The actual budget amounts that should have been reported were $11,239,091. The County did not present a revenue budget to the Commission for approval when the Commission approved the expenditure budget. In addition the County did not enter the revenue budget into the budget to actual reporting system to aid in budget monitoring. The County continued to have budget compliance, monitoring and reporting issues in the current year, and therefore no progress has been made regarding budget in the current year. Corrective Action Plan ? We did hire a Finance Director and then almost immediately put him to work as Interim County Manager. A full time County Manager finally started March 22, 2023. The Finance Director?s goal is to have the County?s reporting to the DFA a routine matter ? accurate and on time. Responsible Position: Finance Director Timeline for Correction: June 30, 2024 2022-003 (2018-002) Maintenance of Capital Assets (Material Weakness) Repeated. Condition ? ? Construction In Process is not maintained and lacks a consistent process for adding to the depreciation schedule. ? Depreciation schedule was not updated or calculated for the entire fiscal year. The County digressed in its maintenance of capital asset records and documentation. Corrective Action Plan ? One of the goals of the new Finance Director is a complete review of Catron County?s capital asset records. Responsible Position: Finance Director Timeline for Correction: June 30, 2024 Catron County Corrective Action Plan (continued) 2022-004 Personnel File Maintenance (Significant Deficiency) Statement of Condition ? We tested a sample of 10 Payroll transactions and noted the following: ? Three instances (3 of 10) where the current payrate was not substantiated by a personnel action form. ? One personnel file did not include any current documents ? all documents were for 2017 and prior. ? One personnel file lacked a PERA membership application. Corrective Action Plan ? The County has made available training through NM EDGE where we can learn to improve procedures, and best practices to develop strategies on completing internal controls. Auditors did provide valuable feedback on what was necessary to complete Personnel files and those suggestions will be implemented form there on. Responsible Position: HR/Payroll Clerk Timeline: June 30, 2023 2022-005 Solid Waste Receipts Audit Trail (Significant Deficiency) Statement of Condition ? The Solid Waste department?s receipting system lacks a clear audit trail. ? No schedule indicating receipts by customer, only a total page of deposit amount (5 deposits for dump fees totaling $9,696) ? Cash deposits were co-mingled with other cash deposits for the day and therefore not traceable specifically to solid waste cash receipts (all solid waste receipts ? 10 receipts tested totaling $19,392) ? No receipts are issued for each customer (receipts only issued upon customer request) No copies or records of receipts that were issued were maintained (all solid waste receipts ? 10 receipts tested totaling $19,392) Corrective Action Plan ? 1. Solid Waste Clerk will attach a corresponding customer receipt to all spreadsheets. 2. Treasurer?s Office has reconciled the second issue listed above. 3. Convenience Center Attendants will immediately receipt all customers. Responsible Position: Solid Waste Clerk/Coordinator Timeline: April 30, 2023 2022-006 Travel and Perdiem Procedures and Regulations Not Properly Followed (Other Non-Compliance) Statement of Condition ? We tested a sample of 10 travel transactions and noted the following: ? 5 instances where no travel form (per policy) was attached to approve travel $2730.64. ? 1 instance where mileage rate reimbursed was $.46 per mile rather that $.45 per mile ? total over allowable reimbursement was $1.25. Corrective Action Plan ? New travel forms have been created pursuant to DFA Per Diem rates from Memo dated April 12, 2022. New staff has been proactive in ensuring that travel requests are handled timely and properly. Responsible Position: Accounts Payable Timeline: Completed Catron County Corrective Action Plan (continued) 2022-007 Lack of Maintenance of Grant Documentation (Material Weakness) Statement of Condition ? During our test work of federal award reimbursements and expenditures and New Mexico capital Outlay Appropriations, documentation and supporting invoices and reimbursement requests as well as grant award agreements were not available or present in County records. Reimbursement requests are not timely. County is not following award guidelines to maintain the accounting of grant activity for reimbursement requests, expenditures and supporting documentation. The County has numerous awards that are not managed and status of awards is not current. Corrective Action Plan ? The County hired a Finance Director. Even though he spent most of his first eight months as Interim county Manager, he was able to assemble grant documents and collect grant funds that had been waiting for years to be claimed. As we now also have a full time County Manager, this part of the Finance Director?s job should improve even more. Responsible Position: Financial Director Timeline: June 30, 2023 2022-008 (2020-007) Late Audit Report ? (Other Non-Compliance) Repeated with modification Statement of Condition ? The audit report was submitted to the State Auditor?s Office after the county due date of December 1, 2021. This finding remains essentially the same as prior year. Corrective Action Plan ? We are glad the auditor is taking part of the responsibility here. However, if the County can keep a consistent staff in the Commission Office following proper procedures, the audit will definitely go smoother and quicker. Responsible Position: Finance Director Timeline: June 30, 2024

Finding Number: 2022-001 Condition: The College drew down an estimated amount for student and institutional portion prior to the funds being disbursed to students or used for allowable expenditures. Planned Corrective Action: The College will review its cash management policies and in the future follow U.S. GAAP and the uniform guidance. Contact person responsible for corrective action: Tom Reynolds, Associate Vice President of Business Services and Deputy Treasurer Lakeland Community College Anticipated Completion Date: As soon as possible moving forward starting 12/19/2022

FINDING 2022-003 Contact Person: Jo Ann Treon Phone Number (765)948-4632 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Forms RD 442-2 & RD Form 442-3 will be completed in August 2023. Anticipated Completion Date: Immediately