Corrective Action Plans

Responsible personnel will ensure required prior approval for all projects involving federal funds is obtained prior to moving forward with all federally funded projects.

Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS mst. The business Manager, Federal Programs Director, and Superintendentwill ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: February 14, 2025

Condition: The City submitted the required reports, but the amount reported as current expenditures in two of the quarterly reports submitted and as cumulative expenditures in the annual progress report were incorrect. Planned Corrective Action: The City will review future reports to ensure the appropriate expenditures are disclosed. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

Context: For the three projects sampled for Davis-Bacon requirements, the School Corporation did not obtain the weekly payroll reports certifications from the companies that performed renovations on the School Corporation. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements. Additionally, the School Corporation did not have contracts with the companies that included the clause for the federal wage rate requirements. The total amount disbursed and reported on the SEFA during the audit period is $648,235 and the labor portion was not determinable by the School Corporation. Contact Person Responsible for Corrective Action: Patrick Biggerstaff, Assistant Superintendent Contact Phone Number: (317) 831-0950 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: When utilizing federal funding for capital projects, MCSC will require and retain evidence that contractors, subcontractors, and other relevant agents comply with the federal wage rate requirements set forth in the Davis-Bacon Act. Anticipated Completion Date: April 1, 2025

Information on the federal program: Subject: Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Material Noncompliance, Qualified Opinion Condition and Context: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions - Wage Rate Requirements compliance requirements. The School Corporation had projects for construction of new facilities including an early learning center and improvements to sports facilities which was funded with ESSER II (84.425D) and ESSER Ill (84.425U) grant awards. In our sample of three vendors, the School Corporation did not include Davis-Bacon wage rate requirements in the vendor contract, and therefore the vendor did not include the verbiage within their subcontractor agreements. Also, the School Corporation did not obtain the weekly payroll reports certifications from the construction vendor to monitor compliance with Davis-Bacon wage rate requirements. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements during the audit period. The total project costs disbursed during the audit period in our sample was $3,681,455 which includes material and labor costs. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Vincennes Community School Corporation will comply with the Davis-Bacon wage rate requirements in all future projects using federal funds. Responsible Party for Corrective Action: Michele Fleck, Treasurer Timeline for Completion: Effective immediately.

Information on the federal program: Subject: Education Stabilization Fund (ESSER) - Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013, S425U200013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition and Context: 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 requirements. The School Corporation was required to submit Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER I amount reported on the Year 3 report ($86,004) did not agree to the underlying expenditure records ($196,436) for the period of July 1, 2021 through June 30, 2022. We also noted that the ESSER II and ESSER Ill amounts reported on the Year 3 report ($0 and $1,684,755, respectively) did not agree to the underlying expenditure records ($1,391,963 and $4,330,649, respectively), for the period of July 1, 2022 through June 30, 2023. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Vincennes School Corporation will include the Federal Programs Coordinator when preparing any annual reports to confirm accuracy of the reporting. Responsible Party for Corrective Action: Michele Fleck, Treasurer Timeline for Completion: Effective immediately.

Condition: The community development manager’s payroll expenses charged to the grant were supported by time records, but these records were not reviewed or approved by another individual. Planned Corrective Action: The community development manager will submit his/her payroll time records to either the outside consultant or Chief of Staff who will review and approve accordingly before being charged to the grant. Contact person responsible for corrective action: Joan Hennessey (Outside Consultant) or Dan Bzura (Chief of Staff). Anticipated Completion Date: 3/12/2025

FINDING 2024-002 Finding Subject: Child Nutrition Cluster - Eligibility Contact Persons Responsible for Corrective Action: Lacey Sturgeon, Food Service Director & Melissa Bell, Assistant Food Service Director Contact Phone Number and Email Addresses: (765) 893-4445 / lsturgeon@msdwarco.k12.in.us & mbell@msdwarco.k12.in.us Views of Responsible Officials: Option 1: We concur with the findings Description of Corrective Action Plan: Stronger internal controls are needed in regards to verification of Direct Certifications. We plan to make sure once the certifications are entered that the Food Service Director will check the work of the Assistant Food Service Director and show her approval by signing and dating each final report. Anticipated Completion Date: Effective Immediately

FINDING 2024-006 Finding Subject: Covid-19-Education Stabilization Fund - Internal Controls Summary of Finding: The School corporation did not properly implement a process to identify and assess internal and external risks, or monitor internal controls to ensure they were operating effectively. Contact Person Responsible for Corrective Action: Melissa Embry Contact Phone Number and Email Address: 812-547-2637 melissa.embry@cannelton.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Cannelton management will establish a proper system of internal controls including policies and procedures related to risk assessment and monitoring activities within the federal program. All of the Covid-19 Education Stabilization Funds have been expended at this time. Anticipated Completion Date: August 2025

Altus Public Schools plans to meet the requirements of the Davis-Bacon Act on all federal awards. Weekly payroll reports will be reviewed with vendors to ensure that the fedreal wage rates and fringes are met. Items will be posted at the work site to ensure compliance with the Davis-Bacon Act.

ReGenesis Health Care Corrective Action Plan Audit period: July 1, 2023 - June 30, 2024 Audit Finding: Incorrect Application of Sliding Fee Scale and Lack of Proper Documentation ________________________________________ Summary of Audit Finding – Federal Award Program Audit Department of Health and Human Services 2024-001 Health Centers Cluster – Assistance Listing No. 93.224 In a sample of 25 patient accounts, the audit revealed: • Four instances where the incorrect sliding fee scale was applied and lack of proper documentation maintained for sliding fee applications. ________________________________________ Corrective Actions: Staff Training Action: • Conduct mandatory training for General Practice Managers (GPMs) and Patient Service Representatives (PSRs), as well as for all newly hired front desk staff at orientation and annually thereafter. Content: • Process for sliding fee discount program eligibility determination. • Proper application of the sliding fee scale. • Documentation standards and quality improvement/assurance measures. Timeline: Begin training within 30 days from 1/21/25 and establish ongoing annual sessions. Responsible Party: Senior GPM, VP Strategy & Development Action Plan for Slide Application Process: PSR Responsibilities: • Continue scanning all completed slide applications into the system on the same day they are completed. • Ensure all relevant information is entered into the patient’s chart. • Assign scanned slide applications to respective GPMs for review in eCW. GPM Responsibilities: • Review slide applications in D jellybean daily for accuracy. The review should ensure that: o The document has been scanned into the chart. o Calculations are correct. o The correct proof of income and supporting documentation are included. • Discuss any slides requiring correction with the PSR and provide continued education as needed. • Address excessive errors through performance improvement plans and disciplinary actions if necessary. • GPM to ensure sliding fee schedule is correct and all documentation is present before marking the documents as approved in eCW. Auditing: • GPMs will run daily reports in eCW to audit the front desk’s slide application process. • Physicians Services Billing Manager or designee to review slide application information to ensure correct sliding scale has been applied. • Director of Quality Improvement will also audit process to ensure GPMs are completing this expectation. Standardized Procedures Action: • Review and update the Sliding Fee Discount Program Policy and Procedures annually and as needed • Implement a checklist for staff to ensure proper documentation. • The Physician Services Billing Manager will train billing staff on applying sliding fee discount program adjustments and will conduct internal audits to ensure the accuracy of payer status. Timeline: Review current policies and procedures by 2/7/25. Responsible Party: Senior GPM, Chief Financial Officer and Chief Administrative Officer Quality Control Measures Action: • Establish a quality control process to regularly review sliding fee documentation and application accuracy. Frequency: Quarterly reviews of a minimum of 10 patient accounts processed, from multiple ReGenesis Health Care sites where services from all scopes are rendered. Review Team: Compliance and Quality Improvement/Assurance teams Timeline: Begin reviews in Q1 2025. Responsible Party: Chief Administrative Officer, Chief Financial Officer, Director of Quality Improvement and Risk Management ________________________________________ Monitoring and Evaluation • Quarterly Reports: Summary of quality control findings shared with leadership. • Key Performance Indicators (KPIs): o Reduction in errors in sliding fee application. o 100% compliance with documentation requirements. • Audit Follow-Up: Prepare for Operational Site Visit (OSV) to confirm implementation of corrective actions. • Responsible Party: Chief Administrative Officer, Chief Financial Officer ________________________________________ Communication Plan • Staff Updates: Regular updates during Leadership and QI/QA team meetings on progress and reminders of proper procedures. • Leadership Reports: Quarterly updates to the Board of Directors and RHC Executive Team. ________________________________________ Conclusion ReGenesis Health Care is committed to addressing the identified issues and ensuring compliance with all sliding fee scale policies and guidelines. By implementing the outlined corrective actions, RHC aims to strengthen processes and maintain the highest standards of service for our patients. If the Department of Health and Human Services has questions regarding this plan, please call Rich Long, CFO, at 564-504-3658.

Boone-Apache Schools will take the following strict action to assure that the District is in compliance with the Davis Bacon Act for all future construction Projects that are funded by federal dollars: 1. The district will evaluate that policies and procedures are properly in place to meet the requirements of the Davis Bacon Act which includes Board Policy, and writen procedures. 2. All Administrators and Administrative Assistants will receive webinar training from the United States Department of Education which will be verified by the Superintendent of Schools. 3. The district will develop and follow internal controls that will ensure any time federal awards are used on construction that compliance with contracts, including inserting the prevailing wage clauses and ensuring that federal wage rates and fringes are met by an effective monitoring process which includes collecting and reviewing weekly certified payroll reports from the contractor or subcontractor. Also, ensuring that all items are posted at the work site to ensure compliance.

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 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 requirements. Context: The School Corporation was required to submit Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II and ESSER III amounts reported on the Year 3 report ($288,565 and $115,716, respectively) did not agree to the underlying expenditure records ($139,081 and $88,437, respectively) for the period of July 1, 2022 through June 30, 2023. Corrective Action Plan: The School Corporation will implement a system of internal controls to ensure the amounts reported on the annual data reports agree to the underlying expenditure detail in the accounting system. Person responsible for implementation and projected implementation date: The Treasurer and the Superintendent will be responsible for implementing the corrective action plan, which will start with the next submission of the annual data report.

Finding 2024-004- Voucher Management System I agree with finding 2024-004 and corrective action has been taken by the Executive Director on March 6th, 2025. VMS has been corrected and since HUD has not reconciled the fiscal year 2024 it will be reconciled correctly. Spoke with the agency’s fee accountant and we will continue to work together to not repeat this finding. VMS data is reviewed after submitted, and Executive Director missed the reporting of additional 14 vouchers in the total. Fee accountant made an error and included the 14 enhanced vouchers twice.

Finding 2024-003- Financial Data Schedule. I agree with finding 2024-003 and corrective action has been taken by the Executive Director on March 6th, 2025 The Agency’s Financial Submission was due November 31, 2024 and was not submitted until January 16th, 2025. Information was given to our fee accountant by the timeline requested. Spoke with the agency’s fee accountant on March 6th, 2024 and he agreed that the late submission was due to the agency’s financials not being done in a timely fashion. The fee accountant will do a better job in getting the monthly financials completed faster. This will allow the submission to submitted on time. We will work together to not repeat the finding. It is also the Executive Directors responsibility to make sure financial data is submitted when required. An extension could have been requested.

Corrective Action: The Village has hired a planning and finance tech in April 2024 who has allowed the Village to segregate duties for accounts payable which according to our risk assessmnet is one of our highest risks. The department head's responsibility to review and approve invoices has increased. The Village involves the manager, assistant manager, mayor and mayor pro tem in the accounts payable process. The manager of assistant manager reviews all payments. The Village requires dual signatures on payables, the mayor or mayor pro tem is the second signatory. The Village also implented a change in the responsibilities of staff to segregate duties of the payroll function. The human resources officer processes payroll. We continue to look opportunities to cross-train employees. The Village has automated our receipt process with Open.Gov. The assingned employee generates an invoice for all payments, once the invoice is noted as paid OpenGov generates a journal entry in Excel for the finance officer or designee to record the payment. As part of management oversight, the Council receives a check register, cash balances, and a financial report monthly. The Village continues to review possible segregation of duties, if personnel expertise allows. Bank reconciliations are up to date. Proposed Completion Date: The Village has increased personnel and cross-trained employees to implement segregation of duties. The Village believes with the additional personnel and the management review procedures, that we have a process in place to prevent any material misstatements of the financial statements. We implemented this in April 2024, so the additional segregation of duties was in place at year end.

Condition: The System obtained a loan from the Department of Housing and Urban Development ("HUD") during their fiscal year June 30, 2021. The proceeds of the loan were used to repay a loan with another financial institution during that same year. The HUD loan includes continuing reporting requirements, which require the loan to be reported on the Schedule until it is repaid. The System improperly excluded the HUD loan balance from their Schedule in previous years. The beginning of the year loan balance has been reported on the System's Schedule for the year ended June 30, 2024, in accordance with 2 CFR 200.502(b). Planned Corrective Action: Management will put procedures in place to identify federal reporting requirements for federal loans and grants. Contact person responsible for corrective action: Michael Haynes, CFO and Debbie Caldwell, Controller Anticipated Completion Date: 06/30/2024

FINDING 2024-004 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate, Material Weakness Summary of Finding: This was a repeat finding. An effective internal control system was not designed or implemented at the School Corporation to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions - Annual Report Card High School Graduation Rate compliance requirement until the 2023/2024 school year. The School Corporation had not established internal controls for most of the audit period to ensure that the required documentation to remove a student from a cohort was confirmed and maintained with the withdrawal forms prior to removing the student from the cohort. Contact Person Responsible for Corrective Action: Jami Parks, Business Manager Contact Phone Number and Email Address: 812-794-9630, jami.parks@scsd1.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Starting in the 2023/2024 school year, the building principal now signs off on the supporting documentation that is being retained to support a student’s withdrawal from the cohort. Anticipated Completion Date: The anticipated completion date was the 2023/2024 school year.

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Material Weakness Summary of Finding: There is no administrate review of reimbursable expenses submitted to MAESSU by the district payroll clerks. Lack of an internal control. Contact Person Responsible for Corrective Action: Jami Parks, Business Manager Contact Phone Number and Email Address: 812-794-9630, jami.parks@scsd1.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Payroll Clerk will submit the reimbursement requests to the corporation Business Manager for review before the reimbursement is submitted to MAESSU for payment. Anticipated Completion Date: The anticipated completion date will be with the April reimbursement submission.

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 Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility 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 eligibility compliance requirement. Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal review control in place for 26 of the 60 applications selected for testing. Additionally, for one of the 60 selections, the student was improperly classified as free when the annual income per the student's application exceeded the corresponding threshold for that determination. Corrective Action Plan: The School Corporation will implement a system of internal controls to ensure that the applications are being formally reviewed by the Food Services Director and the Corporation Treasurer. Person responsible for implementation and projected implementation date: The Food Services Director and the Corporation Treasurer will be responsible for implementing the corrective action, which will begin with applications for the 2025-2026 school year.

Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility 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 eligibility compliance requirement. Context: During testing over controls for eligibility, for 16 of the 60 applications selected, we noted there was no formal evidence that the applications had been reviewed and further, the application did not specify if the student was eligible for free or reduced lunch. We also noted for 2 of the 60 selections, management was unable to provide support for the student that was selected. Corrective Action Plan: The Food Services Director and the Treasurer will both sign off on the applications once they have completed their review to determine if the application was accurately denied or approved for free or reduced meals. The completed and reviewed applications will be maintained in a safe and secure location, so they are easily accessible in an instance where they would need to be referenced. Person responsible for implementation and projected implementation date: The Food Services Director and the Corporation Treasurer will implement the corrective action plan starting with applications received for the 2025-2026 school year.

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER I and ESSER III amounts reported for the reports covering the FY22 time period ($22,163 and $409,347, respectively) did not agree to the underlying expenditure records ($3,796 and $404,347 respectively) for the period of July 1, 2021 through June 30, 2022. Additionally, we noted that the ESSER II amount reported for the reports covering the FY23 time period ($131,439) did not agree to the underlying expenditure records ($153,216) for the period of July 1, 2022 through June 30, 2023). We also noted there was no documented, secondary review of the information in the FY23 annual data reports by someone other than the preparer. Contact Person Responsible for Corrective Action: Dr. David Stashevsky Contact Phone Number: 765-378-3329 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The assistant superintendent will manage the grant with the superintendent providing oversight. The assistant superintendent will coordinate the receipts and expenditures of funds with the corporation treasurer. The superintendent will review all financial reports and approve in writing with notification sent to the assistant superintendent and treasurer. Anticipated Completion Date: The correction will be on the next annual report when it is due.

Management agrees with the findings and will take the necessary corrective actions. The Organization will create an internal control mechanism to track Federal Awards throughout the year in order to prevent and detect any potential material misstatements and make it available to the auditors at the end of the year.

Information on the federal program: Subject: Education Stabilization Fund (ESSER) - Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 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 to ensure compliance with requirements related to the grant agreement and the reporting compliance requirements. The School Corporation was not formally reviewing the ESSER reports being submitted by comparing the underlying expenditure detail to the amounts reported for each grant for the reporting period. Context: The School Corporation was required to submit six Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. Crowe noted the following reporting errors for the Year 3 reports (July 1, 2021 through June 30, 2022). The ESSER If amount reported on the Year 3 report ($585,040) did not agree to the underlying expenditure records ($581,468). This is the exact amount reported as the SEA reserve amount on the Annual Data Report. Crowe noted the ESSER Ill amount reported on the Year 3 report ($0) did not agree to the underlying expenditure records ($351,831). Crowe noted the following reporting error for the Year 4 reports (July 1, 2022 through June 30, 2023). The ESSER Ill amount reported on the Year 4 report ($1,062,765) did not agree to the underlying expenditure records ($1,054,618). This is the exact amount reported as the SEA reserve amount on the Annual Data Report. Corrective Action Plan: The School Corporation will implement internal control procedures to ensure the amounts reported in the annual data reports agree to the underlying support and detail from the internal records. A formal review process will be implemented. Person responsible for implementation and projected implementation date: The Corporation's Treasurer and Superintendent will be responsible for implementing the corrective action, which will be implemented immediately.