Corrective Action Plans

While the Village of Lexington followed current internal controls for all aspects of the federal awards granted, we did not adopt a document that covered all five compliance areas as outlined in the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. A written policy and procedure document will be adopted by the Council by December 31, 2024.

Finding 2024-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Voucher & Emergency Housing Vouchers Assistance Listing Number: 14.871 & 14.EHV Noncompliance – N. Special Tests and Provisions – Housing Quality Standards Non Compliance Material to the Financial Statements: Section 8 Housing Choice Vouchers - Yes Emergency Housing Vouchers - No Material Weakness and Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions. Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussions with management, the Authority did not properly abate fifteen (15) out of twenty-nine (29) annual failed inspections selected for testing. Context: The Authority did not properly abate fifteen (15) out of twenty-nine (29) failed inspections selected for testing. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Our sample size is statistically valid. Known Questioned Costs: Section 8 Housing Choice Vouchers $50,873 Emergency Housing Vouchers $1,308 Cause: There is a material weakness in Section 8 Housing Choice Vouchers and a significant deficiency in Emergency Housing Vouchers in internal controls over compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers Program is in material non-compliance with the special tests and provisions type of compliance related to HQS inspections and the Emergency Housing Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: We agree with the Auditor’s observations on the re-inspection of the failed units. The Authority had an independent contractor whose contract was terminated due to their unacceptable performance with HQS inspections. As a result, two HQS inspectors were recently hired, and a clerical person to assist in improving the quality control component of the program as it relates to HQS inspections. In addition, the Authority recently hired a Director of Leasing and Occupancy, and a Supervisor of the department, and has implemented a more stringent oversight to ensure that internal control policies are being followed in a timely manner to show improvement in this area, and an overall improvement to the entire function of this department. We are also actively seeking to fill two vacant Tenant Interviewer/Investigator positions. The current staffing change mentioned above puts the agency in a position to implement and ensure a tracking system being able to capture areas on Annual HQS unit status, First Inspection if failed for life threatening HQS deficiencies rescheduled within 24 hours and 30 days for all other deficiencies. Abatements are placed on all units having two failed HQS inspections. All current occupied units are being reviewed for HQS inspection status, and a resolving issues to those units not in compliance with the program. Views of responsible officials and planned corrective action: Ms. Irma Gorham, Executive Director is responsible to remedy the deficiency by March 31, 2025.

The corrective action plan for the internal control material weakness, financial statement preparation (2024-001), is summarized as follows: Corrective Action Planned: The District will rely on its system of oversight provided by the board of directors in reviewing the financial statements, including note disclosures and the schedule of expenditures of federal awards, to mitigate this inherent material weakness in its internal control system. Anticipated Completion Date: Continuous. Responsible: Management and Board of Directors.

Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: The Financial Aid team will continue to work R2T4s as the pertinent information of the drop/withdraw is received from the Academic team. Once notification is received from the Academic department, the Third-Service provider will review and make timely requests for additional documentation to ensure the calculations and returns are completed in a timely manner, based off the requested information needed. Both the Financial Aid and Student Accounts departments will work in conjunction with the Third-Service provider to ensure timely changes reflect on the student’s ledger. Person Responsible for Corrective Action Plan: Christine Schroeder, Assistant VP of Enrollment Services Anticipated Date of Completion: Current action

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements (material weakness) Year ended June 30, 2024 Auditors’ Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the Authority should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. Grantee Response: Transit Authority of Warren County and Executive Director, Wendy Hollabaugh, has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in the year ending June 30, 2025. Further, we acknowledge our responsibility for the financial statements and have the ability to make informed judgments on those financial statements. Executive Director, Wendy Hollabaugh, expects that it will continue to outsource the preparation of the annual financial statements to its audit firm for the year ending June 30, 2025 as this is the most cost effective manner to produce this information.

2024-001 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect. For the amounts tested that were subject to the Wage Rate Requirements the District did not obtain the required certified payrolls during project completion and was unable to obtain them in a timely fashion upon request. As a result, the District did not follow federal requirements to obtain the required certified payrolls from contractors. Auditor Recommendation. We recommend that the District reviews its procedures to ensure that certified payrolls are obtained from any contractors used (including subcontractors) whenever federal funds are used. Corrective Action. District officials will ensure that construction contracts contain these requirements during the bid process and that certified payroll is obtained from the contractors in a timely fashion and retained as audit support. Responsible Person: Mikki Boury, Finance Director Anticipated Completion Date: June 30, 2025

Finding 2024-006 - Material Weakness and Material Noncompliance: Documentation of Payroll and Disbursement (Literacy Excellence Accelerates Performance LEAP) Corrective Action: The Business Office will work with Grant Managers to ensure accurate recording of all LEAP program staff, distinguishing between contract staff and District employee stipends through coding. The Business Director and Grant Manager will continue to collaborate with the U.S. Department of Education to meet coding, budgeting, and spending standards. Responsible Person: Director of Finance and Grant Managers

Finding 2024-005 - Material Weakness and Material Noncompliance: Documentation of Payroll Distribution (Head Start) Corrective Action: The Business Office will enhance the payroll process by collaborating with Human Resources, District Leaders, and Building Principals to monitor staffing, duty location, and work assignments. The Business Office will leverage electronic and digital tools like Child Plus and Title 1 Crate to assist District leaders with employee accounting and will continue to coordinate with Grant Managers and building leaders to maintain accurate staff records. Responsible Person: Director of Finance

Finding 2024-004 - Material Weakness and Material Noncompliance: Eligibility and Reimbursement Request for Child and Adult Care Food Program Corrective Action: The District will collaborate with MDE Nutrition staff to complete training, staff assistance visits, and previously established corrective actions. The Business Director and Food Service Director will schedule additional training and visits with Nutrition liaisons and MDE PAL partners. The District will implement electronic point-of-sale devices and digital filing systems to improve recordkeeping and sharing. Documented training for YCS Food Service Staff will be ongoing. District monitoring will be reinstated to ensure compliance with pre-COVID standards. Responsible Person: Director of Finance and Food Service Director

Finding 2024-002 - Material Weakness: Budget Violations Corrective Action: The Finance Director and Business Office will undergo additional training with Tyler Technologies, Michigan School Business Officials and others to optimize financial processes and transaction processing. The team will adhere to the state business calendar for timely reconciliations, budget amendments, and internal control reviews. Responsible Person: Director of Finance

Finding 2024-007: Year End Reporting Rural Rental Housing Loan-10.415 Noncompliance/Material Weakness: AGREED RCHA Administration agrees it is responsible for completing and submitting Form RD 3560-7, Form RD 3560-10 and Attachment 4-F, Performance Standards Borrower Self-Certification letter, within 90 days following the close of the project year end. RCHA does believe these forms were presented to USDA representatives for the program, and was refused due to RD personnel believing RCHA was using the wrong fiscal year. This issue lasted many months and only after a change of USDA personnel and contact with the fee accountant and auditor, was the issue resolved. Corrective Action: RCHA Administration will have forms completed accurately and presented to those required immediately and will keep thorough copies of those items. RCHA continues to have issues with the MINC program, including approvements for timely payments. Corrective Action: RCHA Administration will complete forms and turn them into USDA personnel on time and accurately. Policies and procedures will be clear, approved and monitored by the Board of Commissioners, and completed by RCHA Administration before June 29th each year. This action will be completed immediately.

Finding 2024-006: Special Tests and Provisions Rural Rental Housing Loan-Assistance Listing 10.415 Repeat Finding 2023-005 Noncompliance: AGREED RCHA agrees that the Rural Development Properties are required to make a $20,000 deposit into the replacement reserve annually until the balance in the account is at $200,00 or higher. These properties should have adequate cash balances that exceed security deposit liability. Corrective Action: RCHA Administration is working on increasing rent and occupancy to improve revenue, as well as discussing options on nonfederal funds to help fund the program. This action will continue. Corrective Action: RCHA Administration and Board members will be approving and monitoring a budget that will help support the RD programs and the aging buildings including building the reserve payments that are required. This is an ongoing action that will continue. Corrective Action: RCHA Administration is discussing re-positioning of programs to assist in improving the RD program and properties. This action continues.

Management will provide the USBE with the correct the amount of ESSER funds expended by FTE categories, the number of FTE’s supported with ESSER funds and the total number of FTE positions on September 30, 2023.

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: a. One instance in which a family was overpaid for one month due to the family obtaining employment. b. One instance in which a family was underpaid for one month based upon their family size and eligibility for the month. Additionally, documentation was not retained to support one month's redetermination of eligibility and check copies for two months were not retained to support the payment to the family. c. Three instances in which a family was underpaid based upon their family size and eligibility for the month. d. One instance in which a check was written to a family who out-migrated from the state of South Dakota and the family did not cash the check; however, the expenses remained to be charged under the Refugee Cash Assistance program. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: a. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate the proration when a client obtains employment during the month. b. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate family size and eligibility. Additionally, document retention requirements will be reviewed with staff. c. The procedures will be reviewed with staff, and an additional review put in place where necessary, to ensure staff are fully trained on how to calculate family size and eligibility. d. The procedures will be reviewed with staff for removing a client from the program, and notifying appropriate staff to void checks. LSS also implemented a new software program during the fiscal year to make the review process more efficient, and less reliant on manual processes. Checks and balances will be integrated into the software, allowing for electronic review of files. The software will also automate some of the ongoing documentation requirements. Anticipated Completion Date: December 31, 2024

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.

UNR – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: Management staff, independent of the preparer, will review and sign off on each report. This review process will include verifying that all information is correctly entered. • How compliance and performance will be measured and documented for future audit, management and performance review: Compliance and performance will be measured through the independent review process, where management will verify and sign off on each report to ensure accuracy. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The Associate Director of Post Award is responsible for remediation of this finding. UNLV – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: UNLV Office of Sponsored Programs will work with PIs to ensure there is properly documented review of progress reports. PIs will be expected to demonstrate review of progress reports and provide supporting documentation for data. • How compliance and performance will be measured and documented for future audit, management and performance review: Effective immediately, UNLV OSP will maintain communications with PIs to perform monitoring throughout the life of the award. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The UNLV Office of Sponsored Programs Executive Director is accountable for exercising oversight and responsibility along with applicable Deans. DRI – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: DRI will implement controls that require the documentation of review and approval on the invoice process. With the current limited resources available in DRI’s Financial Services team, a position will be recruited as soon as possible with an anticipated start date in early spring 2025. It is expected that this position will support the full implementation of review procedures once on board. • How compliance and performance will be measured and documented for future audit, management and performance review: Once the position is filled, all invoices will be reviewed prior to drawing down or requesting reimbursement of funds. Documentation will occur either through the business process in the accounting system or manually as needed. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The Chief Financial Officer may be held accountable in the future if repeat or similar observations are noted. SA – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: Future progress reports will require a review from a Director or higher supervisory approval prior to submission of reports to awarding sponsor/agency. • How compliance and performance will be measured and documented for future audit, management and performance review: Preparing department will provide either a signed version and/or email approval of progress report to the NSHE System Sponsored Programs to be filed with the award in Workday. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The NSHE System Sponsored Programs Director is responsible for remediation of this finding. Name of contact person responsible for corrective action plan: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

NSU – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: To ensure accurate and timely reporting of changes in student enrollment status to the National Student Clearinghouse (NSC), Nevada State University (NSU) will enhance its internal controls by implementing the following measures: o Continue the current bi-weekly enrollment reporting schedule. o Set bi-weekly calendar reminders to ensure timely reporting, supplementing NSC notifications. o Establish end-of-term calendar reminders specifically for reporting graduated statuses promptly. o Work closely with the NSC to identify any students included in submitted enrollment reports whose statuses were not updated within the NSC or National Student Loan Data System (NSLDS), ensuring they are addressed even if they do not appear in the reject file. • How compliance and performance will be measured and documented for future audit, management and performance review: To ensure ongoing compliance and performance in reporting changes in student enrollment status, Nevada State University (NSU) will implement the following measures for tracking and documentation: o NSU will conduct monthly reviews of enrollment status reports to verify the accuracy and timeliness of submissions to the National Student Clearinghouse (NSC). o Detailed logs of all enrollment status submissions and NSC notifications will be maintained, including timestamps and submission confirmations, to serve as an audit trail for internal and external reviews. o Periodic internal audits will be scheduled to assess adherence to the bi-weekly and end-of-term reporting schedule, with results documented for management review. o Key performance indicators (KPIs) will be established, such as the percentage of on-time reports and the accuracy rate of enrollment status updates. These metrics will be reviewed quarterly by management. o Any discrepancies identified during audits will be addressed promptly, and corrective actions will be documented for future reference and performance evaluations. o NSU will compile annual compliance reports summarizing audit results, corrective actions, and performance metrics, which will be available for future audits and management reviews. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The Registrar's Office holds primary responsibility for accurate and timely enrollment status reporting. The Registrar will oversee compliance with internal controls including the bi-weekly and end-of-term reporting schedules. Additional oversight will be conducted by the Provost and Vice President of Academic Affairs. Name of contact person responsible for corrective action plan: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

CSN – Agrees with the finding. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: CSN has contracted with a third-party vendor to help review and process R2T4 accounts within the federally mandated timeframe. CSN is currently in the training phase and expects to have the vendor begin reviewing R2T4 file in the next several weeks. In addition, regular monthly training will be provided to CSN staff and the third-party vendor. Quality control through the review of processed R2T4 files will be performed twice a month. • How compliance and performance will be measured and documented for future audit, management and performance review: In collaboration with the third-party vendor, CSN will run R2T4 queries twice a month to ensure all files are reviewed within the federally mandated timeframe. The vendor will also review internally selected files for accuracy. CSN will also randomly select processed files review to meet compliance requirements. CSN will meet with the vendor on a monthly basis and maintain communication throughout the year to ensure consistency and compliance. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The Assistant Director of Processing in the Office of Financial Aid will be responsible for repeat or similar observations. UNLV – Agrees with the finding. There were two findings at the conclusion of the audit. Corrective action plans as well as measurements of compliance and performance correspond with the following two findings: 1. A return was calculated as $2,270, but should have been $1,975. 2. The second finding was regarding an improper return. UNLV’s calculation was correct at $0, as documented for the audit team. Months after the R2T4 calculation was performed, the student did not return to UNLV. At that time, their Pell Grant was appropriately canceled, but due to a system error, their Pell Grant for the entire year was canceled instead of just for subsequent semesters. Through our internal controls we found this error, but did so beyond the permissible 180-day late disbursement period. The error was unrelated to the R2T4 process and had no bearing on the correctly performed calculation. Since the Pell Grant could not be reinstated, we made the student whole with institutional funds. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: 1. Since the late disbursement period had passed, and the student had no balance due, there was no immediate corrective action that could be taken. The calculation error related to a withdrawal date incorrectly reported by a faculty member during spring break. The PeopleSoft system is set up to prevent the entry of such spring break withdrawal dates, and we were unable to replicate the error. The issue has therefore been escalated to our technical team for investigation and for prevention in future years. Even if this proves successful, we will ensure that at least two staff responsible for oversight of the R2T4 function will sign off each spring that no calculations are based on a withdrawal date that occurs during spring break. The signoff will occur within seven days of the end of spring break, so that if any error is identified we may still correct it while remaining within the appropriate R2T4 timelines. 2. The erroneous retroactive cancellation of Pell Grants for unenrolled students is now a known PeopleSoft issue. Beginning in fall 2024, we have established programming that packages Pell Grants on a semester-by-semester basis so that any changes to a current-term grant do not impact a prior-term grant. • How compliance and performance will be measured and documented for future audit, management and performance review: 1. A report exists in PeopleSoft that documents the withdrawal date of each student for whom an R2T4 calculation is performed. This report will be used to collect signoffs by two UNLV staff with R2T4 oversight that no calculations are based on a withdrawal date occurring during spring break, and will serve as the basis for that signoff. 2. Pell recipients' accounts will be reviewed in spring 2025 to ensure our packaging approach was effective in preventing retroactive grant cancellations. The team will review monthly to ensure we stay within the 180-day late disbursement time frame, which will allow us to reinstate Pell Grants retroactively, should our original solution prove ineffective. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: If similar errors around spring break R2T4 calculations and/or retroactive Pell Grant cancellations occur in the future, of primary accountability will be the Assistant Director of Processing, the Associate Director of Operations, the Associate Director of Processing and Client Services (currently vacant), the Director, and the Executive Director. UNR – Agrees with the finding. The Financial Aid office recognizes a shortfall in this area due to unexpected changes in staffing. • Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place: New R2T4 staff is currently undergoing in-depth calculation training which includes internal trainings, NASFAA workshops, and Federal Student Aid provided trainings. In addition, starting this fall, 100% of R2T4 files are being reviewed by a staff member who was not responsible for the initial calculation. To prevent late returns, our office is calculating returns within 15 days of the withdrawal date and return funds within 30 days of the withdrawal. • How compliance and performance will be measured and documented for future audit, management and performance review: Compliance with the above corrective action will be monitored by the Data Manager, who will be reviewing weekly R2T4 reports completed by R2T4 staff. Reports with return data will be compiled in one centralized location to ensure transparency of current return status, and a physical audit trail documented on the R2T4 coversheet detailing initial calculation date, audit check date, and return to COD date. • Who will be responsible and may be held accountable in the future if repeat or similar observations are noted: The R2T4 staff and the Financial Aid Director will be responsible. Name of contact person responsible for corrective action plan: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu

Management will establish and fund a segregated reserve account.

Finding 2024-002 – Child Nutrition Cluster – Reporting Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The food service director will pull the End of Day Summary Reports from Lunchtime and input the information into the Child Nutrition Portal. All reports will be provided to the controller to confirm accuracy. Once reviewed and approved, the food service director will submit the report through the Child Nutrition Portal. All documents will be scanned together and be retained for audit. Anticipated Completion Date: October 2, 2024

Finding 2024-001 – Child Nutrition Cluster – Eligibility Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: School corporation personnel will conduct an annual review of the income eligibility guidelines used by the food service software. The review will ensure that the guidelines are current, accurate, and consistent with federal and state requirements. The results of the review will be documented, and any necessary updates or changes will be implemented promptly. Anticipated Completion Date: November 13, 2024

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy’s side. The Finance Director is now responsible for the renewals going forward, and this will not be an ongoing issue in the future.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways:1.     We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included.2.     All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways:1. We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included.2. All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: 1. We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. 2. All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.