Corrective Action Plans

Corrective Action Planned: Amputee Coalition has experienced significant turnover in its accounting and senior management staff over the last several years. As part of the new leadership, extensive analyses of contracts, staffing, and operations were completed. As of December 2024, Amputee Coalition has identified and implemented changes with its personnel and the third-party accounting services and consulting firm. Amputee Coalition will make any additional changes necessary to complete the closing process and financial statements more timely and to meet the grantor reporting deadlines for future Federal Financial Reports and audits. Anticipated Completion Date of Corrective Action: For the calendar year December 31, 2024.

Management will file the required calendar year 2023 reports immediately upon completion of the audit, in December 2024, and has addressed the underlying cause as noted above at 2023-001. Anticipated Completion Date of Corrective Action: On or before December 31, 2024.

Going forward the School District will educate staff on the requirements to review all certified payroll prior to payment and include wage rate clauses in all contracts.

Material Weakness Internal Control over Compliance Federal Programs Impacted: Education Stabilization Funds (84.425D, 84.425U) and Supporting Effective Instruction State Grant (84.367) 2023-004 Condition: Wages and benefits charged to federal grant programs were not properly supported with documentation of the employee’s job functions and allowability for the program. Discrepancies were identified between employee contracts, employee time and effort documentation, and actual coding of wages and benefits. The wages and benefits that lacked supporting documentation were determined to be allowable to the programs tested. Criteria: A strong system of internal control includes proper maintenance of all payroll amendments and addendums for all periods in which employees are paid. Documentation of employee wage agreements and time and effort reporting should be maintained and updated as staffing assignments are revised. Auditor’s Recommendation: We recommend that management implement a process to ensure that all employees have current wage agreements. In addition, the wage agreements, time and effort reporting, and actual recording of wages and benefits should be reviewed periodically to confirm agreement of documentation. Management’s Response: Management is aware of this issue and is working on revisions to the internal process and control procedure to address it. Part of this issue is due to limitations in the District’s contract-issuing system. An additional system was developed to be able to electronically issue contract addendums to employees. However, due to extremely high turnover throughout the year, that system has not been implemented. As the District stabilizes its turnover, the system will be implemented and should address all issues with this finding. Gary Manuel, Director of Human Resources, is responsible for the corrective action. Implementation will be completed by June 30, 2025.

The Coalition's accounting staff will complete ongoing training to supplement their current skills. Financial professionals will be sought when reviewing potential board member candidates.

Management will review the year-end financial statements to detect and correct any necessary adjustments.

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

The CFO at TCA Health has addressed the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff were trained in the approved sliding fee scale policy and its requirements. The COO worked with the CFO and third-party billing company, and Athena to roll back the EMR update which contributed to ineffective application of the sliding fee in November 2023. TCA hired a full time Patient Services Manager in 2024 to support ongoing staff training, quality assurance monitoring, and implementation of the updated EMR and registration workflows. Staff have become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. Additionally, TCA began to undergo internal audits of records ensuring that proper documentation is maintained and a patient service manager, utilizing testing template provided by the organization’s auditor.

2023-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The school submitted its audit for the fiscal year ending June 30, 2023, in a timely manner. The audit was submitted December 4, 2024, which was 248 days past the March 31, 2024 deadline. Action plan in response to the finding: Management will implement procedures to ensure that all audit documentation, is available for the audit promptly and the audit report is completed and submitted within the appropriate timeframe. Repeat Finding: No. Planned completion date for a corrective action plan: June 30, 2024 Name of the contact person responsible for corrective action: Marie Rose, Principal

2023-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b) the School remained in compliance with federal requirements. Context: During our review of the school’s accounting records and internal controls, as well as through management inquiry, we noted the following:  For eight of 25 accounts payable transactions tested out of the 15.042 grant, the school did provide adequate documentation to support the allowability of the expenditure.  For twenty-five of 25 accounts payable expenditures tested out of the 15.046 grant, the school paid amounts to and on behalf of illegitimate board members, totaling $82,127.  For twenty-five of 25 payroll disbursements tested out of the 15.046 grant, the school paid board meeting stipends to illegitimate board members, totaling $9,750. Repeat Finding: No. Action planned in response to the finding: Management will evaluate its internal controls over records management to ensure that all accounts payable disbursements are properly supported, and School Board expenditures are only paid out to and on behalf of eligible individuals. Planned completion date for a corrective action plan: June 30, 2024 Name of the contact person responsible for corrective action: Marie Rose, Principal

2023-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Management intends to perform an internal recalculation on the information included on the PRF reports. Those recalculated figures will be reconciled to the respective internal and audited financial statements. Anticipated completion date: June 2025 Contact person responsible for corrective action: Tish Miller, Chief Financial Officer

2023-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. Implementation of the new system put our accounting department behind. When the PRF was reported on, the cost report settlement had not been booked. Therefore, the initial gross revenue amount was off. The District expects to have accounting closed much closer to its fiscal year end starting in 2024. Anticipated completion date: January 2024 Contact person responsible for corrective action: Kim Manus, Chief Financial Officer

Our accounting system does allow for these reports to be produced for the RD Project once we have the opening balance sheet separated by program. We are working with our Net Suite consultants to correct the historical transactions on the balance sheet to insure that all balance sheet accounts are maintained by program.Anticipated Completion Date- December 31, 2024. Responsible Contact Person- Kathleen Boyce, CFAO

Corrective Action: The district will ensure that all supporting documents will be stored electronically first and stored physically as a secondary option. Each department will be responsible for maintaining a copy of all supporting documentation. All checks and contracts will be included in the procurement packets for all expenditure. We are currently implementing this process and strengthening internal controls. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: October 31, 2024

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will 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 Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

The University agrees with the finding and acknowledges the finding was also reported in the previous fiscal year. Despite high staff turnover, the Director of the Financial Aid Office and in collaboration with the Controller’s Office the issue is being addressed for any future reporting.

The University concurs with this finding but cannot respond why the student was awarded outside the of procedure and methodology set up for awarding HEERF Funds. The decisions were made by individuals no longer with the University and no documentation was found to determine why the student was awarded outside the policy in place. The Controller’s Office and Financial Aid Office are working together to make sure that in future funds like the HEERF will have documentation attached to secure that we follow procedure and policy and document any exceptions.

The University agrees with the finding. The University has had a significant amount of staff turnover and reorganization in FY 2023 in the financial aid office. The Interim Director of Financial Aid is collaborating with the controller’s office to make sure that the University has internal controls in place over Federal programs to assure that the Pell reporting requirements are executed in compliance with Federal statutes, regulation and terms and conditions of the federal award. The University is investing in making sure that the Financial Aid Office is staffed and create policy and procedure that assure that we improve internal controls on the Pell process.

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and submitted each report without a review or oversight process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-003, the Chief of Staff to the Board of Commissioners will have the Controller to the Board of Commissioners review the P&E Reports and the Recovery Plan Performance Report prior to being electronically submitted to the Department of Treasury via its State and Local Fiscal Recovery Funds portal. If errors are discovered by the Controller, the Chief of Staff will correct the electronic entry prior to submission. Anticipated Completion Date: This CAP will be completed by October 31, 2024, the deadline for submitting the third quarter 2024 P&E Report.

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

When federal compliance issues arise, the City Finance Officer will communicate them to the Mayor.

DCH Management's response and corrective action plan During the COVID-19 pandemic, DCH Health System (DCH) developed a methodology to identify eligible costs following the Health and Human Services (HHS) produced COVID-19 Provider Relief Fund (PRF) Reporting Requirements and FAQ guidance. DCH's methodology identified costs used to prevent, prepare for and respond to coronavirus that fell into the following categories: COVID-19 specific costs, direct and indirect incremental costs due to COVID-19, and calculated lost revenue. To calculate direct and indirect incremental costs due to COVID-19 for DCH Regional Medical Center, DCH leveraged HHS FAQ guidance from October 28, 2020, that introduced examples demonstrating how providers could calculate marginally increased expenses related to coronavirus using a reasonable methodology of comparing pre-pandemic to post-pandemic average expenses for an office visit. DCH utilized this method to calculate both direct and indirect incremental costs due to COVID-19 on a per-patient discharge basis, which is akin to an office visit for a hospital, per the HHS FAQ guidance. Though this specific example was removed in subsequent versions of the FAQ, HHS never communicated that the guidance that DCH relied upon to calculate incremental expenses was incorrect. DCH's view is that the total cost of patient discharge includes direct patient care and indirect costs (overhead and general administrative costs (G&A) costs). Indirect costs (e.g., facilities, maintenance, utilities, and management salaries) were incurred by DCH to prepare, prevent and respond to COVID-19, consistent with the intention of the purpose of the PRF to provide financial support to providers who experienced lost revenues and increased expenses during the pandemic to maintain national health system capacity.' For instance, the ability to serve COVID-19 patients relied on incurring utility expenses to keep ventilators and other equipment functioning, which the organization utilized more than the norm, which resulted in higher utility costs. These costs were vital for accommodating COVID-19 patients during the pandemic, just as they were necessary for serving other patient types before the onset of COVID-19. These incremental indirect costs were also not reimbursed through other resources. DCH allocated indirect costs in accordance with other accepted government rules as defined in various government regulations such as 2 CFR and the Federal Acquisition Regulation. The indirect costs allocated to patient care costs were considered part of the total cost of patient discharge. In addition, though DCH calculated lost revenue, DCH did not report on lost revenue as part of the system's use of funds through the HHS portal (please note that there was one reporting period where Fayette had to report separately from DCH because of targeted funds received. Fayette did report lost revenue in that period based on a budget to actual calculation). DCH believes that the funds identified and reported are consistent with HHS guidance and the spirit of the law to maintain national health system capacity. It is DCH's understanding that Single Audit Finding for 2022-001 was particularly focused on DCH's approach to identifying indirect incremental costs due to COVID-19, citing these expenses as ineligible costs that were included in the HHS PRF portal submission. Similarly, DCH did not report lost revenues, resulting in 'inaccurate lost revenues reported.' Both FORVIS and DCH acknowledge that DCH incurred eligible expenses and lost revenue sufficient to cover the PRF funds received. Therefore, based on the FORVIS finding DCH implemented processes to submit future PRF reports as suggested in the Single Audit Finding 2022-001., which includes identifying specific individual expenses incurred during the reporting period to prevent, prepare for and respond to COVID-19, rather than utilizing the initial HHS guidance for calculating incremental costs due to COVID-19. In addition, DCH included lost revenue in the portal submission. Through the Single Audit 2022-001, DCH was requested to provide additional information in the form of lost revenues to cover expenses of $24 million. DCH provided documentation to HRSA auditors and received the final Management Decision Letter (MDL) dated August 20, 2024 completing the review of the audit stating the auditors concurred with the finding in the SAR and determined that the procedural and monetary finding were satisfactorily resolved. In the Single Audit 2023-001, DCH's leadership worked collectively with FORVIS auditors to review the findings from 2022-001 and had in-depth discussions regarding the itemized expenses. Both DCH and FORVIS acknowledged that between lost revenues and detailed expenses DCH was able to cover the monies received. DCH provided a detailed expense listing and FORVIS reviewed as part of the audit process. In the findings, FORVIS documented total expenditures reported in the portal were less than actual expenditures incurred. The audit for 2023-001 resulted in an unmodified report of the financial statements with a material weakness reported due to the reported portal expense being lower than the expenses actually incurred. DCH reported information in the portal related to Phase 4 with guidance based on HHS guidelines. DCH changed processes in future portal submissions to report as suggested in Single Audit Finding 2022-001 an9 in concurrence 2023-001. Since reporting had been completed prior to findings, only future submissions could be changed. Phase 5 submissions were also reviewed with no findings reported by Forvis.

Corrective Action Plan for the Material Weakness identified as part of the Single Audit Reports For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Patrick Evans, CEO Material Weakness: The Organization received and utilized the federal award to pay for general contractor services for a construction project that was ongoing at the time of the award. The Organization had entered the procurement of general contractor service prior to receiving the federal award and in accordance with its existing procurement policy,which included a competitive procurement process with a price analysis. However, there was not a procurement policy in place that specifically covered the criteria required under the Uniform Guidance. As a result, the Organization did not have a procurement policy and process in place that resulted in compliance with the Uniform Guidance including the maintenance of records to detail the history of the procurement in accordance with 2 CFR 200.318(i). Corrective action planned: ERC will update the existing procurement policy to be in accordance with the Uniform Guidance. Once the policy is completed, procedures will be developed to ensure compliance with the policy and training provided for personnel responsible for federal procurements. Anticipated completion date: 3/31/2025

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024