Corrective Action Plans

2023-031 Oregon Commission for the Blind Improve controls over compliance reporting MANAGEMENT RESPONSE: We agree with this recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate and well supported. The agency’s practice is to maintain documentation that supports information contained in the case management system. This practice includes requesting information from clients regarding the start date of employment in the primary occupation and the hourly wage at exit. This information can be difficult to locate due to the numerous case notes in the case management system. Due to the difficulty locating this documentation in the tight timelines of the audit, the agency spent some additional time attempting to locate it after the audit testing period had closed. The agency did find the supporting documentation for one of the two clients that was not located during the audit. For the other client, the agency identified documentation showing that we had requested this information from the client through multiple methods, but it was never received. The agency has created a new case-note category for documenting client employment start date and wages at exit. The agency will provide training to staff on the use of this case note category to ensure this documentation is able to be located more easily and to reinforce the importance of maintaining documentation to support information contained in the case management system. Anticipated Completion Date: August 1, 2024 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

2023-028 Department of Human Services Strengthen controls to ensure adequate supporting documentation and accuracy over reporting MANAGEMENT RESPONSE: We agree with the first recommendation. We disagree with the second recommendation. We agree with the first recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We disagree with the second recommendation. The RSA-17 is currently reviewed by both Program Leadership as well as the ODHS Grant Accounting Manager. Certification is evidenced by the signed RSA-17. This level of review meets federal requirements. Additional review and discussion may be had as a form of best practice but should not be considered a control mechanism. The Grant Accounting Unit will highlight the certification process in the RSA-17 desk manual to delineate between control functions and best practices. Anticipated Completion Date: June 30, 2024 Contact person: Keith Ozols, Vocational Rehabilitation Services Director; Travis Labrum, Grant Accounting Manager

Federal Agency: Department of Homeland Security Federal Program Name: Hazard Mitigation Grant Assistance Listing Number: 97.039 Recommendation: We recommend that the quarterly reports be reviewed by an appropriate member of management. That review should be documented to ensure a complete audit trail. In addition, all reports should be stored in a centralized location for easy future access. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County is working on implementing a review by management for all HMGP Grant quarterly reports. In addition, this review will be documented and stored in a centralized location for easy future access. The County is looking into creating a policy that would require divisions to save their grant information on a shared drive, while we are also looking at purchasing a grant management software as a repository for all related grant documents. Name(s) of the contact person(s) responsible for corrective action: These HMGP grants are in several divisions, so the directors over those divisions should be responsible for the corrective actions. This would include Tamara Richardson, Utilities Director; Gaye Sharpe, Parks and Natural Resources Director; Jay Jarvis, Roads and Drainage Director; and Keith Tate, Facilities Management Director. Planned completion date for corrective action plan: September 30, 2024

Criteria: According to 2 CFR, Part 200.303 of the Office of Management and Budget’s Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal controls to ensure compliance with federal statues, regulations, and the terms and conditions of federal awards. Condition: Domestic Abuse Intervention Services, Inc.'s internal controls over review of cost allocation journal entries, allowable costs and activities, period of performance, cash management, matching, and reporting were not properly documented. Cause: Sufficient training was not provided to individuals responsible for the documentation of internal controls over compliance requirements. Effect or Potential Effect: This could result in noncompliance, disallowed costs, or discontinuance of federal funding. Recommendation: We recommend formally documenting the controls over each area by providing additional training on documentation and forms to provide evidence of review. Views of Responsible Officials and Planned Corrective Actions: Domestic Abuse Intervention Services, Inc. agrees with the finding. DAIS will implement effective and written procedures and training for the review of cost allocation journal entries, allowable costs and activities, period of performance, cash management, matching, and reporting. The written procedures will explicitly lay out the processes for review and approval of each of these compliance components per each federal Assistance Listing that DAIS receives. The Director of Administration will use the most up to date 2 CFR Part 200, Appendix XI - Compliance Supplement to identify the specific compliance requirements for each of the Assistance Listings and create the written procedures. All reviews and approvals will also be documented henceforth. Shawn Walker, Director of Administration, will oversee the implementation of this corrective action.

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

The YWCA will implement the following changes in its accounting procedures: 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

COVID-19 Emergency Rental Assistance – Assistance Listing Number 21.023 Recommendation: We recommend the Authority implements an internal control over compliance to evidence the expenses are approved to be charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Monthly reports are provided for Cost Distribution by Deputy Director of Financial Operations to Deputy Director Programs for review of appropriate charging. Corrections are provided back to Finance and made in the financial system. Name(s) of the contact person(s) responsible for corrective action: Ellen Eudy, Deputy Director, Financial Operations and Marni Holloway, Deputy Director, Programs Planned completion date for corrective action plan: June 30, 2024

See response in attached financial statements

Federal Award Findings and Questions Costs Corrective Action Plan Year Ended August 31, 2023 Finding No. 2023-001: Inaccurate Enrollment Reporting CFDA Numbers: Various Program: Student Financial Assistance Cluster Corrective Action: Students will be required to request special permission to re-enroll, thus ensuring that their graduation is reported before any additional enrollment or withdrawal. Additionally, a thorough assessment of the management review process will be performed to identify areas that will help ensure the accurate submission of data to the NSLDS. We anticipate revised processes in the Spring of 2024. Contact Person: Jaci Casazza Expected Implementation: April 30, 2024

Currently, the College marks students withdrawn on the date the withdrawal is officially processed in the system, indicating their last data of attendance. The withdrawal policy will be updated to indicate that the withdraw date to be reported for all students withdrawing at either the program or campus level should be processed as the "last date of attendance". In the case of the 5-year program (4+1 internally), we currently do not officially "enroll" a student into the master's program until their bachelor's degree is conferred. The official admit date will be updated to reflect the term a student enters the master's program officially, which will begin after the conferral of their bachelor's degree. Our policy and processes for the 4+1 program will be updated to reflect this change.

The finding from the schedule of findings and questioned costs for the year ended December 31, 2023 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. Finding 2023-001 Condition: The Organization does not have proper segregation of duties and appropriate level of review and approval prior to charging costs to a federal program. The same individual was approving timecards and reimbursement packets without an additional layer of review. Additionally there was no documentation of review of the reimbursement packets prior to being submitted for reimbursement. Planned Corrective Action: Management has implemented a process to ensure review of the reports prior to finalization and submission to the funder. One person will gather data and appropriate paperwork for reporting and reimbursement purposes. To ensure proper segregation of duties, there will be 2 different individuals that approve timecards and gather reimbursement packets. In addition, a second person will review and approve completed reports and packet prior to submission. This review process will be properly documented and evidenced through signature of the reports. Anticipated Completion Date: March 31, 2024 Contact Person: Pam Schuellerman, Executive Director

For expenditures made pursuant to the American Rescue Plan Act funds received pursuant to Act 2 of 2022, management concurs there were 26 payments totaling $25,836 made after the 90-day performance period ended and more than one retention payment was made to 34 qualified staff members amounting to $31,530. Management will contact the Pennsylvania Department of Human Services and inform them of this finding to determine the appropriate corrective measures.

Special Education-Grants for Infants and Families– Assistance Listing No. 84.181 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

Special Education Cluster – Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend that the Department review its procedures to ensure that expenditures charged to the program are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Infants and Toddlers Supervisor will conduct monthly reviews of outstanding purchase orders in Oracle, addressing issues promptly with the Business Operation Officer/Financial Analyst. Professional development sessions will be attended to enhance invoice scrutiny for allowable expenses within the grant period. Quarterly reminders and Financial Quarterly Review meetings will be instituted for supervisors, ensuring timely action on outstanding purchase orders. Following will be implemented: 1. Infants and Toddler Supervisor will hold monthly meetings with the Financial Analyst and the secretarial staff to ensure consistent actions are taken when generating purchase orders and processing invoices. 2. The Infants and Toddler secretary will review invoice dates against contracts and purchase orders to ensure they fall within grant timelines before submitting them to the supervisor for signature. 3. Infants and Toddler Supervisor will confirm that purchases made with grant funds are allowable and within the designated grant period. The Supervisor will cross-reference invoice dates against grant periods before signing and sending to accounts payable. 4. The infants and Toddler Supervisor will confirm the work being invoiced has been completed and vendor details are checked, and dates verified. 5. Grant Accountants will provide transaction detail reports (at least quarterly). The Infant and Toddlers Coordinating Supervisor will review and sign-off on the quarterly transaction reports. 6. The Financial Analyst will meet monthly with the Infants and Toddler Supervisor and Coordinating Supervisor to ensure grant allowable expenses are adhered to and invoicing is updated and falls within grant-specific timelines. Name(s) of the contact person(s) responsible for corrective action: Office of Infant and Toddlers/Coordinating Supervisor & Fiscal Analyst and Business Operation Office/Fiscal Analyst & Office of Infant and Toddlers/Coordinating Supervisor Planned completion date for corrective action plan: June 2024

Finding No. 2023-003: Period of Performance (Significant Deficiency - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that it complies with the CDBG timeliness standard specified in 24 CFR Section 570.902. In addition, we recommend that the City ensures that it adheres to the workout plan it submitted to HUD. Administration’s Comment: The City will adhere to procedures to comply with the CDBG timeliness standard specified in 24 CFR 570.902. Anticipated Completion Date: May 2024 Contact Person(s): Holly Kawano, Department of Budget and Fiscal Services, Federal Grants Coordinator

Identifying Number: 2023-005: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: The following instances were identified during testing of enrollment reporting: 7 instances in which a student’s status change was certified outside the 60-day reporting requirement, 7 instances in which a student’s status change was not reported within 60 days to the National Student Loan Data System (NSLDS) nor included in reporting to the National Student Clearinghouse (NSC), and 2 instances in which a student’s program start date reported in NSLDS did not agree with student records. Corrective Action Taken or Planned: The STC Financial Aid Office and Registrar will work to develop a process to review errors in the three systems that are involved in enrollment status reporting and identify any solutions. A common folder for submittal rosters will be shared between the offices so that they may also be reviewed for accuracy. National Student Clearinghouse issue notifications will also be kept on file for future reference. Contact person: Rich Kluin, Vice President – Finance and Operations, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.

Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Period of Performance Significant Deficiency in Internal Control over Compliance Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance Finding Summary: Our testing over activities allowed and allowable costs and period of performance identified one expenditure that fell outside of the period of performance under the grant and two expenditures that did not agree to supporting documentation. Responsible Individuals: Jamie Schaefer, John Neth Corrective Action Plan: The Organization will review and strengthen the controls surrounding the period of performance and activities allowed and allowable costs. There are no questioned costs related to this finding. The Organization is in the process of implementing a new enterprise resource planning software which will include a grant module. The grant module will have automated controls surrounding Period of performance evaluation and costs will be drillable to ensure cost claimed and supporting documentation are in alignment. Anticipated Completion Date: October 1, 2024

Planned Correction Action: Moving forward grants will not be set up with account #s for use until the funds are received and award letter is issued with actual start date. This will stop any expenses being posted prior to the start date. Name of Contact Person and Completion Date: Jeremy Roche, Assistant Superintendent of Finance and Operations. This plan will go into effect immediately.

2023-001 Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: We have controls in place to ensure that costs charged to a grant are incurred within the grant period of performance. This finding exposed a vulnerability that circumvented our controls. We will use this finding to pinpoint the cause(s) and make the necessary corrective adjustments. Name(s) of the contact person(s) responsible for corrective action: Deborah Grupp-Patrutz and Steve Simmons Planned completion date for corrective action plan: Prior to June 30, 2024

FINDING 2023-010 Finding Subject: ESSER (Education Stabilization Fund) – Allowable Activities, Allowable Costs/Cost Principles Federal Programs: Education Stabilization Fund Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed and Allowable Costs/Cost Principles compliance requirement. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying payroll disbursements from grant funds. On a monthly basis, Payroll coordinator will print payroll disbursements from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

FINDING 2023-006 Finding Subject: Special Education Cluster - Activities Allowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation did not have internal controls in place over payroll disbursements. A detailed report of payroll disbursements was paid without evidence of review and approval by a knowledgeable person. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Develop process and procedures for verifying disbursements from grant funds. On a monthly basis, Corporation Treasure will print expenditure report from federal grant funds to be reviewed, verified and signed off by Superintendent/CFO. Anticipated Completion Date: To begin immediately, March 2024

Corrective Action Planned: The identified payments relate to postage expenditures recorded in the Child Support Enforcement Grant. Postage expenditures are controlled in the State's mailing system through mail codes. Agencies send approved postage budgets to the Department of Administrative Services (DAS), who then creates a new mail code or adds additional funding to existing codes in the system. All mail processed through the mailing system is charged to these individual mail codes. A monthly expenditure report from the mailing system is interfaced with NH First, and the DAS uploads a journal entry to the general ledger to record these expenditures. The review and approvals for these postage transactions occur upfront at the agency level, not through a NH First approval workflow. DHHS and DAS will work together to document adequate evidence of this upfront review and approval.

NHED concurs with the finding identified with the expenditures of $3605. The NHED will have the LEA’s submitting for indirect costs after September 30th upload an invoice and back up documentation into GMS. The NHED concurs with the findings identified with expenditures of $5,172. There were in fact some items that were charged outside the period of performance. This happened prior to us receiving the FY22 audit finding and putting in place new controls to prevent. We have since put into place DOE-OBM-33 to ensure payments are being reviewed closely to the period of performance at multiple times. We have also corrected any items charged to the wrong CAN. The NHED concurs with the findings identified with expenditures of $816. We will look into the district returning these funds or other enforcement actions. In addition to the DOE-OBM-033 process, the Division of Learner Support has created and implemented a transfer of funds procedure.

Individual Responsible for Corrective Action: Linda Fleischman, Registrar Corrective Action: The Registrar’s Office will reach out to Jenzabar to determine what is triggering the incorrect program start date. Beginning with the summer 2024 students, each new student record will be reviewed prior to the initial National Student Clearinghouse submission to ensure that the start date is being reported correctly. Anticipated Completion Date: August 15, 2024

Names of Responsible Individuals: Brandon Rhone, Analyst Financial Aid Systems, Chad Wick, Director Financial Aid and Brian Emery, Associate Director Financial Aid Corrective Action: The University will transition from a manual to an automated review process. The COA data that was inputted at the beginning of the award year did not match all budget components causing inaccuracies. The Financial Aid office was adjusting the budget components of the COA manually, which resulted in miscalculations. When these calculations were performed COD might not have been updated and therefore the COA could be inaccurately reported. During the 2023 and 2024 fiscal years the Financial Aid office experienced several staffing changes. The Financial Aid office will review all student COA calculations to ensure that the COA used for originating and disbursing funds is correct. The Financial Aid office will set up automatic processing of key reports to identify rejected origination records. The Financial Aid office will set up the Direct Loan COD Reject Report (DCRR) and the Pell COD Reject Report (PCRR) to run Sunday night and be available Monday morning to be reviewed by the Financial Aid Advisors. The Financial Aid office will make the necessary corrections and update by the end of the week. The Financial Aid office will run Batch FA Transmittal Register (FATR) to confirm that all anticipated awards have passed all rules and are ready to transmit. Those that don’t pass will be reviewed and students will be contacted for updated/corrected information. COD records will be exported nightly through an automated process to ensure all deadlines are met and that we are not exceeding the 15 calendar day limit. The Financial Aid office has also modified the setup of their Student Information System for 2024-2025 so that the COA will be automatically calculated which will eliminate the need for any manual calculations of COA. This automated process should eliminate improperly calculated COAs. Anticipated Completion Date: June 30, 2024