Corrective Action Plans

FINDING 2023-002 Finding Subject: Emergency Connectivity Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: 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 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation completed reimbursement requests and submitted them online; however, there was no evidence of an oversight or review process to ensure that the reimbursement requests were for allowable activities, allowable costs, and within the period of performance. Contact Person Responsible for Corrective Action: Derek Coulombe, Director of Technology Contact Phone Number and Email Address: (317) 856-5265; dcoulombe@decaturproud.org Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will develop procedures to ensure disbursement requests are printed out and a representative from the Business Department documents review of them for allowable activity before final submission. Anticipated Completion Date: March 1, 2024

Finding Number: 2023‐004 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City did not have adequate controls in place to ensure obligations were liquidated (paid) within the required 60 days. Contact Person Responsible for Corrective Action: Terri Daniels (ODG), Regina Greear (ODFS), Denise Fair Razo (DHD) Anticipated Completion Date: June 2023 Planned Corrective Action: During the AFCAP process, the OCFO will work with the Health Department to implement additional controls to ensure all subrecipients and contractors submit invoices timely and that they are reviewed, approved and processed timely and accurately for payment prior to the 60 liquidation requirement period.

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend the Organization put procedures in place to identify the performance period when charging invoices to grants, particularly during the start and end of the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional and recurring training will be provided to both program and accounting staff. Grant procedures will be updated to expand review and monitoring of expenditures at beginning and end of grant periods for all federal grants. This will include hiring of an additional oversight position over all federal grants. Name(s) of the contact person(s) responsible for corrective action: Drew Erickson, Controller Planned completion date for corrective action plan: 04/30/2024

Contact Person: Kasi Turner, Registrar Corrective Action: We manually reported a student as withdrawn on 2/17/2023. The status change came in as an error on the 3/16/2023 submission (the following month) and we manually updated the status and status start date for the student again. However, it looks like the student’s status reverted to Three-Quarter time on the final transmission on 5/1/2023. We will commit to closer monitoring of withdrawals submitted manually by our office on subsequent enrollment transmissions through the Clearinghouse. Anticipated Completion Date: December 15, 2023

Finding number 2023-001 – Special Tests and Provisions-Enrollment Reporting-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action was implemented in December 2023. The school's management agrees with the finding and has implemented procedure whereby changes in enrollment status reported to the National Student Clearinghouse will be sample reviewed by the Registrar within NSLDS five business days following the reporting date to ensure the accuracy of the information. As an additional layer, the Financial Aid Manager will also calendar a review reminder. Permanent address changes will be reported on a six-week cycle after the add/drop period each term. Address changes will also be sample reviewed to ensure accuracy within NSLDS.

2023-004 Period of Performance U.S. Department of Education Special Education - Grants for Infants and Families Assistance Listing Numbers: 84.181A Recommendation: We recommend the program thoroughly review the dates on vouchers to ensure the activity is recorded to the right grant award based on the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ECECD takes this matter seriously and as of September 2023, has taken immediate corrective action to address and rectify it. Upon identification of this compliance discrepancy, ECECD reviewed its internal processes and procedures to ensure that costs are appropriately incurred only within the specified period of performance. To prevent any further occurrences of costs being incurred outside the approved period, ECECD has enhanced our oversight mechanisms, implemented additional checks, and reinforced the importance of adhering to the stipulated timeframes within our organization. The cross-training and second review on all invoices has been implemented by the lead financial coordinator. ECECD also established a tracking log to ensure invoices are received and processed within the period of performance. Furthermore, ECECD began conducting a comprehensive review of all incurred costs after the period of performance to identify and rectify any discrepancies. Any such costs that were found to be in violation of federal compliance requirements have been addressed, corrected, and reported as necessary. To prevent any future lapses in reporting, the agency contract program manager will work collaboratively with ASD to develop a system to ensure all costs are incurred timely in the period of performance. This proactive measure will help us maintain transparency and accuracy in our reporting. ECECD is fully committed to strengthening our processes to ensure full compliance with reporting requirements moving forward. Name(s) of the contact person(s) responsible for corrective action: Carmel Pacheco-Aragon, Chief Financial Officer. Planned completion date for corrective action plan: June 30, 2024

Response and Corrective Action Plan: The District will annually prepare a calculation of the modified total direct cost allocation base for all federal awards before applying the indirect cost rate to federal programs.

Identifying Number: 2023-003 Finding: For 2 out of 17 (11.7%) expenditures tested, portions of the expenditures had service periods that extended beyond the grant’s period of performance and were charged to the grant for reimbursement. Corrective Action Taken or Planned: To prevent a recurrence, grants transactions will be reviewed by the Principal Investigator/Program Director, the Strategic Advancement unit, and the Finance Office for allowability and alignment with the grant’s performance period. Anticipated Completion Date: This process has already been implemented by the College. Responsible Persons: Nick Branson, Assistant Vice President for Strategic Advancement Jean Stephan, Controller

Date: 12/27/2023 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Year ended June 30, 2023 Finding Number: 2023-008 Finding: The Office of the County Manager did not have internal controls established over the direct payments made to participants of the Emergency Rental Assistance Program. Corrective Action Taken or To Be Taken: Internal controls will be monitored/created for future awards. If already taken, date of completion: If to be taken, estimated date of completion: January 2024 Agency Response Does the Agency Agree with finding?: Yes 􀜈 No 􀜆 Partially 􀜆 If No or Partial, Please explain reason(s) why: Additional Comments: Division Responsible for Corrective Action Plan Name, Title: Cathy Hill, Comptroller Address or Mailstop: 1001 E. Ninth St. City, State, Zip Code: Reno, NV 89512 Phone Number: (775) 328-2552 Email: chill@washoecounty.gov Reviewed and Approved Cathy HillDigitally signed by Cathy Hill Date: 2023.12.27

Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.

U.S. Department of Education 2023-001 NSLDS Enrollment Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: During testing of enrollment status reporting, we noted that the incorrect enrollment status, effective date, and program begin date was reported to NSLDS. Recommendation: The College should evaluate their procedures and policies related to reporting status changes to NSLDS and enhance as deemed necessary to ensure that accurate information is reported to NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Cause-Enrollment Status Reporting: Montgomery College utilizes the National Student Clearinghouse (NSC) as a third-party provider in order to submit student information to the NSLDS. Student enrollment status corrections were uploaded to NSC timely, however, monitoring of the upload through success was inconsistent, resulting in error reports preventing the accurate and timely update to the enrollment statuses. No review was completed to ensure the upload was completed in NSLDS. Cause for Effective Date Reporting - Inaccurate Student withdrawal effective dates were not identified timely due to delays in the review of student withdrawal status. Cause for Program Start Date Reporting - Inaccurate Student program begin dates were due to a programming issue with the file transmission software. Program start date was updating each semester to the latest semester start date. There was insufficient review to identify the problem and recommend a solution to resolve. The following actions have been implemented to resolve the deficiencies: Review of error reports by an employee not responsible for correcting the errors to ensure completeness and timeliness of the corrections submitted. Use of internal weekly reports to identify students who dropped below half time status or withdrew entirely from a semester. Use of the NSC online error reporting tool to correct errors monthly. Errors are corrected using this tool within eight days of receipt of the error report, which provides the NSC two days to resubmit the information and meet the ten-day resolution requirement. Utilize the Enrollment Reporting Summary Report (SCHER1) to ensure completeness and timeliness of error correction submissions. The Dept of Enrollment Services has coordinated with the Office of Information Technology to adjust the programming on the file transmission to NSC to ensure accuracy and minimize discrepancies. Manually submit corrections directly to NSLDS on an as-needed basis. Name(s) of the contact person(s) responsible for corrective action: Director of Enrollment Services- Earnest Cartledge Planned completion date for corrective action plan: December 2023

Finding Number: 2023-001 Planned Corrective Action: The Dayton Early College Academy will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 07/01/2023 Responsible Contact Person: Steven Hinshaw, Treasurer

Federal Program Name: • Coronavirus State and Local Fiscal Recovery Funds – ALN 21.027 • Block Grants for Prevention and Treatment of Substance Abuse – ALN 93.959 Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on the incurred date, rather than paid date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the audit finding. The previous process for grant salary, fringe, and indirect billings was based on salary paid date and therefore on a cash basis rather than accrual. The policy and process were immediately updated when the issue was identified during the fiscal year 2022 audit to bill based on period incurred rather than paid date, but the issue was identified after the invoices in question were sent. Revised invoices were not sent as total costs incurred during the period of the award, excluding the amounts noted in the finding, were still well over and above the award amount. All questioned costs were allowable but were outside the grant period and there are other eligible expenses during the period of performance which could have been billed to fully draw down on the award. Name(s) of the contact person(s) responsible for corrective action: CFO, Controller, and Grants Manager Planned completion date for corrective action plan: Will implement in fiscal year 2024

Finding: 2023-002: Questioned Cost – Material Weakness Costs for US Department of Transportation, Mobility Management Grant 20.507 Section 5307 included a $30,000 charge for use of the Data Management System (DMS). The charge is based on a contract rate charged to outside entities that varies depending on the number of users. Management stated the charge was to recoup costs for use of the DMS. Costs for the DMS consist of historical costs to get the system functioning, along with current personnel costs to operate the system and provide the contracted training. The historical costs occurred outside the period of performance and are thus unallowable. Personnel costs are already being charged to the grant through the allocated payroll and benefits of trainers and other personnel, and thus should not also be charged through the contract rate. In addition, if the contract rate includes a profit component this would also be unallowable to charge to the grant. Auditor Recommendation: We recommend that costs charged to federal grants be reviewed by an individual familiar with the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 as part of the SEFA review process. Contact Person Responsible for the Corrective Action: Lisa Cappellari, Chief Financial Officer, LisaC@paratransit.org Management Response and Corrective Action Plan: After the end of Fiscal Year 23-24 on 6/30/2024, Jody Wadley, Finance and Grants Manager, and Lisa Cappellari, Chief Financial Officer, will compile all expense to be charged to any federal grants. Tiffani Scott, Chief Executive Officer, will review the expense against the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 to make sure all expense is eligible.

Corrective Action to be Taken for Finding 2023-002 - Report Deadline Tracking o Catholic Charities will create a shared calendar for use by the Caseworkers, Program Director, Operations Director, and Fiscal Manager to document all deadlines of required reports and staff responsible for completing the reports. o This calendar will be monitored and updated by all staff with new arrival dates, quarterly report deadlines, close of case report dates, billing dates, Match Grant enrollment dates, 180-day budget deadlines, and 240-day budget deadlines. - Trainings o The Program Director will contact the staff of United States Council of Catholic Bishops, here after referred to as USCCB, when an individual begins employment and request a login and password into the USCCB resource website, MRS Connect, which has all USCCB trainings recorded and saved for staff to review. o Within 30 days of an employee’s start date the individual will participate in all approved USCCB training on reporting requirements. - Case File Review o Within the first week of arrival, the Program Director will review a case file. o Thereafter, a weekly case file review to monitor that case files have required documentation in accordance with the federal guidelines will be completed.

Management’s Corrective Action Plan Management takes its responsibility to maintain effective internal control over the federal award that provides reasonable assurance that the agency is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award seriously and gave significant consideration to what additional controls would be effective to ensure the proper amount of indirect costs are charged to all federal grants. To prevent another occurrence, the organization will: On October 17, 2023, the agency refunded the indirect costs that were overbilled in error. By December 31, 2023 and annually thereafter, the Director of Grants Management will provide training and technical assistance to all Grant Specialists and Grant Accountants on allowable costs, including detailed training on proper determination of indirect costs for each grant. This training will also be incorporated into the onboarding process for any new grant staff. Continue its current policy that the Director of Grants Management complete a detailed review of each grant reconciliation monthly, to ensure all costs charged to the grant are reasonable and necessary for the performance of the award. This review will include appropriate tests of indirect costs including ensuring the appropriate indirect cost base is used, all items required to be excluded from the indirect cost base are excluded, and the appropriate indirect cost rate is applied to the indirect cost base. Continue its monthly analytical review to test the reasonableness of grant revenue relative to grant-funded expenditures. At least twice annually, the Controller will complete a second detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. At the end of each award cycle, the CFO will complete a third detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. Going forward, should indirect rates or methodologies change for any award, the CFO will review the grant reconciliation the first month following the effective date of the change to ensure the change has been properly implemented.

Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System’s expense tracking spreadsheet, which identified the expenses claimed under the federal program as allowable costs included three expenses which were subsequent to December 31, 2022, and therefore, outside the period of performance. Although invoices were approved for payment, only one invoice included documentation relating to specific approval as allowable costs related to the grant. Likewise, the Health System’s expense tracking spreadsheet did not include a documented secondary review and approval by someone other than the preparer. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a control process which includes an independent review and approval of the expense tracking spreadsheet which identifies the expenses claimed under the federal program as allowable costs and retain documentation of the review process. The expenses referenced as being outside of the period of performance were costs to a vendor whom was contracted/engaged prior to the period of performance. Due to supply chain/vendor demand issues, the work was completed subsequent to the period of performance. It was our understanding that these are eligible expenses under the program, as the work and payment was delayed due to supply chain/vendor demand issues. However, if necessary, we have identified other qualifying expenditures incurred within the period of performance we can submit which will satisfy allowable costs claimed for the period of performance. Anticipated Completion Date: 01/31/2024

Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the agency and are considered cost share for the grant as the work on the grant continued past the grant end date. We will review our grant close-out procedures to ensure that grants are closed out in a timely manner based on the grant end date preventing subsequent charges to the grant award. Anticipated Completion Date: March 1, 2024

Management’s response - In response to the finding indicated in the governance letter, management recognizes that the physical work performed for this expense occurred in FY23, but this is also an ongoing project and the period of performance for the ARP ESSER grant ends on 9/30/2024 not 6/30/23. Therefore, Management believes their interpretation is also correct. All federal and state grants with a period of performance ending 6/30/23 were accrued back to FY23 ensuring payments and receipts activities were in the correct time frame. Final reimbursement was requested, and the grants were closed out. The implementation of our new financial system also added an extra layer of complexity to our end of year accounting. Work in 2 different systems that do not work cohesively with each other was very challenging. We respect and appreciate the work of our auditors and understand that at times we will disagree and interpret things differently, which is what happened in regard to the expense for the HVAC project surrounding the "period of performance" language.

Name of Auditee: Poughkeepsie Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2023 CAP Prepared by: Thomas Shanley, Accountant Phone: (845) 485-8931 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2023-002 (a) Comments on the Findings and Recommendations - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action Taken - The Authority also agrees with the recommendation and will review all compliance requirements and HUD notifications for all new funding sources. (c) Planned Implementation Date - The Authority expects to complete the corrective action by March 31, 2024.

State Agency: Office of Children and Family Services Single Audit Contact: Bonnie Hahn Title: External Audit Liaison Telephone: 518-486-1034 E-mail Address: Bonnie.Hahn@ocfs.ny.gov Federal Program(s) (ALN # [s]): Rehabilitation Services-Vocational Rehabilitation Grants to States (84.126) Audit Report Reference: 2023-010 Anticipated Completion Date: January 15, 2024 Corrective Action Planned: New York State Commission for the Blind (NYSCB) is updating the Internal Controls and Data Validation policy for the RSA 911 report to implement an additional control to ensure the accuracy of the key elements including ‘Start date of Employment in Primary Occupation’ #350. The Senior Vocational Rehabilitation Counselor (VRC) will review the start date for employment during their review of cases when the Individualized Plan for Employment (IPE) is approved and at the time of successful closure. The Senior VRC will also verify that the employment start date is entered and accurate on the employment information form in the case management system. Training on this additional internal control will be provided to the Senior Vocational Rehabilitation Counselor’s and District Managers virtually on December 11, 2023. State Agency: State Education Department Single Audit Contact: Jeanne Day Title: Auditor 3 Telephone: 518-474-5919 E-mail Address: Jeanne.Day@nysed.gov Federal Program(s) (ALN # [s]): Rehabilitation Services - Vocational Rehabilitation Grants to States (84.126) Audit Report Reference: 2023-010 Anticipated Completion Date: December 2023 Corrective Action Planned: Adult Career and Continuing Education – Vocational Rehabilitation (ACCES-VR) will continue to implement and document review processes and methods. The implementation of the Aware electronic case management system is complete and will enhance the agency’s review process. A review process memo is currently in development related to Testing and will clearly document the scope and requirements associated with the review process.

Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that only expenses incurred during the period of performance are billed to the grants.

2023-001 Cash Disbursement Review and Approval. BPC established its policies and procedures that included processes for proper approval of all transactions in September of 2023 during the audit for the previous year. The transactions without approval were all prior to the new policy and procedure. The organization continues to follow written policies and procedures for proper approval of all transactions posted in the general ledger.

Finding number: 2023-002; Finding: During our testing, we noted that internal controls were not properly designed over activities allowed or unallowed, allowable costs/cost principles and period of performance to identify program expenditures from other expenditures in the cost center. Additionally, we noted controls were not operating as designed to ensure payroll expenses charged to the program were properly approved. In our sample of 20 payroll expenditures, two had no evidence of timesheet approval. Correction actions taken or planned: Additional review and approval of allowable expenditures will be done by another individual outside of the preparer. Any payroll related dollars charged to the grant will require sign off by the manager prior to charging the expense to the grant. Anticipated completion Date: February 2024; UW Health employees responsible for Corrective Action Plan: Heather Brahm, Director of Finance & Controller, and Jamie Soyk, Program Director of Financial Reporting

Finding Number 2023-005 — Significant Deficiency in Internal Control/Non-Compliance — Appropriate Expense Period of Covid 19-ESSER II 23b — Credit Recovery Condition: During expense testing of ESSER funds, a journal entry that reclassed the cost of Edmentum, program licenses for Plato courses, had expensed the entire annual license fee. The period for eligible expenditures did not begin until October 1, 2022. This journal entry expensed the full cost of the invoice, $11,914.50, and the district did not prorate the costs to include only those expenses from October 1, 2022 through June 30, 2023. The District did not adhere to the proper period for expenditures. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop a summary of all federal grants. This summary will detail the fiscal year it is associated with but more importantly, it will provide the proper period of eligible expenditures for each federal funding source. This summary may be used and readily available at the time approvals are granted for expenditures. If an expense does not fall within the eligible time period, the expense can be rejected by the approver. This summary will be shared with all administrators and staff. In addition, the process for reclass journal entries will also include a pause to check that each invoice associated with a federal grant, is falling within the proper period of expenditures. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools