Corrective Action Plans

Finding 2023-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the projects and related expenses submitted to FEMA for reimbursement. Current Status: In progress. Resolution: Management will develop and implement additional internal controls to ensure documentation is retained to evidence the operating effectiveness of the internal controls. These internal controls will ensure expenses included in FEMA grant applications are reported completely and accurately. The additional internal controls will include a reconciliation of application expense detail to final paid invoices along with a notation that each expense is allowed to be included in the FEMA submission. The reconciliation will be reviewed and approved by the Cottage Health Director of Finance prior to final FEMA submission and evidence of the review will be retained. Contact Person: Lawrence Thomas, Director of Corporate Finance Anticipated Completion Date: November 29, 2024

FINDING 2023-06 Finding Subject: Child Support Enforcement - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance Summary of Finding: No documented oversight Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will meet with every department that has state grants and make sure that all invoices are double check for proper expenditures and have both employees sign off on the claim. Anticipated Completion Date: August 30, 2024

FINDING 2023-04 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: Reports were incorrectly completed, excluded amounts for the report period. Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2024

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented additional procedures to more efficiently review payroll and supporting documentation. We updated our fiscal policies and procedures in 2022 to document a standardized process for review of payroll. Payroll cannot be processed without adequate review and documentation. Payroll is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

Management Response The documentation provided to the auditors did not make it easy for the auditors to trace the general ledger totals to the amounts billed to cost reimbursement contracts. The Garden records all expenses incurred for a given award in its general ledger, regardless of whether full funding of the expenses is available. This is so the Garden can see the full cost of the activity and make informed decisions in the future. The reports used to bill the federal awards only pulls expenses in the period of the award. In all cases, no amounts were billed to any federal award after the award had expired. Corrective Action Plan Education and reverification of the processes documenting the flow of information from the general ledger to the federal award billings has been provided to accounting personnel involved in federal award accounting and billing. Contact person(s) responsible for the corrective action: Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org Anticipated Completion Date: Education on the above has already started and will be completed August 31, 2024.

FINDING 2023-005 Finding Subject: COVID 19 Reporting Summary of Finding: We were required to submit quarterly P & E reports, ours were submitted in error Contact Person Responsible for Corrective Action: Amy Roberts Contact Phone Number and Email Address: ARoberts@dalevilleindiana.org 765-378-6288 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will create controls so reports will be submitted in accurate manner in the future Anticipated Completion Date: March 1, 2025

Planned Corrective Action: MARR will retain a CPA consultant to establish formal written policy documenting significant accounting procedures including but not limited to the independent review of the grant period of performance when recording transactions and preparing grant reimbursement requests. Evidence of the review to be documented and maintained according to the procedures to be implemented.

FINDING 2023-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: Finding 2023-005 found that the County did not have an effective system of internal controls in place to ensure accurate and complete reporting of Project and Expenditure (P&E) reports for the Coronavirus State and Local Fiscal Recovery Funds (SLFRF). The County was unable to provide supporting documentation for current period and cumulative obligations, resulting in reporting errors. This issue was isolated to the one annual P&E report submitted during the audit period. Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number and Email Address: 812-738-8241; cshireman@harrisoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County Auditor's office acknowledges the need for strengthened internal controls and improved processes to ensure compliance with reporting requirements for federal awards. A system of internal controls will be designed and implemented to ensure segregation of duties in the preparation, review, and submission of federal reports. This will involve designating different personnel for the preparation and review of P&E reports to ensure accuracy and thorough oversight before submission. Staff involved in federal reporting will receive training on SLFRF compliance and reporting requirements, including proper procedures for documenting obligations and reporting them accurately. The County will review its procedures to ensure compliance with federal reporting requirements periodically. This will help identify any potential issues in a timely manner and allow for immediate corrective action if needed. In addition, regular reviews will verify that corrective actions from prior audits are fully implemented and maintained. Anticipated Completion Date: December 31, 2024

o LifeWire’s Senior Accountants, Controller and Co-EDs carefully review all costs charged to contracts to ensure they fall within the appropriate contract period. As of September 9, 2024, all 2024 contract charges are captured in the correct periods. o If the staff of LifeWire has any question about the permissibility of a given charge, we will reach out to the contract manager, obtain clarification and/or permission in writing, and ensure that documentation is filed and maintained appropriately. If we are unable to obtain this permission, we will find another funding source for the charge or find alternate methods of supporting survivors’ needs. o Name of Responsible Individual: Jeannette Biffle, Controller

IN THE HRSA PROVIDED DOCUMENTATION, IT STATES "FUNDS CAN BE USED FOR FACILITY EXPENSES SUCH AS LEASE OR PURCHASE OF PERMANENT OR TEMPORARY STRUCTURES, OR TO RETROFIT FACILITIES TO ACCOMMODATE REVISED PATIENT TREATMENT PRACTICES TO SUPPORT INFECTION CONTROL DURING THE PERIOD OF PERFORMANCE." WE BELIEVE THAT WE HAVE ADHERED TO ALL EXPENSE AS ALLOWED BY HRSA AND HAVE MET THE INTENT OF THE HRSA PROGRAM AND GUIDANCE PROVDIED, INCLUDING DUE DILIGENCE OF CALLS TO HRSA AND CONVERSATIONS WITH THE AUDITORS OF OUR INTENT TO PURCHASE THE ADDITIONAL CONDO UNIT TO ALLOW FOR MORE SPACE TO MEET AND PROVIDE SERVICES TO THE INDIVIDUALS AND FAMILES THAT WE SERVE DUE TO THE COVID-19 VIRUS.

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The City submitted four P&E reports during the audit period; however, the controls in place were not effective to prevent, or detect and correct, errors. As a result, errors in reporting were identified. The current period and cumulative expenditures reported consisted of the amounts expended by the beneficiaries who were awarded funds from the City, rather than total amounts expended to the beneficiaries, resulting in current period expenditures and cumulative expenditures being incorrectly reported on all four reports as follows:  Quarterly Report: October 1, 2022 to December 31, 2022 Current period expenditures were overstated by $40,350. Cumulative expenditures were understated by $262,057.  Quarterly Report: January 1, 2023 to March 31, 2023 Current period expenditures were understated by $2,338,864. Cumulative expenditures were understated by $2,499,656.  Quarterly Report: April 1, 2023 to June 30, 2023 Current period expenditures were understated by $1,200,000. Cumulative expenditures were understated by $3,699,656.  Quarterly Report: July 1, 2023 to September 30, 2023 Current period expenditures were overstated by $2,126,306. Cumulative expenditures were understated by $1,573,349. Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number and Email Address: 812-948-5333 and lmoeller@cityofnewalbany.com Views of Responsible Officials and Explanation and Reasons for Disagreement:  We concur with the finding.  However, the issue and non-compliance deals with the interpretation of the federal rules regarding the appropriate amounts to report and when to report them by subrecipients of the monies. INDIANA STATE BOARD OF ACCOUNTS 19 Office of the Controller  New Albany City Hall  142 E Main Street, Suite 314  New Albany, Indiana 47150 Telephone: 812-948-5333  www.cityofnewalbany.com City of New Albany, Indiana Linda Moeller City Controller  The non-compliance is not related to policies or controls not being effective to prevent, detect or correct errors. In fact, the reporting system initially implemented by the City and put in the federal reports provided the actual expenditures for those periods by recipients of the grants.  However, the City does agree that after full examination and review of the federal rules the initial full amount of funds provided to the subrecipients should have been reported in full versus the actual expenditures during the periods. Description of Corrective Action Plan:  Current period and cumulative expenditures reported will consist of the amounts advanced to subrecipients. Anticipated Completion Date:  The City has already made this correction in its most recent Quarterly Report April 1, 2024 to June 30, 2024.

Block Grants for Prevention and Treatment of Substance Abuse - Assistance Listing No. 93.959 Recommendation: We recommend the County conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the benefits from the expenditures were received). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Training on accrual basis of accounting is presented during year-end training. The Department will participate in trainings offered by the County regarding the accrual basis of accounting for expenditures and will ensure accruals are properly captured within the proper period. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor- Controller and Tarrah Shockley, Division Chief. Planned completion date for corrective action plan: June 30, 20

Block Grants for Community Mental Health Services - Assistance Listing No. 93.958 Recommendation: We recommend the County conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the benefits from the expenditures were received). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Training on accrual basis of accounting is presented during year-end training. As accruals are only recorded in the Financial Management System (FMS) on an annual basis department will have to manually accrue expenditures when charging other departments for costs incurred. The Aging and Adult Services Department will participate in trainings offered by the County regarding the accrual basis of accounting for expenditures and will ensure sure accruals are properly captured in the proper period when charging costs to BHRS. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor- Controller and Tarrah Shockley, Division Chief. Planned completion date for corrective action plan: June 30, 2024

FINDING: 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The P&E report was prepared by one employee without an oversight or review process in place to ensure accuracy. The report submitted was not mathematically accurate or complete. Per Resolution 2022-1028, approved on December 12, 2022, the City obligated funds for six separate projects totaling $2,257,927. However, the P&E report submitted on April 18, 2023 only included one project resulting in an understatement of total obligations of $1,807,927. Additionally for the one project submitted the key line items of “Current Period Expenditures”, “Total Cumulative Expenditures”, and “Current Period Obligations” as reported on the P&E report did not agree to the City’s financial ledger Contact Person Responsible for Corrective Action: Lynn M. Gorski, Clerk-Treasurer Contact Phone Number: 574-936-2124 Views of Responsible Official: We concur with the finding from SBOA. Description of Corrective Action Plan: There was very little training on how to enter information into the Treasury website for the 2022 year. When it was entered there was only one obligation in the amount of $68,609 even though Resolution No. 2022-1028 noted the intent on spend. Because of lack of training on entering the information it was understated. When the information was entered for the April 2024 report all obligations were entered. When the next report is processed, I will have another staff member verify what is entered prior to submission to the Treasury Department. Anticipated Completion Date: April 30, 2025 Lynn M. Gorski Title: Clerk-Treasurer Date: August 26, 2024

FINDING 2023-006 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – US 12 Stormwater Drainage Improvement Project – Reporting Summary of Finding: The Michigan City Sanitary District did not design or implement a system of internal controls that would have prevented the omission of required progress reports, and lack of oversight process. Contact Person Responsible for Corrective Action: Mary Lynn Wall 219-873-1404 Ext 2006 Contact Phone Number and Email Address: 219-873-1404 Ext 2006 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Sanitary District will review the federal grant requirements in order to ensure required reports are submitted in a timely manner. Reports will also be reviewed and documented by another employee prior to submission. Anticipated Completion Date: 08/26/2024

FINDING 2023-004 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – Body Camera - Reporting Summary of Finding: The City did not design or implement a system of internal controls that would have prevented the omission of required progress reports, and lack of oversight process. Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 Ext. 2006 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The City department responsible for federal grant reporting will review the grant requirements in order to ensure required reports are submitted in a timely manner. Reports will also be reviewed and documented by another employee prior to submission. Anticipated Completion Date: 08/26/2024

FINDING 2023-003 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – Body Camera – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: The City entered into a grant agreement on 03/03/2023 for the purchase of body cameras. The invoice for the body cameras was dated 10/28/2022, prior to approval from the state. The purchase was outside the period of performance. Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 Ext. 2006 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: In order for the City to insure that internal controls are in place to prevent noncompliance with federal awards, the City Controller’s office will review and discuss with department personnel, all federal grant applications to ensure compliance with allowable costs and period of performance. Anticipated Completion Date: 08/26/2024

Finding 2023-03 Expenditure of Funds Outside Contract Period Condition: Testing revealed that the Organization claimed expenditures against the grant that occurred before the official grant period. Although these expenditures were made outside the period of performance, they were submitted for reimbursement without securing prior authorization from the pass-through entity. Corrective Actions Taken or Planned: The Organizations’ Board and Executive Team consisting of the Chief Executive Officer (CEO) and the Chief Operating Officer (COO) and key Overdose Lifeline (ODL) Staff to include the independent bookkeeper and Grant and Finance Manager recognize the need to enhance internal controls and mechanisms to ensure purchase do not occur outside grant periods.

Views of Responsible Officials Responsible/Contact Official Paul Barenfus, CLO, and Sylvia Sanchez, CFO Management Response The ERP Grant is a very different grant from previous grants received by the Credit Union. Although management followed the instructions provided on the CDFI website, it was not clear that running the loan through the ERP track for eligibility was only one of several steps. After auditors noted that 4 loans were ineligible, management searched the website to find the second track that the loans had to be qualified through, the Majority-Minority Census. The team has not had to qualify loans like this in the past, and the additional third step for qualification was not understood. Management has since replaced the unqualified loans on the 2023 SEFA with eligible loans. Documented procedures for the ERP Grant have been completed and are being followed. Anticipated Completion Date This item is complete.

VSS has hired and is onboarding and participating with YPTC with a timeline of the remainder of the current fiscal year (FY24) and the beginning of next fiscal year (FY25). YPTC’s scope of work will include evaluating, updating, and training on new finance policies and procedures to include but not limited to reviewing period of performance requirements.

Boston Fire Department (BFD) incorporated and implemented proper control procedures around all grant related matter; including but not limited to programmatic reporting and oversight. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

FINDING 2023-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Kosciusko County Sheriff's Office applied for the Indiana Local Body Camera Grant (ILBC). The sheriff’s office was awarded this grant on January 1, 2023, with a grant cost amount of up to $31,920. This grant is a reimbursable grant through the Indiana Department of Homeland Security. The period of performance was from January 1, 2023, to December 31, 2023. The Kosciusko County Sheriff's Office ordered body-worn cameras and equipment on April 26, 2023. The invoice for the cameras and the camera equipment was paid on July 14, 2023. The Kosciusko County Sheriff's Office then submitted a Reimbursement Claim Form on September 11, 2023. The Reimbursement Claim Form shows the Sheriff's Office incorrectly requested the full $31,920. They received $31,920 from the Indiana Department of Homeland Security on September 27, 2023. However, the county had only spent $9,581 of the grant money towards the body camera purchase. Therefore, there is a remaining balance in the fund of $22,339 as of December 31, 2023. Due to the period of performance, the county should have reimbursed the Indiana Department of Homeland Security $22,339. On May 9, 2023, the Sheriff's Office grant administrator submitted a Program Report for the ILBC grant. This report was filed without an implemented internal control or evidence of a review. The report was completed and submitted by the Sheriff's Office grant administrator. The report incorrectly indicated that all expenditures had been completed. As of the date of the submission, the county had not purchased the bodyworn cameras and all federal funds had not been expended. Contact Person Responsible for Corrective Action: Alyssa Schmucker Contact Phone Number and Email Address: 574-372-2325 aschmucker@kosciusko.in.gov View of Responsible Officials: We concur with the findings identified. Description of Corrective Action Plan: The Kosciusko Sheriff’s Office, grant coordinator will contact IDHS for instruction on how to return the $22,339.00 and prepare a claim to be processed by the Kosciusko County Auditor’s office. The grant balances are submitted each month by departments these are checked and confirmed by the Auditor’s Office this one was overlooked in the review process. The person who applied for the grant no longer works for the county. It is believed the new person handling the grants was not aware that this grant even existed. The Grant Administrator(s) will have someone sign off on the grant report submissions and forward all reports to the Auditor’s Office. Anticipated Completion Date: It is anticipated that this will be completed as soon as the information to return the funds is received from the state and the claim is submitted to the Auditor for payment. This claim will be paid as soon as it is received. On or before 12/31/2024.

Finding 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County had not properly designated or implemented a system of internal controls, which would include appropriate segregation of duties that would likely be effective in preventing, or detecting and correcting, noncompliance. A single employee prepared and submitted reports without a documented review or oversight process in place to prevent or detect and correct errors. The County submitted three P&E reports during the audit period. No report was submitted for the period of October 1, 2022 to December 31, 2022 although there was activity during this time period. For the three reports submitted, all activity for the reporting period was not included and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We are putting Internal Controls in place specific to the Covid-19 Coronavirus State and Local Fiscal Recovery Funds grant. We will put a checklist together when it is submitted by other departments with a review and approval process for the disbursement by the governing body before the claim can be processed. Anticipated Completion Date: October 2024