Corrective Action Plans

U.S. Department of Education Education Innovation and Research CFDA #84.411C Finding Summary: A complete system of internal controls requires all expenditures to be properly approved and supported by appropriate documentation. In addition, all expenditures charged to the federal programs are required to be allowable costs under the program and allocated in accordance with CFA’s cost allocation plan. Responsible Individuals: Lona Teague, Jessi Black, All Staff Corrective Action Plan: Staff will ensure that all expenditures are supported by appropriate documentation and allowable under the program it is allocated to. The finance department will ensure all expenditures are properly approved before payment. Anticipated Completion Date: 06/30/2024

Community Service Block Grant– Assistance Listing No. 93.569 During our testing of costs recorded during the beginning of the approved period of performance (January 2022), we noted there were two transactions charged to the federal program in January 2022 for utility costs. Based on the review of the supporting invoices costs were incurred prior to the beginning of the performance period in November and December 2021. The total amount of the transactions was $1,370.49. Recommendation: The organization should work with the federal agency to provide additional documentation or justification for the expenses, or to adjust the budget or funding limits to ensure that all expenses are within the approved period of performance. It is important to address any period of performance findings as soon as possible to avoid potential penalties or repayment obligations. The Organization should also review its process of entering invoices into the accounting software to ensure the correct period is used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Upon discovery of costs incurred prior to the approved performance period. The first step involves meticulously examining the documentation to verify the timing of the expenses and identify any ineligible costs. Following this, the organization will transparently communicate the issue with the funding agency, providing a detailed explanation of how the error occurred and expressing commitment to resolving it. Guidance will be sought from the funding agency on the appropriate steps to take, with a focus on reconciling the total amount of costs incurred before the performance period and adjusting the grant budget accordingly to exclude these expenses. If any funds were already disbursed for the ineligible costs, efforts will be made to reimburse the funding agency or adjust future disbursements as necessary. To prevent similar issues in the future, internal controls will be reviewed and strengthened, including implementing stricter procedures for expense approval and providing training to staff involved in grant management. Detailed documentation of all corrective actions taken will be maintained, and continuous monitoring of expenses and adherence to grant requirements will be conducted throughout the remainder of the performance period to mitigate any potential compliance risks. Through diligent implementation of this corrective action plan, the organization aims to address the issue effectively and prevent funds from being required to be returned to the funding agency. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2024.

Finding Number: 2022-001 Planned Corrective Action: This finding was expected, as it is a continuation of the same finding as the prior year in 2021. The 2022 year was already well underway before the issue was initially identified following the 2021 year. EGCC has determined the root cause of the issue. For unknown reasons, and without directive to do so, EGCC’s previous Registrar (who is no longer employed by EGCC) stopped producing enrollment updates for NSLDS. Our current Registrar is working with The National Clearinghouse to update historical records for students who previously attended or are currently attending EGCC. As of June 2023, records up to and including the Fall 2021 semester have been updated, and updates for the Spring 2022 semester are in progress. EGCC expects to be current with enrollment updating by August 2023. Anticipated Completion Date: 08/31/2023 Responsible Contact Person: Ken Rupert – Registrar

FINDING 2022-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, other matters. 2022 Q4 P&E report failed to include a $1,500,000 expenditure. Recommendation is that management of County design and implement a proper system of internal control including policies and procedures to ensure that the County provides Treasury with complete and accurate information for the P&E report. Contact Person Responsible for Corrective Action: Adam Gadberry Contact Phone Number and Email Address: 317.346.4392 agadberry@co.johnson.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The $1,500,000 expenditure for road repairs was one of two tranches for road repairs. The first tranche was in the proper location of -122 while the second tranche was placed in location -201 and as a result the expenditure was inadvertently missed. The County became aware of the issue and included this expenditure on the subsequent P&E Report for Q2. Moving forward as programs are added, the location of those funds should be in location -122. When they must be in a different location, access will be given to the Board of Commissioners Executive/Administrative Assistant to track expenditures. Anticipated Completion Date: June 30, 2024

The district did not have clear guidance and was unsure of how entries shoiuld be made. This was a process that had not been done before. Request was made prior to Mississippi Department of Education guidance and before the MCAPS update was available. Entry correction ahs been made and district will update policy to verify correct entries.

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-006 – Period of Performance – Significant Deficiency Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all expenses include supporting documentation/invoice indicating period of performance. Grantee Response and Corrective Action Plan 2022-006: The Center for Black Women's Wellness has proactively updated our credit card policy in 2022. The CEO reviews the credit card statement monthly for discrepancies and allowable costs. Additionally, credit card holders are responsible for reviewing their credit card statements monthly for discrepancies and allowable costs. This measure aligns with our broader fiscal management improvements, which also involve the engagement of a Contractual CFO in April 2024 to oversee and refine our financial operations. These initiatives are part of our commitment to maintaining rigorous financial integrity and ensuring that all transactions are transparent and compliant with regulatory requirements. Additionally, we have resolved past documentation issues, such as those arising from the abrupt departure of an employee, by implementing robust procedures to avoid similar incidents in the future. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

FINDING 2022-001 Contact Person Responsible for Corrective Action: Terri Gadd, Clerk-Treasurer Contact Phone Number: (765) 364-5150 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Starting with the 2023 reporting of State and Local Fiscal Recovery Funds (SLFRF) Compliance Reporting to U.S. Treasury: The City of Crawfordsville management will follow the following process. 1. Before processing request from designated organizations the Clerk Treasurer and Mayor or a designated person, will review documentation and approve for payment/claim processing. 2. After approval a claim will be submitted to the Clerk Treasurer office for payment. 3. Clerk Treasurer will prepare and submit monthly expenditure report to the Mayor or designated person. 4. Annually before the Clerk Treasurer, reports to the U.S. Treasury expenditures the Clerk Treasurer and Mayor, or designated person, will review and confirm expenditures. 5. Clerk Treasurer will submit report to U.S. Treasury following prompts. 6. Clerk Treasurer will notify Mayor of the annual report submission. Anticipated Completion Date: January 2024

Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing payroll expenditures. The organization will significantly increase the practice of capturing payroll expenses in the appropriate period and within the appropriate grant period to report grant expenses for reimbursement. Completed before January 2024.

At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to handle new responsibilities for the first time in a new remote setting, as the Organization worked diligently to continue operations. Since many of the shows were being cancelled or modified from their traditional format, smaller projects related to design buildout, maintenance, and advertising were taken on. Many of these projects involved smaller retail purchases for which documentation was not properly retained. The Organization acknowledges the findings and has since hired a new CFO and instituted policies and procedures surrounding documentation of all cash disbursements and expenditures of federal awards.

Finding 2022-003 Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027 COVID – 19 Coronavirus State and Local Fiscal Recovery Funds. Pass-Through Award Numbers: Good Shepherd, pass-through Gregg County: SKM_C55822012711390 Trinity Mother Frances, Pass-through Smith County: Not available Santa Rosa, Pass-through the City of San Marcos: Not available Award Period of Performance: Good Shepherd, pass-through Gregg County, September 1, 2021 – November 30, 2021 Trinity Mother Frances, Pass-through Smith County, October 1, 2021 – November 30, 2021 Santa Rosa, Pass-through the City of San Marcos, March 03, 2021 through December 31, 2026 Corrective Action Planned: Management concurs with the finding and is in the process of performing a full audit of all expenditures reported to the respective pass-through agency. Upon completion of that review, we will seek guidance from the respective pass-through agency as to the appropriate corrective action. Responsible party: Lee Sonne, Vice President of Finance and Controller, jointly with the Melissa Crenwelge-Nedbalek Accounting Director responsible for Grant Reporting Implementation Date: Full audit of reported expenditures has begun in each ministry. Ultimate resolution is dependent on timing and results of meetings with the respective pass-thru agencies, but we expect to have procedures completed by June 30, 2024 to request the meeting with the pass-thru agencies.

Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

The School System concurs with the auditor’s findings and recommendations. 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.

2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who is knowledgeable of the period of performance is reviewing and approving all transactions prior to payment. Action Taken: For each accounting procedure, internal controls have been put in place. The Board’s payroll processing goes through three levels of approval before it is processed. The expenditures process goes through three levels of approval before the bill is paid. The Board is verifying that each report or process is approved by at least three levels of approval and within a timely manner. Expenditure checks are issued every two weeks. The approval of these checks is also approved by an officer of the Board of Directors. Any out of the ordinary practices have both the approval of the Executive Director and an officer of the Board of Directors. With the past issues of this Board, the Board added an internal control for the sake of period of performance, for reports that are submitted to Workforce WV. In addition, these reports will be reviewed and approved by one of the managers of the Board within the time the report is due.

Weinberg staff assigned to grant will review program definitions and attend webinars to ensure complete understanding and compliance.

Community Partners acknowledges that while performance reports were maintained for internal Community Partners grants, prior practice did not ensure that performance reports for fiscally sponsored programs were maintained by Community Partners. Current management will ensure that Community Partners maintains records to illustrate all required reporting is completed per funder requirements. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expenditures will be fully supported and approved by staff before posting. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

Item: 2022-002 Assistance Listing Number: 93.498 Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services Award Year: Period 2 Funds – Period of Availability January 1, 2020 – December 31, 2021 Compliance Requirement: Reporting Criteria or Specific Requirement: Management is responsible for reporting complete and accurate usage of Provider Relief Funds to the Health Resources & Services Administrator (“HRSA”) for each applicable period. Condition: Certain unreimbursed expenditures, totaling $479,490, reported by management as qualified expenditures for Period 2 within the HRSA Reporting Portal were improperly reported as all being incurred in Q3 of 2020 when in fact a portion of the expenses we incurred through and should have been reported in Q1 2020, Q2 2020, Q4 2020, Q1, 2021, Q2, 2021, Q3 2021 and Q4, 2021. However, we noted that all qualified expenditures were still incurred within the proper period of performance. Additionally, management did not retain proper documentation of the review and approval of the reporting submitted to HRSA. Name of Contact Person: Janae Ben-Shabat, CFO Phone Number: 480-516-3116 Anticipated Completion Date: March 31, 2024 Views of Responsible Officials and Corrective Actions: Touchstone Behavioral Health d/b/a Touchstone Health Services will implement controls to ensure the proper review and approval of federal award reporting to the federal awarding and to ensure the reporting is accurate. Additionally, management will implement a review control such that an individual outside of the preparer reviews the federal award reporting.

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

Views of Responsible Officials and Planned Corrective Actions: 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.

Management agrees with the finding. The necessary written documentation to comply with the Uniform Guidance will be prepared by December 31, 2024.

Management agrees with the finding and has established procedures to provide timely support for identify eligible loans deployed in the TM. Reports tracking these loans will be reconciled to the total financial products closed reported on future Annual Performance Reports.

Finding 2022-003 During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the new financial system, we believe adequate controls have been established and are working properly to ensure compliance with federal and program regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: May 2023

2022-004 - Year Ended December 31, 2022 Department of Health and Human Services CFDA #93.829 Section 223 Demonstration Programs to Improve Community Health Services (CCBHC) Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance Finding Summa,y: - Rimrock Foundation's final expenditures identified as eligible and claimed under the federal program were reviewed and approved by separate individuals outside of the preparer. However, the reports submitted for reimbursement had no evidence of review and approval by a separate individual outside of the preparer. Rimrock Foundation's statistical reports submitted under the federal program also had no evidence of review and approval by a separate individual outside of the preparer. Responsible Individuals: Jeffrey Keller, CEO and Shirley Ehlang, Lead Financial Accountant Corrective Action Plan: Rimrock will have the statistical reports prepared by the Grant Financial Specialist and reviewed by the Lead Financial Account. The payment will be requested by the Lead Financial Accountant and the CFO or CEO will review the entire packet of documentation. Completion Date: December 2022

Finding 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that funds are disbursed for incurred expenditures prior to reimbursement requests. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

Finding 2022-003: Costs Incurred Outside Period of Performance (Significant Deficiency over Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that the costs incurred are appropriately charged based on the contracts’ performance periods. Anticipated Completion Date: by March 31, 2024 Responsible Person: Ann Metzger, Vice President Finance