Corrective Action Plans

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

The City’s Community Development Department is in the process of rewriting its Policies to include the CDBG-CV provisions. Those policies should be completed within the next couple of months.

Finding 2022-005: Activities Allowed, Allowable Costs, and Period of Performance – Material Weakness. Management Response: We are reviewing our internal controls (SOPs, Operational Manuals and Handbooks), including the document retention policy to assure retrieval. Interdepartmental review of the program contract and the Operations Manual will be held to assure understanding of allowable expenses. 1. Managerial training will be administered to assure Program expenditures are allowable. 2. Operations Manual is being updated to have a process that insures approval workflows for allowable costs. 3. Accounting Policies & Procedures Manual is being updated to improve internal controls & show clear process of compliance over expenditures.

Finding Reference Number: 2022-002 Federal Agency: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus Relief Fund ALN Number: 21.019 Responsible Official: County Commission Views of Responsible Individuals: We understand the importance of having adequate documentation for Federal Grant programs. We hired an outside agency to oversee the Coronavirus Relief Fund who did not provide us the adequate documentation needed. We did; however, provide email confirmations that the monies spent were reported to the Treasury. The County will handle all Federal Grant programs in the future to ensure that adequate documentation is maintained by the County.

(A) Colorado School of Mines will ensure appropriate reviews of expenditures occur to ensure they are within the period of performance for the federal award, and ensure that staff have an appropriate understanding of the related period of performance requirements or obtain clarification from the federal grantor, as appropriate. (B) Mines did not update published Procurement Policies specific to approval limits by position to accurately reflect the delegated approval authority. Mines will update the published policies to accurately reflect delegated approval limits and review the procurement approval process.

Finding 2022-03 Expenditure of Funds Outside Contract Period Condition: In the course of testing direct disbursements for adherence to appropriate cutoffs concerning the contract's period of performance, it was discovered that the Organization incurred a substantial amount of expenditures on contracts prior to the official contract start date. These disbursements took place without acquiring proper authorization for making disbursements prior to the contract's commencement. Despite the unique nature of Naloxone inventory being treated as a prepaid asset due to its delayed usage, the majority, if not all, of the Naloxone units were fully expended before the contract officially commenced. Corrective Actions Taken or Planned: The Organization?s Board and Executive Team consisting of the CEO and the COO acknowledge the finding of expending funds outside the contract period. This finding is connected to the purchase of the emergency medication naloxone. The Organization decided to purchase with no assurance of reimbursement in order to eliminate the lack of emergency medication in an overdose epidemic. The Organization had verbal approval but did not secure approval in writing. Numerous policies will be adopted in 2023 to ensure this does not occur again. Some of these policies include the transition to an experienced nonprofit bookkeeper, training for Finance and Grants Management and tracking mechanisms, monthly grants tracking meetings to ensure inventory and spending, and the adoption of a clear and documented approval process should spending, outside a contract period, be required.

Views of Responsible Officials and Planned Corrective Actions - Management recognizes the overall volume of transactions the Organization continues to grow each year and it being one of the reasons this is a repeat finding. The questioned costs were immaterial. While improvements were made during the year, the internal recordkeeping controls and protocols will continue to be reviewed with the new accounting service provider and improved measures implemented.

Finding 2022-001 - Schedule of Expenditures of Federal Awards United States Department of Education Pass Through Entity: Texas Education Agency Federal Program: American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) Assistance Listing Number: 84.425U Federal Award Number: S425U210042 Federal Award Year 2022 Repeat Comment: No Type of Finding: Material Weakness Condition: When reviewing the net assets released from restriction in the draft financial statements presented to the board, management determined and brought to the attention of the auditors the net assets restricted for pre-award costs for the ESSER federal program ($1,976,911) should have been released from restrictions during fiscal year ending June 30, 2022. The auditor, when tying the draft schedule of expenditures of federal awards to the updated schedules, determined the Organization had not included the pre-award federal expenditures related to the ESSER federal program. As a result, the initial testing of the ESSER major program did not include $1,976,991 in ESSER expenditures. When this was brought to management?s attention, the schedule of expenditures of federal awards was updated and the additional expenditures provided for testing. Cause: The additional $1,976,991 was related to ?pre-award? dollars awarded during fiscal year ended June 30, 2022, where allowable expenditures incurred in the previous year were permitted by the grant to be used for the ESSER funds awarded in the current year. Management was not aware of the requirement to include these amounts on the schedule of expenditures of federal awards. Recommendation: We recommend management of the Organization strengthen their internal controls to ensure all federal awards are included on the schedule of expenditures of federal awards. Corrective Action Plan: Prior to June 30, 2023, management will prepare an administrative procedure that requires the auditor to provide a draft financial and compliance report at least one (1) week prior to the meeting of the Board. In the procedure, management will require staff to reconcile the Schedule of Expenditures of Federal Awards to the Statement of Activities and other relevant accounting information to ensure the accuracy and completeness of the amounts disclosed. Person Responsible: Kevin Byrne, Vice President of Finance Anticipated Completion Date: June 30, 2023

COSA has already strengthened year-end and grant period ending procedures by conducting monthly reviews to identify any expenses and unpaid expenses that should be captured and submitted for reimbursement. These reviews are being conducted by the Finance Director and Executive Director.

Finding: 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: National Bioterrorism Hospital Preparedness Program Federal Financial Assistance Listing #93.889 Compliance Requirement: Activities Allowed and Allowable Costs, Period of Performance, Cash Management and Reporting Finding Summary: No independent secondary level of review or approval is performed relating to compliance. One employee is involved in preparing, reviewing and approving information. Additionally, Internal control procedures documented within Coalition?s Grant Management Policy have not been updated since departure of the Grant Management Director. Responsible Individuals: Greg Santa Maria, Executive Director Corrective Action Plan: The SDHCC has updated its invoicing process to include an internal review of all invoices prior to submission for reimbursement by the state. Per the new process, the executive director reviews, prepares and completes the initial invoicing process. Once complete, the invoice is forwarded to the SDHCC treasurer for final review and approval prior to final submission to SD DOH. The review process is formally documented by treasurer signature on face document prior to submission to DOH. Grant management policy is currently in revision. Anticipated Completion Date: For Invoicing Process, practice was changed to reflect final review by SDHCC treasurer on January 10, 2023, beginning with BP4 Invoice number 227. Projected Grant Management policy revision first draft to Board is Friday April 7, 2023.

Federal Program Name: ? Block Grants for Community Mental Health Services ? ALN 93.243 ? Section 223 Demonstration Programs to Improve Community Mental Health Services ? ALN 93.958 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. Management?s response: Management concurs with the audit finding. As the previous process for grant salary, fringe, and indirect billings was based on salary paid date this resulted in expenses on certain grants being allocated prior to the period of performance. While this was at least in part offset by eligible grant expenses not being billed at the end of the grant period, it was not in compliance with 2 CFR 200.1 for period of performance. The CFO, supported by the Controller and Grants Manager, will immediately update the controls and grants billing processes to be based on incurred date rather than paid date. 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 2023.

Department of Treasury 2022-001 Coronavirus State and Local Fiscal Recovery Fund? Assistance Listing No. 21.027 Recommendation: The Office of Management and Budget (OMB) Compliance requires that funds granted through the COVID-19 Coronavirus State and Local Fiscal Recovery Fund may only be used to cover costs incurred during the period beginning on March 3, 2021 and ending on December 31, 2024. We recommend the County select a designated individual to perform a secondary review of program costs to certify claimed expenses have met all compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The covered costs were corrected and provided to the auditors. A designated individual will perform a secondary review before claimed expenses are submitted to ensure compliance in the future. Name(s) of the contact person(s) responsible for corrective action: Tanya Cannady Planned completion date for corrective action plan: N/A

Finding # 2022-003 Title of Finding Allowable Costs/Costs Principles Contact Person Julia Gump Anticipated Completion Date June 30, 2023 Corrective Action planned to be taken: Management will review regulations and implement controls to prevent noncompliance to grant agreements.

2022-001 Special Education Cluster ? CFDA No. 84.027 and 84.173 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: None. Action taken in response to finding: The School district paid for goods/services after the performance period of the grant. All purchase orders and invoices for payment are reviewed by the Town Wide Budget director before posting or processing. This review is to ensure compliance with local, state and federal laws and regulations. Name(s) of the contact person(s) responsible for corrective action: David Ljungberg, Superintendent and Leia Secor, and Town Wide Budget Director Planned completion date for corrective action plan: Procedure currently in place.

Finding 2022-001: Reporting Recommendation: Nebraska Pediatric Practice should strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials: Management agrees with the finding. Although reported in the incorrect quarter, the Entity did incur expenses in excess of the amount of ARPA funds received. In addition, the Entity also suffered lost revenues in excess of the ARPA funds received. Management will refine its review process of HRSA guidance and data entry into the portal to ensure appropriate designation between reporting periods. Nebraska Pediatric Practice, Inc. Corrective Action Plan: Management inadvertently reported expenses in the incorrect quarter of the Period 4 report submission. Although reported incorrectly, reported expenses were still above the total ARPA payments received. For future reporting, management will reinforce the reporting of activities in the proper quarter prior to submission. Completion Date: Completed Contact Person: Mindy Stetson 402-955-6765

See Corrective Action Plan

Finding Number: 2022-012 Federal Program, Assistance Listing Number and Name: ALN 21.027, Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) Condition: Original Finding Description: The CSLFRF subrecipient agreements did not include the CSLFRF assistance Listing Number (ALN) as required per 2 CFR 200.332 (a)(1)(xii). Contact Person Responsible for Corrective Action: Sandra Yu Stahl and Terri Daniels Anticipated completion date: July 2023 Planned Corrective Action: The City has implemented a process to ensure that all subrecipient agreements contain the Federal ALN as required by 2 CFR 200.332. All subrecipient agreements will include a new exhibit as an attachment in the agreement that will include the ALN and any other required grant elements.

During the 2022 audit of PrairieStar Health Center, Inc. our auditors found two instances of the PRF calculation being calculated incorrectly. The two instances were 1) having miscellaneous revenue adjustments in the actual calculation but not in the budget section of the lost revenue calculation and 2) not being able to directly identify if the capital project was completed before the period of availability for period two which is December 31, 2021. This has resulted in a finding in the current year financial statements audit. Management has evaluated the finding and reviewed whether any funds need to be repaid and evaluated its controls around future provider relief reporting cycles. It has been determined that even with the two errors identified lost revenues would have been sufficient to obligate the entire award. Therefore, we have determined no repayment is necessary. If allowed in future provider relief reporting periods, PrairieStar will correct the misreporting. In addition, management will ensure adequate time to review the provider relief reporting prior to the submission deadline in order to catch these oversights. Shandi Stallman, Chief Financial Officer, is the party that has overall responsibility for this corrective action. The anticipated completion date is expected to be March 2023.

FINDING 2022-002 ? R2T4 Calculation Program Name: Federal Pell Grant ALN and Program Expenditures: 84.063 ($729,843) Award Number: P063P213629 Federal Award Year: July 1, 2021 to June 30, 2022 Questioned Costs: $1,988 Condition Found: The R2T4 calculation was completed incorrectly for three of the five students in our R2T4 testing sample. The Federal Pell Grant funds disbursed were not adjusted for module courses that the students did not begin. In addition, the incorrect semester start date was used for two of the three students. Corrective Action Plan: Management agrees with the auditors? finding and their recommendation. The Financial Aid Director recalculated the R2T4s for the students in question. The Financial Aid Director determined that $1,988 of Federal Pell Grant funds should be returned for these students. On September 12, 2022 these funds were returned to the Department of Education. The remaining R2T4 calculations completed by the College were reviewed and there were no additional errors. The Financial Aid Director has improved R2T4 calculation procedures to ensure that the Federal Pell Grant is adjusted for module courses that a student does not begin attendance in before completing the R2T4 calculation. Anticipated Completion Date: The corrective action was completed on September 12, 2022. Contact Person (for both findings): Brian Rains, Director of Financial Aid 417-268-6045

Views of Responsible Officials and Planned Corrective Actions: The County agrees with the recommendation and has discussed additional review procedures with the subrecipients. In addition, the County created a Grants Division with increased staffing that can help provide monitoring throughout the year.

Program: AL 93.575 ? Child Care and Development Block Grant ? Period of Performance Corrective Action Plan: DHHS has already taken steps to prevent this from occurring again with NSP. DHHS also worked with the Office of Child Care (OCC), after last year?s finding, and corrected both the 2021 and 2022 findings. The use of funds to pay agency employee payroll has already been corrected. DHHS will use allowable obligation and liquidation schedules when contracting with other state entities and paying state employees. Contact: Nicole Vint; Rebecca Kempkes Anticipated Completion Date: 12/12/2022

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review of wage rates for eight employees selected for testing. There was no formal documented review for the calculation of indirect costs submitted for reimbursement for four months selected for testing. There was no formal documented review for seven reimbursements requests selected for testing. Washburn Center has designed internal controls over these areas; however, the controls were not formally documented. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: Management will review the current active review process and implement a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: December 2023

View of Responsible Officials The Department does not concur. The Department notes extensions are in place related to COVID-19 and the Tydings Amendment through the Department of Education mitigating the condition noted. The Department will confer with the US DE to clarify the extensions in place and resolve any disparities identified within the finding. Anticipated Completion Date: Completed as of the date of this report Contact Person: Lindsey Labonville, Melissa White Rejoinder Based on the supporting documentation provided by the Department, it did not appear that the expenses identified within the condition found were charged to the correct period of performance during the liquidation period. Subsequently management adjusted the CAN the expenses related to which would correct the condition found.

Quarterly Reporting The State concurs in part with the condition and recommendation. A unique challenge with ERA reporting has been changes in the U.S. Treasury portal for that program, which have impacted the State?s ability to download and provide copies of past reports that have been submitted. In addition, this issue in the reporting portal has been inconsistent, as some previously submitted reports were made accessible by Treasury, while others were not, which resulted in the State being able to access some requisite materials but not others. The State did not have documented procedures to ?pull down? copies of reports it had submitted to Treasury because the State has otherwise been able to rely on access to its previously submitted reports within reporting portals in order to enable the testing required during audit for the relevant periods. Meaning, in the State?s experience with COVID-19 related federal funds reporting, it has been able to access and download past reports for purposes of audit. However, also noted above is that the Treasury portal was recently revised and updated to allow for accessing previously submitted ERA reports that were not otherwise available (the communication from Treasury acknowledging this change was provided by the State). However, the reporting portal change did not take place in time for the State?s auditors to reasonably conduct the necessary testing. The State did provide the data and materials it reported to Treasury for the relevant periods, but auditors were unable to test and validate that data because the State could not access and provide a copy of what was actually uploaded into the portal. Nevertheless, to avoid any such potential issues in the future, the State has already implemented a procedure that involves downloading copies of reports as soon as they are submitted and taking screenshots of portions of the portal where perceived necessary to support what the State has submitted to Treasury. This updated procedure will be memorialized in the program?s transaction processing memo during its next update. Monthly Reporting The State concurs in part but has already implemented related corrective action in line with the recommendation above. The State would also like to note that as part of the ERA reallocation process U.S. Treasury has relied on both quarterly and monthly reporting, and that the State has continued to engage in thorough monitoring of its subrecipient and receives regular reports from that subrecipient, including weekly, biweekly, and quarterly data, which also includes quality control reports. This is inclusive of the monthly reports that were required by U.S. Treasury at one time but no longer are. The State reviews and then discusses reports received at standing, calendared, weekly meetings with the subrecipient and often engages in e-mail correspondence concerning those reports, especially if any questions concerning the data provided arise. However, the State has acknowledged that its documentation of those weekly conversations needed to be more formally memorialized. During the current fiscal year, the State began providing agendas and summaries of topics discussed during the weekly check-ins and will ensure that the program?s transaction processing memo adequately documents this requirement and procedure. The very nature of this program and U.S. Treasury?s facilitation of it has required the State and its subrecipient to stay in close contact, make regular decisions on strategies and policies within the program, and closely consider data relative to it. Anticipated Completion Date Quarterly reporting - Corrective action relative to acquisition of submitted federal reports has already been implemented and this revised procedure will be memorialized in the transaction processing memo for the program during its next update in Q1 2023. Monthly Repotting - Corrective action relative to documentation of weekly meetings was already complete as of the State?s response to this finding, and the State will ensure that the transaction processing memo for the program reflects these measures during its next update in Q1 2023. Contact Person Chase Hagaman, Lisa Cota-Robles, and Emily Larson

Program: COVID-19 Education Stabilization Fund ALN 84.425F Higher Education Emergency Relief Fund ? Institutional Portion Compliance Requirement: Cash Management Criteria: Pursuant to 2022 Compliance Supplement ESF Section 2 III Cash Management, the College is required to disburse funds within three days of draw from G5. Condition: The College had approval from the Department of Education to transfer allowable activities to other expenditures that were applicable under the grant guidelines and replace debt forgiveness outside the period of performance. This caused cash management to become out of compliance with the three days to apply expenditures from the date of drawdown. Context: The College originally applied funds to debt forgiveness in which the parameters of the three days to apply funds did apply. The debt forgiveness was not approved by the Department of Education for items before March 13, 2020. The Department of Education gave written approval to the College to reclass invoices that were applicable under the grant guidelines. This produced the draws being over three days from drawdown for majority of the items. Cause: On September 23, 2022, the College was asked to contact the Department of Education for guidance on debt forgiveness or obtain a waiver. The College?s request for a waiver was denied on November 29, 2022. The Department of Education gave written approval to the College to apply invoices that are within the guidelines of the grant as grant expenditures instead of the original debt forgiveness. Transferring allowable activities resulted in noncompliance with the criteria of expending funds within three days of draw. Effect: The College could be asked to return funding if draws are viewed as out of compliance after the reclassification. Questioned Cost: None Repeat Finding: No Recommendation: The College needs to ensure they understand high-risk grant requirements by reviewing the compliance supplement, the Department of Education?s website and making contact with the Department on questions of concern. Views of Responsible Officials: The College requested a reclassification of expenditures for the grant year. The request was approved by the Department of Education. The College will request any clarification on items from the Department when in question to ensure they understand the requirements of the grant. No further action is required.