Corrective Action Plans

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure group care facility employees had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department partially concurs with the finding. The Department is committed to ensuring the health, safety, and well-being of all children in our care. As stated in the Effect of Condition on the audit finding, the auditors found all group care facility staff sampled during the audit had a cleared background check prior to working in the facility. While the Department agrees the use of definitions such as ?effective date? and ?start date? in FamLink could be misleading, the Department does not concur internal controls were not adequate to ensure group care facility employees had cleared background checks before having unsupervised access to children. The Department is confident that all staff who work with children and youth have cleared background checks. Effective April 1, 2023, the Department implemented a new process for processing background checks for group care facilities to strengthen internal controls, documentation, and clarification on the ?effective date.? The updated process is outlined below: ? A new form was created with clear instructions for the group care facilities to provide the applicant/employee information, including the background check confirmation code, directly to the Department?s Background Check Unit (BCU). ? The BCU works with the applicant/employee through the fingerprint background check process. ? The results are sent directly to the BCU at which time they complete a child abuse/neglect history check and, if needed, a suitability assessment. The BCU documents the results in FamLink with the date the background check is completed. ? The BCU emails the results to the group care facility and the Department?s Licensing Division (LD) group. If the applicant/employee is cleared and is not a renewal, LD staff adds the applicant/employee to the group care facility in FamLink with the clearance information attached. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements to ensure staff properly considered the income information obtained from data matching when determining client eligibility and benefits for the Temporary Assistance for Needy Families program. Questioned Costs: Assistance Listing # 93.558 Amount $0 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department has established processes in place to ensure income information is properly considered during client eligibility and benefits determination for the Temporary Assistance for Needy Families (TANF) Program. During eligibility determination at application intake, the eligibility worker: ? Interviews the client to determine income. ? Compares client reported information and cross matches against the Income Eligibility and Verification System (IEVS) per the Code of Federal Regulations (CFR). ? Resolves discrepancies for all new or previously unverified information received. ? Uses the information to determine if the client income is below the maximum earned income limits for TANF per WAC 388-478-0035. ? Verifies all circumstances as required in WAC 388-490-0005 and follows requirements when discrepancies exist, which include taking appropriate actions if the information is questionable, confusing, or outdated. The Department utilizes Spider, which is a tool that combines several different data matches including IEVS. In addition, the Department uses templates to appropriately and comprehensively document the eligibility determination to ensure consistency, accuracy, and that lean processes are followed. ? The Earned Income Template o Addresses income received within 30 days of the application date and any discrepancies found between the case record, online verification systems, previously projected income, and income type. o Does not require documentation if there is no income reported and when no discrepancy is found in cross matches. ? The Final Narrative Template o Includes completing check boxes to document types of cross matches reviewed during application intake and a summary of the transactions that occurred. In all seven exceptions identified by the auditors, the client?s situation did not require the eligibility workers to use the Earned Income Templates due to: ? No income reported. ? No income found in IEVS and other cross matches. ? No discrepancies. ? No changes within 30 days. The eligibility workers did create documentation using the Final Narrative Template for all seven cases with notation stating: ?Reviewed the following system(s): Spider.? All these actions were consistent and aligned with the Department?s "Standard Remarks and Narrative Documentation? procedures. Alerts are not generated for all income fluctuations but as appropriate when a review and potential action is required. This is to minimize creating unnecessary alerts which would take staff time away from other required and mission-critical actions. The Department asserts that the system is working as designed, which is evidenced by the fact that the Department accurately determined eligibility in all seven cases identified as exceptions by the auditors. The Department will continue to: ? Review IEVS information at application intake and verify and document any discrepancies between what is reported by the household and what is shown in the cross matches. ? Use templates to ensure documentation supports the eligibility decisions. ? Generate alerts when an applicant is budgeted with zero income, but the IEVS data match shows income. ? Use the final narrative documentation template, that includes check boxes, to notate cross matches reviewed during application intake. Completion Date: Not applicable Agency Contact: Rick Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

2022-003 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: The County should enhance its procedures and internal controls regarding preparation of the Project and Expenditure Reports to ensure that information reported is accurate and agrees to supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : New Castle County self-reported the variances in expenditures and obligations due to accruals of costs to previously reported quarters. Such variances can be common with just-in-time reporting. Regarding the omitted projects, the Reporting Portal has undergone several updates throughout the period of performance. These updates contributed to confusion in required data for projects. The omitted projects were included in the subsequent reports after the data points were known and tracked. Regarding the reporting of project obligations, Treasury?s definition of obligation is very broad and FAQ 13.17 allows the recipient to use its discretion to determine when an obligation is incurred. Such discretion calls for the interpretation of several source documents. In each report total obligations were not less than total expenditures nor did total obligations exceed available funding. Name(s) of the contact person(s) responsible for corrective action: Benjamin Morris-Levenson Planned completion date for corrective action plan: June 30, 2023

The Office of Vice President of Research and the Controller?s Office worked with the University?s Workday Finance team to configure its accounting system with an automated control that prevents general (nonpayroll) expenditures from being charged to the grant after the period of performance end date, one root cause of cost transfers. In addition, for payroll expenditures, the above teams updated grant labor costing allocations in its accounting system to contain an end date that coincides with the period of performance end date which restricts labor costs from being charged after the period of performance. The post award specialists will begin reviewing the labor costing allocations on a periodic basis. Also implemented in fiscal year 2023, before each payroll is processed by the Director of Payroll within the accounting system, grants that have ended are identified by the Assistant Controller and Director of Sponsored Program Accounting and the payroll expenditures are removed from the feed and not charged to the grant. The University has also hired individuals whose sole responsibility is to review general (non-payroll) expenditures charged to grants. Further, the University?s post award specialists are continually trained on the importance of allowed and unallowed expenditures and are now reviewing grant level budget versus actual reporting on a periodic basis to identify noncompliance. Tara Thomason, Controller and Assistance Vice President, is responsible for addressing the above items by December 2023.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Sue Pitts Contact Phone Number: 812-268-6077 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will implement a system of internal controls related to the preparation and submission of the Project and Expenditure (P&E) Reports. The Clerk-Treasurer will prepare the reports to be reviewed by the Deputy Clerk-Treasurer, prior to submission, to ensure that all projects, sections, and key line items are complete and supported by the ledger. Starting in 2024, the reports will be submitted by the April 30th deadline. Anticipated Completion Date: January 2024

FINDING 2022-002 Contact Person Responsible for Corrective Action: Valeriano F. Gomez / City Controller Contact Phone Number: 219-391-8300 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Additional Internal controls to address Finding 2022-002: A.- 1. East Chicago SLFRF reporting personnel, will be expanded to include a review of Quarterly Project and Expenditure Reports by a city senior accountant. 2. All personnel will jointly review Quarterly Project & Expenditure Report when completed, before proceeding to submission in portal. 3. Review by city personnel of previous Quarterly Reports to include the initial Interim Report (SLT-4798, 8-31-21) to address issues. 4. To address possible error in reporting tier will e-mail Treasury (SLFRF@treasury.qov.) for guidance and direction. Per Project and Expenditure Report User Guide April 1, 2023. B.- 2. East Chicago SLFRF reporting personnel will include the project ledger to future SLFRF Compliance Quarter Reports to ensure accurate reporting within the proper timeline / period. Note: In addition, with further discussion, we will continue to work on finding other proposals to improve internal controls issues related to Finding 2022-002. Anticipated Completion Date: Corrective actions should be in place for next SLFRF Quarterly Report (2nd Qtr. 2023).

FINDING 2022-005 Julia Reeves Auditor Contact Person 812-988-5485 Contact Phone Number: Views of Responsible Official: I agree with the findings as they are listed. Description of Corrective Action Plan: The Auditors office will have a member of the subrecipient review and sign off and date that the invoice was approved with allowable service, prior to coming to the auditor?s office for payment. Anticipated Completion Date: December 31, 2023

FINDING 2022-004 Julia Reeves Auditor Contact Person 812-988-5485 Contact Phone Number: Views of Responsible Official: I agree with the findings as they are listed. Description of Corrective Action Plan: Auditor?s office will Generate a report with a date range and keep the report on file for verification to confirm report. The Auditor?s office will verify report before submission. Anticipated Completion Date: December 31, 2023

Finding No. 2022-003 ? R2T4 Return Calculation Errors Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: For returns of Title IV Funding when a student does not complete the enrollment period for which funds were disbursed, the amount of earned Title IV grant or loan assistance is calculated by determining the percentage of Title IV grant or loan assistance that has been earned by the student and applying that percentage to the total amount of Title IV grant or loan assistance that was or could have been disbursed to the student for the payment period or period of enrollment as of the student's withdrawal date. Standard term-based institutions must always use the payment period as the basis for the determination. The unearned amount of Title IV assistance to be returned is calculated by subtracting the amount of Title IV assistance earned by the student from the amount of Title IV aid that was disbursed to the student as of the date of the institution's determination that the student withdrew (34 CFR 668.22(e)). Condition / Context: The auditor selected 21 unenrolled students who had Title IV returns for testing. For each student selected, the return amount was incorrectly calculated because the payment period was not used as the basis for the determination. Our sample was statistically valid. Cause: Unauthorized break periods and start dates were used to determine the base period for calculation. MATC's review process was not effective to detect and correct this error. Staff responsible for calculating R2T4 returns were not properly trained in the requirements. Questioned Costs: $5,097 Effect: MATC has determined that a total of 425 returns were incorrectly calculated, with an estimated net error of $5,097. Recommendation: We recommend MATC re-evaluate its review process for Title IV returns, and provide additional training for management and staff to ensure the calculations and compliance requirements are understood and that control processes are operating effectively to ensure proper returns. District Response: MATC agrees with the finding and has developed, documented and implemented a process and correct the student record errors, provide updated training and update R2T4 procedures to ensure proper calculation going forward. Al Pinckney, Executive Director of Financial Aid 12/6/2022

U.S. Department of Education 2022-004 Special Education Cluster ? Assistance Listing No. 84.027 and 84.173 Recommendation: The Board should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Fiscal Services will improve internal controls over the procedures that ensure expenditures to a program are incurred within an award?s allowable period of performance. During the year-end close out process, the Lead Restricted Funds Accountant will review the close out of all restricted funds against the grant periods. If expenditures are inadvertently incurred outside of the grant period, the expenditures will be reclassified to an existing like grant if allowable or to the operating budget. If the Lead Restricted Funds Accountant is unavailable or has closed out grants themselves, this review will be done by the Budget Manager. The school district will implement a new financial system in July 2023. The implementation of this new system will allow for more automated internal controls. Name(s) of the contact person(s) responsible for corrective action: Rosa Aquino and/or Sherri Fisher-Davis Planned completion date for corrective action plan: December 31, 2022

Finding Number: 2022-001 . 1655 Old Leona rd Avenue Columbus, OH 43219 Main 614 559 0115 Condition: The Organization failed to submit the financial statement audit report by its due date of December 31, 2022. Planned Corrective Action: The December 31, 2022 due date fell on a Saturday, so the assumption was made that the official due date was the next business day, January 2, 2023. Upon learning of noncompliance on January 1, the Organization submitted the requested report on Sunday, January 1, 2023. The VP of Development and Chief Financial Officer and their departments are now aware that the due date for reporting is the actual due date and will ensure all reports are submitted by the due date. Contact Person Responsible for Corrective Action: Maureen Thomas and Anna Parlet Completion Date: January 1, 2023

Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID 19 HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund Management agrees with this finding and performed a review of claims submitted to the HRSA COVID 19 Uninsured Program identifying payments for ineligible services and refunded the entire overpayment amount. In March 2022, HRSA announced the discontinuance of the HRSA COVID 19 Uninsured Program, and therefore, remediation of internal controls is no longer applicable. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.

Corrective Action: The Grants Accounting team has internally enforced a two-way check on all claims. Claims are reviewed by peer first, then either a Supervisor or Manager of Grants accounting. This two-way review of all claims will ensure that claims are made for invoices during the period of performance. Grants Accountants are also being required to take Financial Management courses online yearly to remain fiscally responsible in their positions. A part of being fiscally responsible is knowing Periods of Performances for grants. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: January 2024

Corrective Action: Management will update written procedures and train the Grants Accounting team regarding period of performance to ensure all requests are made within the proper period based on the period of performance. The procedures and training will include grant period close, cost allowability, requirements for documentation, and review of charges prior to requests. In addition, Grants Accounting has initiated monthly meetings with Government Agencies to closely monitor grant spenddown, address any processing issues, and ensure proper cut-off. These meetings will be instrumental in tracking progress and oversight in our grant management process. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: January 2024

Recommendation: We recommend the Organization implement a process to evaluate if expenses are eligible for reimbursement during the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As mentioned above with the implementation of our new accounting software in March 2023, it allows for expenses and payments to be allocated to each grant as intended and drawn down specifically to that grant. In doing this, it allows for constant and consistent tracking for live to date tracking and allows for revenue and expenses to be reviewed and reported at any point in time. In allowing for constant tracking of this information it allows us to send out monthly and/or quarterly invoices for reimbursement from our grantors. Name(s) of the contact person(s) responsible for corrective action: Sally Worley, Executive Director, Kasey Bunce, Finance Director, Chastity Schonhorst Finance Coordinator, Alisha Bower, Senior Operations Director, Sarah Carlson, Senior Program & Member Engagement Director, and Christine Zrostlik, Marketing & Communications Director. Planned completion date for corrective action plan: This has already been implemented as of March, 2023.

Findings and Questioned Costs Relating to Federal Awards: Insufficient Controls Related to the Application of Indirect Costs Rates Management will enhance procedures related to indirect costs rates matters, including accounting and review process. A Standard Operating Procedure will be developed to address key tasks, responsible parties, and oversight activities. Management expects this SOP to be completed and implemented on or before June 2024.

Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish the recommended control procedure. The Use of Award report was corrected during the course of the audit.

The Corrective action plan will be to follow the period of performance going forward in order to not have this reoccur again in the future. The County management will review all grant documents to make sure they are in Compliance with the requirements. Van Wert County adopted the Standard Allowance for revenue loss up to $10 million for the ARPA funds. Lost revenue dates will be reviewed in the future to ensure supporting documents are also in Compliance with the grant requirements.

The Town of Clinton/School Department will follow grants closeout procedures, consequently, the district will monitor closely all grants spending throughout each grant cycle. For both state-administered and direct grants, regardless of the period of availability, the District must liquidate all obligations incurred under the award not later than 90 days after the end of the funding period unless an extension is authorized. These procedures have been updated in the Financial Procedures Manual (pages 226-230 under Section G - Timely Obligation of Funds)

U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s internal controls were not designed to properly ensure a review over program expenditures occurred that expenses being incurred and the basis for ultimate reimbursement were incurred within the grant award’s period of performance. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will implement controls that address whether expenses incurred have a basis for reimbursement and are incurred within the period of performance. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: March 2024

While our Human Resources Specialist position was filled in May 2021, we are still working to have sufficient HR and accounting staffing to meet our significant growth. Additional positions of Human Resources Manager and Controller will help reduce/eliminate these types of errors in the future.

CONDITION: The ROE did not submit or timely submit the required reports to the Illinois State Board of Education. PLAN: New ROE management is providing close oversight for the timely submission of grant expenditure and performance reports. The Regional Superintendent has created a shared calendar of submission due dates with the Business Manager and Program Directors. Reminders are sent out via email in advance of the due dates, and then management reviews the grant report submissions in IWAS for accuracy and completion before approving and submitting to ISBE. ANTICIPATED DATE OF COMPLETION: This plan was initiated during the new Regional Superintendent’s appointment to office in October 2022 and has been fully implemented since January 2023. CONTACT PERSON: Ms. Jill Reedy, Regional Superintendent

Recommendation: The Organization should follow its cash disbursements policy to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Action Taken: EWP has reviewed its current cash disbursement policy and re-implemented procedures to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Agency leadership staff have been reviewing allowable and unallowable costs to ensure accurate administration of awards. Responsible Person and Anticipated Completion Date: Executive Director, October 2023.

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Finding No.: 2022-006 Federal Agency: U.S. Department of Education AL Program: 84.181 Special Education – Grants for Infants and Families Area: Period of Performance Questioned Costs: $0 Views of Auditee and Corrective Actions: GDOE agrees with the finding. In GDOE’s Munis system, if the Human Resources (HR) pay records are not accurately updated, GDOE payroll will reflect dated pay tables until such time HR makes the appropriate updates based on the project leads request to update accounts to current grant year. GDOE corrected the improperly charged payroll expenditures to the proper grant year via the journal voucher process. Plan of action and completion date: The GDOE Business Office will perform a monthly review of all transactions to ensure charges are recorded in the appropriate grant year. Additionally, Grant Project Managers and Program Coordinators will timely communicate to the Human Resources and Business Office any changes to accounts charged for federally funded payroll expenditures. Plan to monitor and responsible officials: GDOE Comptroller (vacant), will assign an accountant to monitor the expenditures of federal grants and the corresponding periods of performance and liquidation periods. Grant Project Managers, Federal Compliance review team will be responsible for timely communicating any changes in grant year funding to HR.