Corrective Action Plans

Required deposit of surplus cash in the amount of $5,966 into the residual receipts accounts will be made by January 31, 2024. Furthermore, internal controls over residual receipts funding are being strengthened to prevent future non-compliance.

Unauthorized withdrawal from the replacement reserve was corrected during the fiscal year. However, internal controls over replacement reserve withdrawals are being strengthened to prevent future non-compliance.

The underfunded replacement reserve deposit will be deposited into the replacement reserve account by January 31, 2024. Furthermore, internal controls over replacement reserve funding are being strengthened to prevent future non-compliance.

$103,000 to the Project during the fiscal year. Remaining $11,300 included in prepaid expenses will be refunded to the Project by January 31, 2024. Furthermore, internal controls over disbursement of project funds are being strengthened to prevent future non-compliance.

(a) Comments on Findings and Recommendations Management concurs with the finding and auditors’ recommendation enhance internal controls to ensure Project funds are only used for Project activities and expenses necessary for the ongoing operation and maintenance of the Project. (b) Action(s) Taken or Planned Management is aware of the requirements related to use of Project funds. Management refunded to the Project $190,000 on January 31, 2023 and $279,000 on December 20, 2023. Remaining $8,640 included in prepaid expenses will be refunded to the Project by January 31, 2024. Furthermore, internal controls over disbursement of project funds are being strengthened to prevent future non-compliance.

The bookkeeper has created spreadsheets for each grant to make sure each expense is supported by the grant, date, amount, and listed under the correct line in an effort to avoid any mistakes of documentation. See full Corrective Action Plan on district le

The bookkeeper has created spreadsheets for each grant to make sure each expense is supported by the grant, date, amount, and listed under the correct line in an effort to avoid any mistakes of documentation. See full Corrective Action Plan on district letterhead.

Identifying Number: 2023-003: U.S. Department of Education: Student Financial Aid Cluster – 84.268, Federal Direct Student Loans Finding: For one student out of 61 students tested, an incorrect amount of subsidized and unsubsidized loan was awarded. Corrective Action Taken or Planned: STC Financial Aid Office will request a list of Build Dakota students and estimated scholarship amounts at the beginning of the academic year. This information will be added into the student’s financial aid packaging formula to review for potential changes needed in federal aid awards. Once the Business Office has completed applying Build Dakota funds for the term, the information will be shared with the Financial Aid Office to make adjustments to the original estimates used. Contact person: Micah Hansen, Director of Financial Aid, Southeast Technical College Status of finding – The above corrective actions will be implemented beginning July 1, 2024.

The Department will work with the U.S. Department of Education to identify appropriate steps for resolution. In addition, Department leadership directed ESEA and federal grants management training for the Bureau of Federal Programs and all other relevant department staff, which will provided by the Council for Chief State Schools Officer’s Federal Education Group beginning in April of 2024.

Department of Health and Human Services Federal Financial Assistance Listing #10.331, 93.136, 93.243, 93.279, 93.310, 93.393, 93.837, 93.838, 93.865, and 93.898 Research and Development Cluster Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance and Noncompliance Finding Summary: Our testing over activities allowed and allowable costs identified one instance where an employee’s time was not properly allocated between two grants. Additionally, there were four instances where the grant was under/over-charged in our recalculation of payroll and fringe benefits. Responsible Individuals: Jamie Schaefer, John Neth Corrective Action Plan: The Organization will review and strengthen the controls surrounding activities allowed and allowable costs. $2,132.52 of questioned costs resulted from one instance where an employee’s time was not properly allocated between two grants through a submission of a personal action form. The Organization has revised its’ workflow surrounding submission of personal action forms related to grant time and related costs allowing for more control and visibility of amounts and grants being allocated to. ($6.26) of questioned costs resulted from four instances combined to an under allocation of employee benefits to a grant. The Organization is in the process of implementing a new enterprise resource planning software which will include a grant module. The grant module will have automated controls surrounding allocations of personnel costs. Anticipated Completion Date: October 1, 2024

Dear Mr. Waguespack, The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 25, 2024, regarding a reportable audit finding related to controls over waiver and support coordination service providers at the LDH. The LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Controls over Waiver and Support Coordination Service Providers Recommendation: LDH should ensure all departmental policies for waiver and support coordination services are enforced, including documentation to support claims and evidence that deviations from the approved POC meet the needs of the recipient. LDH should consider additional provider training regarding documentation requirements. LDH Response: LDH partially concurs with the finding and recommendation. LDH does not concur with the determination of inadequate controls over waiver and support coordination providers. LLA asserts inadequate documentation prohibits substantiating if deviations where person-centered and/or billed services were performed. A combination of factors and not documentation alone must be considered when determining whether billed services we performed or the services delivered are person¬-centered. A prioritization on documentation as assurance of services provided seem to disregard more effective, nationally recognized, and mandated assurance measures such as electronic visit verification (EVV), prior authorization, and post authorization. Assurance measures like those listed above gear more towards validating whether services were provided than documentation alone. For example, documentation such as progress notes is not intended to verify if a service was provided but summarize the beneficiary's day-to-day activities and demonstrates progress toward achieving his/her personal outcomes as identified in the approved plan of care (POC). Corrective Action Plan: LDH does concur with LLA's recommendation regarding policy enforcement measures and additional provider training. Given the high turnover due to the national direct support worker and support coordinator workforce crisis, as well as the end of COVID-19 public health emergency, we agree with the need for robust training and additional oversight/policy enforcement. Therefore, LDH will develop action steps to address the need for additional provider training and action steps to provide additional oversight policy enforcement. The anticipated completion date of all corrective action is March 30, 2024. You may contact Bernard Brown, Deputy Assistant Secretary, by telephone at 225-342- 8807 or by e-mail at bernard.brown@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 17, 2024 regarding a reportable audit finding related to Inadequate Controls Over and Noncompliance with National Correct Coding Initiative Requirements. LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Controls Over and Noncompliance with National Correct Coding Initiative Requirements Recommendation: LDH management should ensure all required NCCI edits are properly applied to FFS claims. LDH Response: LDH partially concurs with LLA's finding that it did not timely apply NCCI PTP edits for DME and OPH FFS claims for State Fiscal Year 2023. At the time of claim submissions (between July 1, 2022, through March 31, 2023) the current editing product ClaimsXten was not live and LDH utilized the previous editing system ClaimCheck, which was limited by system constraints. Due to this, NCCI edits for outpatient hospital (OPH) and durable medical equipment (DME) were not applied to claims until the implementation of ClaimsXten on March 31, 2023. On June 23, 2023, LDH ensured that the identified claims were recycled prior to the end of SFY '23 as a means of ensuring all required edits were appropriately applied to claims for the fiscal year. Upon completion of the recycle, LDH found that its vendor did not appropriately recoup payments that were associated with the identified claims. The recoupment of these claims took place in December 2023. Corrective Actions: LDH implemented the following steps for corrective action, which are summarized below: 1. Implemented ClaimsXten on March 31, 2023. ClaimsXten houses all of the Medicaid NCCI methodologies and removed previously experienced system constraints that were found within ClaimCheck allowing for full compliance. 2. LDH conducted a retroactive review of all FFS DME and OPH claims submitted from July 1, 2022, through March 31, 2023, in the new editing system. This review occurred on June 23, 2023 and allowed the application of all NCCI editing methodologies including durable medical equipment (DME) and outpatient hospital (OPH) Medically Unlikely Edits (MUE) to all Louisiana Medicaid Fee- for- Service (FFS) claims as applicable. 3. LDH ensured the recoupment of payments were made for claims submitted that should have denied between July 1, 2022, through March 31, 2023. The recoupment of these payments took place on December 28, 2023, making LDH fully compliant for SFY '23. 4. LDH will monitor system functionality by performing bi-weekly audits of claims with its fiscal intermediary to ensure compliance with the requirement that all NCCI edits are properly applied to FFS claims and immediately resolves issues when discovered. 5. LDH will follow its new written NCCI procedures. You may contact Kimberly Sullivan, Interim Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Brandon Bueche, Medicaid Section Chief at (225) 384-0460 or via email at Brandon.Bueche@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated December 21, 2023, regarding a reportable audit finding related to Noncompliance with and Inadequate Controls over Maternity Kick Payments. LDH appreciates the opportunity to provide this response to your office's findings. Finding: Noncompliance with and Inadequate Controls over Maternity Kick Payments Recommendation: LDH should strengthen existing policies and procedures to ensure the Medicaid Fiscal Intermediary is reviewing all maternity kick payments to ensure they are supported with a triggering event. When payments are identified that are no longer supported by satisfactory evidence, LDH should ensure the payments are recouped from the provider. LDH Response: LDH partially concurs with LLA's finding that it did not perform timely post-payment reviews of maternity kick payments, but disagrees on the number of unsupported kick payments. Louisiana is actively working on compliance with this requirement which is detailed in the corrective actions detailed below. Corrective Actions: LDH has restarted the kick payment review process previously established. Gainwell Technologies, the state's Fiscal Intermediary, completed a kick payment review and recovery in December 2023 and will perform quarterly kick payment reviews going forward. This quarterly review timeline has been added to Gainwell’s processing schedule to ensure that future reviews are completed timely. Marisa Naquin, Medicaid Program Manager 2, will be responsible for implementation of the corrective actions. Specific to the 110 kick payments identified in this finding as potentially unsupported, LDH's review determined that 35 of the identified 110 kick payments had a valid triggering event and should not be recovered. LDH recovered 71 Medicaid kick payments, valued at $874,096.35, and 4 CHIP kick payments, valued at $43,798.46, on the December 26, 2023 check write. You may contact Kimberly Sullivan, Interim Medicaid Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Marisa Naquin, Medicaid Program Manager 2 at (504) 408-1828 or via email at Marisa.Naguin@ la.gov with any questions about this matter.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 26, 2024 regarding a reportable audit finding related to inadequate internal controls over eligibility determinations. LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Internal Controls over Eligibility Determinations. Recommendation: LDH should ensure its employees follow procedure relating to eligibility determinations and redeterminations in the Medicaid and CHIP programs to ensure the case records support the eligibility decisions. LDH Response: LDH partially concurs with LLA's finding of inadequate controls over eligibility determinations. For the one noted Medicaid error of failing to discontinue coverage for a recipient who moved of out of state, LDH concurs. The LDH staff member who received the reported out of state address noted in the case record that coverage was already terminated and no further action was necessary when in fact it was not terminated at the time. For the one noted Medicaid error of not performing all required eligibility determinations before enrolling the recipient, LDH concurs. The eligibility determination system approved coverage for the recipient based on self-attestation of resources prior to checking the electronic data sources for verification. For the one noted Medicaid error of not perform all required eligibility determinations before transitioning the recipient, LDH concurs. In transitioning the recipient from a program without a resource test to one with a resource test based on a change in circumstance, LDH used existing resource information in the case record without requesting or checking for any new information. For the fourteen noted Medicaid errors of renewals not performed, LDH does not concur. When possible, LDH attempted to perform an ex parte renewal per federal guidelines. If an ex parte renewal could not be completed to extend benefits, a "standard" renewal is required which involves mailing a renewal form to the recipients to complete and return. During the public health emergency (PHE), LDH was operating under a March 25, 2020 CMS approved waiver for certain flexibilities in meeting the timeliness of Medicaid renewals. LDH used the flexibility to suspend processing of standard renewals. Audit staff were informed the noted cases would have needed a standard renewal and therefore not processed per the waiver. For the one noted CHIP error of not discontinuing coverage on a recipient that was invalidly enrolled prior to the start of the PHE, LDH does not concur. The recipient was validly enrolled. LDH staff did not timely act on a task to terminate coverage for this beneficiary prior to the beginning of the PHE in March 2020. Under the continuous eligibility provision of the FFCRA of 2020, a state could not terminate individuals from Medicaid if such individuals were enrolled in the program as of the date of the beginning of the emergency period, unless the individual voluntarily terminates eligibility or is no longer a resident of the state. No exceptions were noted for delays in taking negative action, therefore, out of an abundance of caution to not jeopardize the entirety of enhanced federal funding for keeping recipients enrolled during the PHE, LDH reinstated the coverage. For the one noted CHIP error for not discontinuing coverage on a recipient who became ineligible for a separate CHIP program, LDH concurs. The recipient was covered under the CHIP conception to birth option and coverage should have been terminated when her pregnancy terminated. She was inadvertently reinstated for coverage by the eligibility system. For the thirteen noted CHIP errors of not following policies and procedures regarding documentation of renewals, LDH does not concur. When possible, LDH attempted to perform an ex parte renewal per federal guidelines. If an ex parte renewal could not be completed to extend benefits, a "standard” renewal is required which involves mailing a renewal form to the recipients to complete and return. During the PHE, LDH was operating under a March 25, 2020 CMS approved waiver for certain flexibilities in meeting the timeliness of Medicaid renewals. LDH used the flexibility to suspend processing of standard renewals. Audit staff were informed the noted cases would have needed a standard renewal and therefore not processed per the waiver. As for the performance audit report issued in August 2023, the LDH formal response dated August 10, 2023 addressed the concerns that were noted at that time. Corrective Actions: 1. For the out of state finding in this audit and the August 2023 performance audit report, the LDH formal response dated August 10, 2023 addressed this issue. 2. LDH will make changes to the Medicaid eligibility system to ensure resources are re-verified when recipients transition from programs without a resource test to those that require a resource test. LDH has already implemented changes effective June 2023 to automate checking of electronic data sources for verification of resources as part of the recipient's annual renewal. 3. By the end of the PHE Unwind process, LDH will have completed a renewal and/or closed any separate CHIP cases that inadvertently remained open during the PHE and are no longer eligible for coverage. 4. LDH did adhere to regulations, guidance, and/or approved waivers in processing or suspending renewals and transitioning recipients to other coverage during the PHE. LDH continues to firmly believe the "case record" contemplated in CFR 435.912(f) includes all aspects of data repositories or system actions in the case, along with text fields in the case notes and the documents in the LDH document management system. In accordance with 42 CFR 433.112(b) and 45 CFR 164.312(b), LaMEDS logs system activity and enables the State to examine and document system actions. You may contact Kimberly Sullivan, Interim Medicaid Executive Director at (225) 219-7810 or via e-mail at Kimberly.Sullivan@la.gov or Rhett Decoteau, Medicaid Section Chief at (225) 342-9044 or via email at Rhett.Decoteau@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has reviewed the finding “Control Weakness over Social Services Block Grant Activities Allowed or Unallowed”. The finding noted that as of June 30, 2023, the Department of Children and Family Services (DCFS) did not have a formalized process in place to ensure Temporary Assistance for Needy Families (TANF) grant funds transferred to the Social Services Block Grant (SSBG) were only used for programs or services for children or their families whose income is less than 200 percent of the federal poverty level. DCFS continuously strives to improve processes and controls and concurs with the finding. In addition to developing written procedures to document the department’s process for ensuring expenditures related to TANF funds transferred to SSBG are used only for services related to children and families who meet TANF income requirements, DCFS will no longer utilize TANF transfer funds on salaries to caseworkers through its Public Assistance Cost Allocation Plan. The new procedures, which include monthly reports of TANF eligibility to support TANF transfers to SSBG, were implemented in October 2023, and system enhancements to Tracking Information Payment System (TIPS) is in progress. The expected date of completion is January 2024. The contact person for the Title IVE Foster Care program is Sharla Lewis-Thomas, Child Welfare Manager 2, and she can be reached at (318) 487-5437 or Sharla.Thomas.DCFS@LA.GOV.

Dear Mr. Waguespack, Below is the response by Central Louisiana Technical Community College to the audit finding for fiscal year 2022-2023. Finding: Inadequate Controls Over and Noncompliance with Higher Education Emergency Relief Fund Requirements Central Louisiana Technical Community College concurs with this finding. Corrective Action Plan: Finance inadvertently included the Oakdale campus activity in its lost revenue calculation. CLTCC does not anticipate any new Higher Education Emergency Relief Funds for lost revenue. At the direction of the federal government, Amanda Cain, CLTCC Vice Chancellor of Finance and Administration, will either return the funds or apply the funds to HEERF institutional expenditures within the open award period.

Dear Mr. Waguespack: The Division of Administration, Louisiana Office of Community Development (LOCD) is submitting the following in response to the audit finding titled "Restore Louisiana Homeowner Assistance Program Awards Identified for Grant Recovery." LOCD acknowledges the LLA finding of "Restore Homeowner awards identified for Grant Recovery." In response to the 2016 Floods, the LOCD created the Restore Louisiana Homeowner Assistance Program (HAP). Grant recapture procedures were established from the beginning of the program and have been implemented timely. It is impossible to administer a disaster recovery program that will not have certain files requiring grant recapture during the life of the program. The Restore Program requires a duplication of benefits check on all files prior to grant execution. For example, it is always possible an applicant may receive additional funding, e.g., insurance proceeds that are deemed duplicative by law. The Restore Program has controls in place to capture these amounts in the grants management system, subrogation agreements executed with each applicant, and recapture procedures to recover the funds. From the very beginning, the Restore Program was created to minimize the potential of applicants' ending up in recapture. As a result, the state has issued over $670 million to 17,262 homeowners of which 86, or 0.50% are in recapture. As the Restore Homeowner Program comes to a close, LOCD does not anticipate further files requiring recapture of funds. LOCD agrees with the observation of 10 files with a potential grant recapture as a necessary ongoing activity for the Program. LOCD will continue to follow the established recapture procedures for these grant awards to ensure ultimate compliance, however, this is not a corrective action, but rather the continued implementation of program protocols. The contact person responsible for these ongoing compliance activities is Ginger Moses, OCD Chief Operating Officer. The anticipated completion date for activities addressing this finding will coincide with the closing of the Restore Louisiana program. If you have questions or require additional information, please feel free to contact me.

Dear Mr. Waguespack : The Division of Administration, Louisiana Office of Community Development (OCD) submits the following in response to the audit finding titled "Inadequate Recovery of Small Rental Property Program Loans." The Small Rental Property Program (SRPP) has two tiers of compliance obligations. The federal compliance requirements are for the CDBG funds issued to a borrower to meet a National Objective and be expended on an Eligible Activity. On top of the federal requirements, the State has its own program requirements. Upon the initial placement of an eligible tenant in a habitable unit at a restricted rent amount, the U.S. Department of Housing and Urban Development (HUD) requirements have been satisfied. Most of the matters made the subject of your report deal with the borrower's non-compliance with the State's program rules, not the HUD requirements. OCD has allocated approximately $653 million to the SRPP program to fund approximately 4,500 applicants and we maintain an ongoing monitoring process to promote compliance and continued availability of affordable housing. Consistent with the program's mission of preserving and expanding much needed affordable housing, OCD's primary focus for the SRPP is to assist property owners in achieving and maintaining compliance, i.e., creating and continuing affordable housing opportunities, as opposed to foreclosure and/or recapture of funds, and are, therefore, not subject to recapture by HUD. In summary, as of June 30, 2023, the LLA reports that 814 applicant files have been identified as noncompliant. Of these, 166 files have been determined to be uncollectible, leaving 648 files that are actively being addressed. OCD's compliance and repayment efforts relating to the state imposed continuing requirements of the program are ongoing. The optimal outcome of these efforts is the continued availability of affordable housing through compliance. In June 2016, OCD, working with the Louisiana Housing Corporation (LHC) and HUD, identified 397 SRPP borrowers that did not meet a National Objective. Immediately thereafter, OCD's Legal Section and LHC program staff began communicating with non-compliant borrowers and evaluating proposed workouts. OCD sent default letters to and initiated recapture efforts on all borrowers. Each file is processed with a goal of either achieving compliance, securing repayment, or identifying another viable workout plan. As of June 30, 2023, of the 397 files identified, 83 borrowers have become compliant, 20 have either partially or fully repaid their loans, 18 borrowers have transferred their housing obligations to other compliant properties and 166 have been determined uncollectable for various reasons. As noted in the audit, OCD continues to seek technical assistance regarding the enforcement of mortgages through the judicial foreclosure/public auction process. In conclusion, OCD will continue the efforts to recover those loans determined to be ineligible in accordance with policies and procedures that are acceptable to HUD. Concurrently, OCD will also continue to assist rental property owners to become compliant and to resolve any program compliance issues, thus increasing available affordable rental housing and reducing or eliminating the need to recapture funds from rental property owners, where appropriate. The contact person responsible for the corrective action is Ginger Moses, OCD Chief Operating Officer. Once approved by HUD, the anticipated completion date for this corrective action plan will coincide with the closing of the SRPP program. If you have questions or require additional information, please feel free to contact me.

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has reviewed the finding “Improper Employee Activity in Federal Program”. The Department concurs with the finding and continues to prioritize prevention and detection of improper activity associated with programs it administers. The Fraud and Recovery Unit (FRU) investigated two employees for suspected payroll fraud. The FRU determined that one employee received wages from DCFS and a secondary employer for the same hours worked. DCFS is pursuing recoupment of wages paid for the duplicative hours and will seek recoupment of funds in the amount $875.00 from this employee. DCFS is conducting additional inquiries related to the other employee’s suspected activities to determine the actual loss to the agency and will proceed accordingly. Both employees are no longer employed with the Department. DCFS will continue to investigate improper employee activities and emphasize the consequences of illegal acts. If you have any questions, please contact Rhonda Brown, Fraud and Recovery Unit Director, at Rhonda.Brown.DCFS@LA.GOV.

The District will review all grant documentation prior to allocating expenses to grants.

MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as well as 24 PS 8.807.1. In specific, these procedures will include 1) obtaining all relevant information pertaining to procurements involving federal assistance from any cooperative purchasing group and 2) obtaining quotations from three qualified providers where applicable and documenting those results. These two (2) updated procedures will be implemented during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for future purchases where applicable.

MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as well as 24 PS 8.807.1. In specific, these procedures will include 1) obtaining all relevant information pertaining to procurements involving federal assistance from any cooperative purchasing group and 2) obtaining quotations from three qualified providers where applicable and documenting those results. These two (2) updated procedures will be implemented during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for future purchases where applicable.

Planned Correction Action: Moving forward grants will not be set up with account #s for use until the funds are received and award letter is issued with actual start date. This will stop any expenses being posted prior to the start date. Name of Contact Person and Completion Date: Jeremy Roche, Assistant Superintendent of Finance and Operations. This plan will go into effect immediately.

Audit Finding Reference: 2023-003 Improve Controls and Documentation over Payroll Process Planned Corrective Action: Beginning with the first payroll of the calendar year 2024, the Portland Public School District went to the ADP payroll system. This change in payroll ERP system allowed for the overhaul of the payroll process that was currently in place. The Executive Director of Finance worked with ADP to ensure that permissions for both the Human Resources and the Payroll teams were specifically set up so that they did not have access to each other’s processes. The HR generalists have been trained to process the information that once was processed by payroll personnel. Furthermore, access is not managed by staff but by a department head to ensure that proper access for individuals is maintained. Proper documentation of time and attendance is maintained in payroll and electronically filed with each payroll period in an organized manner. The Executive Director of Finance is always looking for continuous improvements for proper documentation in payroll. Name of Contact Person: Helene DiBartolomeo, CPA Executive Director of Finance Anticipated Completion Date: Internal controls - 1/1/2024 Documentation - 2/23/24 353

Audit Finding Reference: 2023-004 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking due to the employee longer working in the district. The grant manager did verify that the employee worked the hours noted, but lacks the employees’ signature. This is not a typical occurrence Time and Effort is used and submitted. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Procedure has changed a reminder will be communicated by March 30th.