Corrective Action Plans

2023-005: Special Tests & Provisions Federal Program Title: Student Financial Assistance Cluster Assistance Listing Number: Various Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Recommendation: ISU should review the requirements and implement a monitoring control to monitor the checks throughout the year. In addition, for the checks outstanding greater than 240 days, the University should return the funding to the U.S. Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ISU reopened the prior financial aid years in COD and completed returns of federal aid funds via G5/6 from identified outstanding checks. ISU has implemented the following monitoring controls: At the beginning of each month finance runs check reissue forms for all checks that the check date is 180 days or older. These are mailed to the check recipient. Around the 15th of the month any checks containing Title IV funds that have not been reissued will be turned to the financial aid office. Financial Aid is provided with the date by which the funds need to be returned. Financial Aid attempts to work with the student to get the checks cashed if they are not successful will return funds before the 240-day limit. They will then notify Finance to cancel the original check. Name(s) of the contact person(s) responsible for corrective action: Lisa Leyshon, AVP Finance/Controller, James Martin, Director of Financial Aid Planned completion date for corrective action plan: Implemented in 2020.

2023-003: Procurement Federal Program Title: Research and Development Cluster Assistance Listing Number: Various Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Recommendation: ISU should evaluate its procedures and implement an additional control to document reasons for obtaining competitive bids. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Grant Accounting and Purchasing will both review requisitions within Jaggaer to make sure appropriate bids, and or exemptions are documented or attached. Name(s) of the contact person(s) responsible for corrective action: Lisa Leyshon, AVP Finance/Controller and Kirsten Broughton, Director of Grant Accounting Planned completion date for corrective action plan: Implemented in February 2024.

Finding Number: 2023-002 Condition: The College provided funds to two individuals for transportation in advance of being approved for participation in the program. Planned Corrective Action: The College has returned the questioned costs by transferring the expenditures out of the grant funds and reducing the next drawdown for the grant. The College will immediately suspend the practice of providing grant funds to individuals prior to their approval for participation in program. Moving forward, the College will require the Program Director to approve all applicants for eligibility prior to any training or support activities beginning. This will include a review of the application materials, eligibility documents, and any other required materials. Participants who do not meet the eligibility requirements will receive written notice of the reason for denial and will not be admitted to any programming or receive any supportive services. The College will also look to have staff members involved in grant administration receive targeted training and education on the revised grant disbursement procedures as well as general grant administration training. Contact person responsible for corrective action: Vice President for Finance & Business Anticipated Completion Date: 06/30/2024

2023-002 Housing Trust Fund Program – Assistance Listing No. 14.275 Recommendation: CLA recommended that PHFA review their procedures around administrative expenses charged to the HTF program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHFA will implement electronic time tracking, this will replace the current manual process of preparing timesheets that are entered into a database used to accumulate administrative expenses charged to federal programs. PHFA is currently in the process of implementing a Human Capital Management system that will allow employees to track the time they work on federal programs. Name of the contact person responsible for corrective action: Adrianne Trumpy, Director of Accounting Planned completion date for corrective action plan: July 1, 2024

Management will review its process for requesting reimbursements and reconciling same to the ledger.

2023-007 Student Financial Assistance – Assistance Listing No. Various Recommendation: We recommend the College review the R2T4 requirements and implement procedures to ensure the R2T4 calculations are using the correct number of break days and are accurately completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Clarkson College will review the R2T4 requirements and will implement procedures to ensure R2T4 calculations are completed accurately. Name(s) of the contact person(s) responsible for corrective action: Andrea Padilla-Rosas Planned completion date for corrective action plan: July 2024

Audit Finding Reference: 2023-002 Management’s Views and Planned Corrective Action: Food Service Balance – We will ensure that we spend the surplus food balance funds in 23-24 and not make a transfer of the funds from the district unless needed to ensure we don’t have an excess fund balance beyond the limit allowed. Name of Contact Person and Completion Date: Name – Bridget Cross Anticipated Completion Date – will be corrected for the 23-24 Audit

􀀃 Finding􀀃2023􀍲004􀀃 􀀃 Finding􀀃Subject:􀀃Child􀀃Nutrition􀀃Cluster􀀃–􀀃Allowable􀀃Activities,􀀃Allowable􀀃Cost/Cost􀀃 Principles􀀃 Summary􀀃of􀀃Finding:􀀃Internal􀀃Controls􀀃were􀀃not􀀃effective􀀃and􀀃did􀀃not􀀃prevent􀀃unallowable􀀃 activities/cost􀀃 Contact􀀃Person􀀃Responsible􀀃for􀀃Corrective􀀃Action:􀀃Director􀀃of􀀃Food􀀃Service􀀃 Contact􀀃Phone􀀃Number􀀃and􀀃Email􀀃Address:􀀃(260)431􀍲2030,􀀃msnyder@sacs.k12.in.us􀀃 􀀃 Views􀀃of􀀃Responsible􀀃Official:􀀃We􀀃concur􀀃with􀀃the􀀃finding.􀀃 Description􀀃of􀀃Corrective􀀃Action􀀃Plan:􀀃 All􀀃claims􀀃shall􀀃be􀀃created􀀃by􀀃the􀀃Assistant􀀃Food􀀃Service􀀃Director􀀃and􀀃reviewed􀀃for􀀃 compliance􀀃within􀀃the􀀃allowable􀀃cost􀀃category􀀃prior􀀃to􀀃payment􀀃by􀀃the􀀃Director􀀃of􀀃Food􀀃 Service.􀀃In􀀃the􀀃event􀀃that􀀃the􀀃Director􀀃of􀀃Food􀀃Service􀀃must􀀃initiate􀀃a􀀃claim􀀃first,􀀃the􀀃 Assistant􀀃Food􀀃Service􀀃Director􀀃would􀀃then􀀃review􀀃the􀀃claim􀀃prior􀀃to􀀃issuance.􀀃All􀀃claims􀀃are􀀃 returned􀀃to􀀃the􀀃Assistant􀀃Food􀀃Service􀀃Director􀀃for􀀃review􀀃of􀀃accuracy􀀃after􀀃the􀀃payment􀀃 method􀀃has􀀃been􀀃authorized􀀃to􀀃ensure􀀃accuracy􀀃and􀀃compliance.􀀃Both􀀃parties􀀃will􀀃initial􀀃 documents􀀃appropriately,􀀃as􀀃well􀀃as􀀃maintain􀀃all􀀃copies􀀃of􀀃proof􀀃of􀀃purchase/service􀀃with􀀃 original􀀃claim􀀃form􀀃documents.􀀃􀀃 Anticipated􀀃Completion􀀃Date:􀀃3/18/24􀀃

The Department has instituted additional internal controls to ensure that expenditures are liquidated within 90 days of the end of the period of performance as required. This includes a monthly reconciliation of all federal sources performed by the Grants Manager and reviewed by the respective Budget Manager and Finance Director to address any identified issues before the liquidation date. As a redundancy measure, the Budget Manager reviews AP contract activity associated with federal fund sources via the Provider Utilization Report to monitor the liquidation rate in correlation with the liquidation date to ensure all expenditures are captured within the period of performance. Post-liquidation date journal activity is mainly aligned with transactional code cleanup, not necessarily new expense posting outside the period of performance. As such, it doesn’t include or constitute changes to previously submitted federal reporting. To mitigate transactional errors, the Budget Manager, in coordination with the Grants Manager, thoroughly reviews the coding of procurement requests that utilize federal funds for the appropriateness of use and accuracy. This includes deactivating federal fund sources in the statewide accounting system to prevent transactions posting outside of the period of performance. These additional internal controls related to the period of performance were implemented in July 2023. The Office of Internal Audit will perform a review of the updated processes to ensure they are effective in correcting the above findings no later than March 31, 2024.

The Department has instituted additional internal controls to ensure that expenditures are liquidated within 90 days of the end of the period of performance as required. This includes a monthly reconciliation of all federal sources performed by the Grants Manager and reviewed by the respective Budget Manager and Finance Director to address any identified issues before the liquidation date. As a redundancy measure, the Budget Manager reviews AP contract activity associated with federal fund sources via the Provider Utilization Report to monitor the liquidation rate in correlation with the liquidation date to ensure all expenditures are captured within the period of performance. Post-liquidation date journal activity is mainly aligned with transactional code cleanup, not necessarily new expense posting outside the period of performance. As such, it doesn’t include or constitute changes to previously submitted federal reporting. To mitigate transactional errors, the Budget Manager, in coordination with the Grants Manager, thoroughly reviews the coding of procurement requests that utilize federal funds for the appropriateness of use and accuracy. This includes deactivating federal fund sources in the statewide accounting system to prevent transactions posting outside of the period of performance. These additional internal controls related to the period of performance were implemented in July 2023. The Office of Internal Audit will perform a review of the updated processes to ensure they are effective in correcting the above findings no later than March 31, 2024.

DCH has implemented the programming changes in Georgia Medicaid Management Information System (GAMMIS) to recoup capitation payments dating back to April 1, 2023 for members who were deemed retroactively eligible for Medicare. For any current Managed Care Organization (MCO) member that gets retroactive Medicare coverage, that member’s MCO capitation payments are recouped back to the day before the effective date of the Medicare benefit or back to 4/1/23 whichever is later. A monthly report entitled MGD-4218-M captures the recoupment activity.

GDOL acknowledges this is a repeated finding from previous years, therefore the Department concurs with this finding and offers the following response preceded by the auditor’s findings: Auditor’s Findings: The Georgia Department of Labor did not have effective internal controls in place to ensure unemployment benefit payments were made correctly and only to eligible claimants. 1) Claimants did not self-certify for benefits in eighteen instances GDOL Response: Employer Filed Partial Claims (EFC) are submitted by employers on behalf of the claimant. The employer is responsible for attesting to the employment status and weekly earnings of the claimant for the EFC submitted. An affidavit certifying that the employer has obtained earnings from other employment as well as other requirements must be completed before EFCs can be entered or uploaded. Claimants for which EFCs are submitted are considered to be still attached to the employer and are exempt from the requirement to register for employment services per Georgia Employment Security Law Rule 300-2-4-.02. Such individuals are not required to be nor certify on a weekly basis to be able, available and actively seeking work. We recognize the state auditor's recommendations to add the self-certification. However, the current unemployment system is obsolete, having been put into production in 1982. This finding will persist until our new modernized unemployment insurance (UI) system is implemented in 2026. 2) Fraudulent employer-filed claims were filed for thirteen claimants GDOL Response: When we identify employer fraud schemes, we follow the guidance issued by the United States Department of Labor (USDOL) and collaborate with the United States Department of Labor Office of Inspector General (OIG) to investigate these cases. Additionally, we have taken the following measures to safeguard the system against fictitious employers: • Effective December 6, 2021, the Employer Filed Partial Claims (EFC) process was revised to require individuals (employees) to complete an EFC profile to include a real-time identity verification before payments can be made. Employers are responsible for submitting the request for the payment to certify to the individual’s employment status, but the individuals must certify their identity and personal information for the claim to be processed. Employees are notified when a claim is filed on their behalf and provided instructions for their portion of completing the EFC process. The MyUI Customer Portal dashboard provides all the EFC correspondence sent to the individual as well as the status of the profile setup and identify verification. • Before the implementation of the EFC profile requirement, GDOL utilized the Social Security Administration (SSA) crossmatch and Systematic Alien Verification for Entitlement (SAVE) verification processes to verify the identity of claimants where employers submit claims on their behalf. • Effective June 29, 2023, GDOL implemented additional employer filed claims safeguards and security measures to reflect amended Georgia Employment Security Rule 300-2-4-.09. Employers must now meet the following conditions to submit Employer Filed Partial Claims on behalf of their employees: o Employer accounts must have been registered with GDOL for more than 5 years. o Employers must be current on all quarterly tax and wage reports. o Employers must be current on all quarterly contribution taxes, assessments, penalties, and interest. o The week ending date on employer filed claims cannot be older than 30 days. The amended Georgia Employment Security Rule also clarifies that part-time employees are not eligible for Employer Filed Partial Claims. BPC and Integrity merit staff continue to establish pseudo claims when fraud is confirmed to relieve victims of liability and the fraudster is unknown. Otherwise, the payments are moved to the fraudsters claim account, if identified. GDOL has procured a vendor to build and implement a modernized UI system. We are also pursuing data analytics tools to expedite the identification and detection of fraudulent activities. These tools will also be incorporated into the modernized solution. 3) Proof of employment or self-employment or a valid offer to begin employment and proof of wages was not submitted by five Pandemic Unemployment Assistance (PUA) claimants. One of these claimants was not eligible to claim benefits in Georgia. GDOL Response: The claimants who established PUA entitlement with a weekly benefit amount greater than the minimum or later determined to not be eligible were based on wages entered by the claimant and/or wages reported by the employer. The Coronavirus Aid, Relief, and Economic Security (CARES) Act only required proof of wages to be submitted. If claimants did not submit proof, federal requirements only allowed for payment of the minimum weekly benefit amount and no disqualification of benefits. Claims established at a higher weekly benefit amount had to be reduced to the minimum amount if no proof was provided. To date, no proof has been provided by the claimants cited. The claims were reduced as appropriate. An overpayment has been established on all five claims identified for the difference in weekly benefit amount for weeks paid over the minimum amount under CARES and for the entire amount for weeks paid under Consolidated Appropriations Act (CAA)/American Rescue Plan Act (ARPA). GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe “legacy’ technology. Due to the system’s age and other limitations, many automated processes and corrections cannot be fixed and/or easily implemented. As such, many processes must be handled manually by staff. This includes reviewing all the PUA proof documents submitted to determine the validity and eligibility for each PUA claim. Based on the volume of workload and staff limitations, GDOL has been unable to quickly complete this manual review to correct the finding. It is anticipated this manual review will continue throughout the FY24 audit review period. Summary: GDOL’s limited technology resources will hinder our ability to update our current system to satisfy the state audit’s recommendation. Therefore, we acknowledge that this finding will persist until a system-wide resolution is implemented in the new modernized UI system. The new solution will include a self-certification and dual certification process for employer filed claims and include controls over eligibility determinations for current and future UI programs. GDOL greatly appreciates the feedback and recommendations and will consider this information in our endeavors to modernize our UI system and business processes.

We concur with this finding. Although the Wagner-Peyser Program transitioned to TCSG in December of 2022, related activities also continued at GDOL. Staff at the career centers continued to serve Georgia taxpayers in need of employment services rather than turning them away. As a result, staff continued to charge the Wagner-Peyser grant, and there were Wagner Peyser grant funds still remaining at GDOL. Journal vouchers were entered to allocate indirect costs to the Wagner-Peyser grant pursuant to GDOL's federally approved cost allocation plan. Journal vouchers were also used to correct other expenditures that should have been charged directly to Wagner Peyser. GDOL will ensure that all journal vouchers are properly supported by documentation, either attached directly to the journal voucher or the journal voucher will reference the supporting documentation which can be retrieved either electronically or manually.

Name of contact person - Mr. Joseph Gudac, Business Manager Corrective Action - We will follow our policy for federal purchases subject to quotation/bid/sole source requirements moving forward. The district will follow the policy for obtaining three quotation/bid requirements for federal purchases. In the event purchases are made through cooperative purchasing programs, three quotes will be documented when federal purchases are disbursed. We also implemented processes to improve documentation relating to the “reason” and “cost analysis” of sole source noncompetitive procurement. Anticipated Completion Date - The District will implement the above procedure immediately.

Corrective Steps: Will review and train staff to follow all purchasing processes and procedures. Will ensure segregation of duties between personnel that initiates a PO, paying the invoice and receiving goods. Completion date: Immediately. Plan for Monitoring: Monthly meeting with purchasing staff to ensure purchasing procedures are being followed.

There is no disagreement with the audit finding. The Programs was struggling with turnovers and not knowing what entries were allocated correctly. Payables were entered in the accounting software from purchase orders which caused the reports to be inaccurately stated in the amount of $6,239.00. The unexpended funds will be returned to the Department of Health and Human Services to remain in compliance. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: February 24, 2024

Finding 2023-001 – Title I Grants to Local Education Agencies – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Amy Phillips Contact Phone Number: (765) 662-2546 ext 8070 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Marion Community Schools will establish an internal control system that will require review of all timesheets and payroll registers by the Chief Financial Officer (CFO) or the Assistant Chief Financial Officer (Asst CFO). Timesheets/payroll registers will be reviewed for any new or updated wage amounts and provide a second sign off documenting that these were reviewed and approved. The payroll employee should bring these forward for initial review, however, the CFO/Asst CFO will still review registers as a double check and to prevent errors. Payroll changes should be kept together for easy reference, as well as with the payroll file for the period in which the change was made. Anticipated Completion Date: Immediately

Although we checked and double checked the information as shown in COD under the R2T4 section, there still appears to be an issue with regards to COD correctly showing Vacation time in COD. Going forward, we are actually printing out the R2T4's to ensure that the correct number of days are listed on the R2T4 sheet and maintaining hard copies in addition to saving online.

The largest issue regarding student working when they are in class is communication. Faculty are supposed to alert the work office when they are cancelling class. However, they are only alerting the Provost about cancelling classes and they are keeping a calendar of cancelled classes. We will continue to remind faculty that they must let the Work Office know directly when they cancel class. All managers have been informed that their workers cannot work during a class period unless the professor has emailed the work office. We are looking at new payroll vendors who may be able develop a system for student schedules and the payroll system to help integrate data so that we can access class schedules within the Payroll system and blackout periods where they cannot work.

Cluster name: Student Financial Assistance Cluster Assistance Listings numbers and names: 84.007 Federal Supplemental Educational Opportunity Grants 84.033 Federal Work-Study Program 84.063 Federal Pell Grant Program 84.268 Federal Direct Student Loans Luisa Ott Anticipated completion date: June 30, 2024 The District agrees with the finding. After reviewing the student in the finding, the District reprocessed the Return of Title IV calculation. The one student record was updated and resulted in an amount of $8 to be returned to the student by offsetting their current balance with the District. The District will fund the reimbursement with institutional funds. During the fiscal year ending June 30, 2023, the District has created supporting automated processes to identify potential Return to Title IV accounts. The District has started the implementation project of using the student information system to automatically calculate student Return to Title IV calculations. The District will continue to strengthen procedures surrounding Return to Title IV compliance requirements.

Reviewing all areas of this finding, the District needs to assist with extra help from the district office and ensure that all student records are updated timely based on the review of income eligibility forms or direct certification information, plus additional training.

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe and affordable housing to low-income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Reexamine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: Testing of thirteen family files revealed the following deficiencies: 1. One file used an incorrect utility allowance. 2. One file failed to allow a disability deduction. 3. Two files calculated an incorrect housing assistance payment Auditor’s Recommendation: This is a repeat finding. A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027 Name of Contact Person: Angela Newell, Administrative Officer Corrective Action: Carbon County implemented a procurement policy in 2023 and is in the process of updating Standard Operating Procedures to comply with the Policy. The review of Suspension and Debarment requirements will be incorporated into these Standard Operating Procedures. Proposed Completion Date: June 30, 2024

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, DISASTER GRANTS-PUBLIC ASSISTANCE (PRESIDENTIALLY DECLARED DISASTERS), ASSISTANCE LISTING No. 97.036 Name of Contact Person: Angela Newell, Administrative Officer Corrective Action: Carbon County implemented a procurement policy in 2023 and is in the process of updating Standard Operating Procedures to comply with the Policy. The review of Suspension and Debarment requirements will be incorporated into these Standard Operating Procedures. Proposed Completion Date: June 30, 2024

Department of Health and Human Services Newberry County Memorial Hospital respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend the Organization perform a detailed review of the supporting documentation to ensure accurate expenses are inputted in the internal tracking spreadsheets that is ultimately used by the Management to input into the HRSA reporting portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The hospital attempted to track COVID supplies to each nursing unit cost center. This required the Materials Management department to track detailed items in a spreadsheet format. Human error resulted in two of the items being charged with an incorrect amount. The hospital is implementing a new procedure that will improve tracking each expense from the storeroom. An additional step will be for the ACFO to check each month's COVID expense allocation to the spreadsheet to identify potential errors and improve accuracy of the reporting the claimed expenses. Name(s) of the contact person(s) responsible for corrective action: John L. Doyle, Chief Financial Officer Planned completion date for corrective action plan: September 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call John L. Doyle, CFO, at 803-405-7137