Corrective Action Plans

THE FORMER CLARENDON ONE AND CLARENDON FOUR AUDITS WERE ISSUED LATE AFTER CONSOLIDATION BEGAN. BEGINNING WITH THE 2024-25 AUDIT, TIMELY AUDIT SUBMISSIONS WILL BE PRACTICED.

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2023. Finding 2023-001 Responsible Party Name: Gina Rice Position: Director of Accounting Telephone Number: 816-238-4511 ext 131 Federal Agency U.S. Department of Agriculture Federal Program Emergency Food Assistance Program (Food Commodities) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action We will establish a process to ensure required eligibility documentation is maintained in accordance with federal program requirements which will include periodic monitoring and review performed by personnel not directly involved with program administration. Anticipated Completion Date June 2025

2023-011 Excess Food Service Fund Balance (Material Weakness) Management’s Response: We completed and Excess Balance Use of Funds report and worked with the State to understand exactly the parameters of this/ The funds were spent down and we are working hard to make sure to stay under the three months of expenses as worded in CFR Title 7, 210.14(b). Again management is trying to take on a bigger role as this monitoring was not considered prior to COVID. Fund Balances at year end averaged no more than $10,000. Name of Contact Person and Completion Date: Toni Butterfield Anticipated Completion Date - Immediately

Child Nutrition – Report Testing Recommendation: We recommend that the District reviews its procedures and controls over reporting for the Child Nutrition Cluster program to ensure all reports are accurately reporting information and are reviewed by someone other than the preparer and that review is documented prior to submission of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will review its procedures over its reporting of claims to MDE to ensure claims made to MDE is properly supported by the District's meals count. Name(s) of the contact person(s) responsible for corrective action: Tariro Chapinduka, Director of Business Services Planned completion date for corrective action plan: June 30, 2025

U.S. Department of Agriculture Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.569 and 10.565 Condition: CACLV does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. CACLV has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respective identifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2025.

FINDING 2023-009 Finding Subject: Child Nutrition Cluster – Non-Profit School Food Service Accounts Summary of Finding: Receipts for the grant were posted to the ledger by one individual without an oversight or review process in place to ensure the remitter, amount, fund, and receipt classification were accurate. Additionally, the same individual received the ACH notifications when monies from monthly meal reimbursements were credited to the School Corporation's bank account and performed the bank reconciliations. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Food Service Director and Business Manager hold a monthly financial meeting to review the food service finances. A report listing all receipts for the previous month to the food service fund will be reviewed at this meeting. This item will be added to the agenda. Anticipated Completion Date: March 31, 2024

FINDING 2023-008 Finding Subject: Child Nutrition Cluster – Special Tests & Provisions - Verification Summary of Finding: One individual performs the verification process without documented review/oversight by a second employee not involved in this process. The lack of controls resulted in non-compliance in which the procedures performed at the School Corporation and the resulting supporting documentation provided were insufficient to verify the student's eligibility status of one of three students which were verified during the audit period. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The verification process will be performed by Pam Frost and reviewed by the Business Manager. Anticipated Completion Date: December 31, 2024

FINDING 2023-007 Finding Subject: Child Nutrition Cluster - Reporting Summary of Finding: Monthly reimbursement claims for breakfast and lunch meals served are prepared and submitted without documented review or approval by a second individual not involved in the preparation of the reimbursement claim. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will calculate the monthly claims to be submitted to the DOE/CNP and email this information to the Business Manager for review before submittal. Anticipated Completion Date: March 31, 2024

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not being reviewed by an individual other than the individual making the initial determination. As a result, three of forty sampled students received the incorrect eligibility status in the system software when compared to supporting documentation (Direct Certifications and/or income-based applications). Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently all income based applications for free/reduced lunch status are processed by Pam Frost and then reviewed by the Business Manager. Beginning in the 2024-2025 school year Direct Certification students will also be reviewed by the Business Manager. Anticipated Completion Date: August 31, 2024

FINDING 2023-004 Finding Subject: Child Nutrition Cluster – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. The School Corporation paid $23,682 of administrative salaries that were allocated to the School Lunch fund based on fixed percentages. There was no supporting documentation to indicate how the percentages were determined or time records indicating time spent on the program by the applicable administrators. INDIANA STATE BOARD OF ACCOUNTS 40 􀀃 “Meeting􀀃students􀀃where􀀃they􀀃are􀀃and􀀃leading􀀃them􀀃forward…every􀀃student,􀀃every􀀃day”􀀃 Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently 50% of Pam Frost’s salary is paid from the Lunch Fund. A new internal control will be created to document that 50% of her time is spent on food service work and 50% of her time is spent as the ECA treasurer for the elementary school. Anticipated Completion Date: August 31, 2024

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Business Manager and Food Service Director hold a monthly financial meeting to review the status of finances for the Food Service. A review of the payroll distribution reports for the previous month will be added to the agenda of this meeting. Anticipated Completion Date: March 31, 2024

Corrective Action Plan Findings - Federal Award Program Audits Department of Agriculture Finding 2023-001 - Child Nutrition Cluster - School Breakfast Program - Assistance Listing Number 10.553, National School Lunch Program - Assistance Listing Number 10.555, Summer Food Service Program for Children - Assistance Listing Number 10.559 Condition: The year-end financial reports contained several errors related to the recording of receipts and expenses of the Major Federal Award Program. Auditors’ Recommendation: The District should implement a process that includes monitoring activity related to Federal Programs. It is recommended that individuals within the District obtain training related to internal control systems or consider the use of a 3rd party specialist. Planned Corrective Action: The District has had turnover since the completion of the previous audit (June 30, 2022), staff in key positions have turned over multiple times. As of the date of this report, the District has hired and implemented training for key staff to ensure proper grant management in the future.

2023-004 Allowable Costs Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Pass-Through Agency: Georgia Department of Education Criteria: In accordance with the terms of the Child Nutrition Grant and 2 CFR 200, Cost Principles for States, Local Governments, and Indian Tribes, specific documentation must be maintained to support salaries and wages charged to the federal program. Where employees are expected to work solely on a single Federal award or cost objective, charges for their salaries and wages will be supported by periodic certifications that the employees worked solely on that program for the period covered by the certification. These certifications will be prepared at least semi-annually and will be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Where employees work on multiple activities or cost objectives, a distribution of their salaries or wages will be supported by personnel activity reports or equivalent documentation. Corrective Action Plan: We concur with this finding. The District is developing corrective actions to strengthen Child Nutrition Cluster Department internal controls, policies, and procedures and ensure adherence through improved monitoring. Through collaboration, the Finance Division and the School Nutrition Department will review payroll detail reports and ensure periodic certifications for all employees are completed timely. Estimated Completion Date: Fiscal Year 2025 Contact Person: Dr. Connie Walker, School Nutrition Executive Director Telephone: 678-676-1200 E-mail: Connie_R_Walker@dekalbschoolsga.org

Federal Program Child Nutrition Cluster - Passed through the Pennsylvania Department of Education and Pennsylvania Department of Agriculture ALNs 10.555 and 10.553 Education Stabilization Fund - Passed through the Pennsylvania Department of Education ALN 84.425 Criteria Per the Uniform Guidance 2 CFR 200.510, the auditee is required to prepare a schedule of expenditures of federal awards (SEFA). Condition The District prepared a SEFA and provided information relating to the federal programs including grant agreements and other supporting documentation. However, the SEFA prepared by the auditee required material adjustments as a result of audit procedures. Cause Certain account reconciliations were not performed prior to the audit, which impacted amounts reported on the SEFA. Effect Amounts reported on the SEFA provided by the auditee were not accurate. The SEFA was subsequently updated through audit procedures, including inquiry and review of grant documentation of awards received and amounts expended. Questioned Costs None. Context A SEFA was prepared by management; however, several adjustments were required in order for the schedule to accurately reflect the current year activity. Repeat Finding Yes. See finding 2022-003. Recommendation In order to meet Uniform Guidance requirements, the District should prepare the SEFA from the grant award documentation and any other relevant information including the assistance listing numbers, grant award amounts, grant amounts received, grant amounts expended, and grant revenue recorded. The amounts reported in the SEFA should reconcile to the general ledger. Management Response The new Assistant Business Manager has been trained in Uniform Guidance requirements as well as Federal program guidelines. This should not happen in the future.

The District agrees and has already implemented processes to ensure receivables are created with each claim created in CNIPS

Contact Person Evan Peltier Planned Corrective Action Dunseith Public School Dist. #1 will implement the recommendation from Brady Martz. Planned Completion Date The planned completion date is June 30, 2025.

Contact Person Evan Peltier Planned Corrective Action Dunseith Public School Dist. #1 will implement the recommendation from Brady Martz. Planned Completion Date The planned completion date is June 30, 2025.

Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 06/30/2025. Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end 09/30/2024. Mr. Joseph Gombo, executive director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-371-1220. Contact Person Responsible for Corrective Action: Joseph Gombo, Executive Director

Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

Condition: The Food Service Department did not perform its verification process by the date required by the state pass-through agency. Corrective Action Planned: No applications were submitted to be verified. The school district prompted caregivers on numerous occasions to return the forms without receiving any. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent

Condition: Free or reduced meals applications could not be provided. The Food Service Department did not process free or reduced priced meals applications for the 2022-2023 school year. Corrective Action Planned: The School District has hired a qualified leader for the School Nutrition Program in order to comply with the requirements of this program. Additionally, the school district has enrolled all but the Brooks Elementary School as Community Eligibility Provision (CEP) sites and we are no longer required to collect these forms. At the Brooks School, these forms were sent to families from the Brooks School during the FY24 school year. Despite the efforts of the school and Food Services Director, no forms were returned to the school. Presently the forms are not required for the Brooks as the CEP eligibility requirements were reduced from 40% to 25% for determination. Anticipated Completion Date: 2/15/2025 Contact: Peter Cushing, Assistant Superintendent

Condition: Claims support could only be provided by the School for two months. For one month, support was in the form of spreadsheets with tray counts in lieu of a point-of-sale system. For the other month, the tray count spreadsheets were accompanied by reports from the point-of-sale system. The point-of-sale system reports provided did not agree to the amounts claimed for reimbursement. The tray counts did not indicate whether the meal provided was paid, free or reduced. The claims for reimbursement submitted by the School used allocation percentages derived from prior year claims when estimating amounts to be claimed as paid, free and reduced. The tray count spreadsheets for the other months could not be located by the School. Corrective Action Planned: In January 2023 DESE sent an auditor to review the Medford School Nutrition Program. Before this review, there was significantly limited oversight by the central office finance team. Almost no documents were prepared before the review as required by DESE. As a result of this audit a 58-item, 19-page Corrective Action Plan was issued to the district. A new district leader was assigned for departmental oversight. The district then had weekly meetings with DESE to address the corrective action plan, for this was the single largest CAP DESE has issued to any district of our size. Nearly $1.3 million in reimbursements were withheld from the district from approximately November 2022 through the end of the Fiscal Year. DESE issued the reimbursements with a nominal penalty during the summer of 2023. At the end of FY23, the district terminated the director of the program. We are now training several individuals in the MCPPO program for enhanced oversight. DESE forced an immediate return audit for FY24. This was an exceptional action as DESE has only rarely done this. The same reviewer attended and noted significant improvements as a result of district actions undertaken. As relates to this particular finding, the School Department has purchased and is consistently using a point of sale system for students to purchase their meals. The system is used to track all transactions. Anticipated Completion Date: 2/17/2025 Contact: Peter Cushing, Assistant Superintendent

Finding No.: 2023-006 Federal Agency: U.S. Department of Agriculture AL Program: 10.555 Child Nutrition Cluster Federal Award No.: 7GU300GUB Area: Reporting Questioned Costs: $0 Views of Auditee and Corrective Actions: GDOE agrees with the finding. GDOE submitted monthly reimbursement claims for meals and snacks served to eligible students beyond the required 60-day reporting period and did not report sub awards of $30,000 or more to the Federal Funding Accountability and Transparency Act Sub Award Reporting System (FSRS) in FY 2023. Plan of action and completion date: At the start of FY 2024, the CNP Office added personnel to the processing of claims activity. The additional personnel to the process is to ensure the requests are reviewed and processed in a timely manner before transmitting to the GDOE Business Office for reimbursement draw and payment processing. After the transmission, the CNP Office will follow-up and confirm, via email, with the assigned personnel conducting the draws, that the requested draw/payment for claims reimbursement are completed in a timely manner. In addition, the Child Nutrition Programs Office will request for confirmation from the responsible personnel within the Business Office that the required Subaward report is submitted and posted to the respective SEFA to the FSRS. Plan to monitor and responsible officials: The CNP State Administrator, Franklin Cruz, and the Comptroller will ensure that claims are submitted and processed timely.

Finding No.: 2023-004 Federal Agency: U.S. Department of Agriculture AL Program: 10.555 Child Nutrition Cluster Federal Award No.: 7GU300GUB Area: Eligibility Questioned Costs: $0 Views of Auditee and Corrective Actions: GDOE agrees with the finding. GDOE did not published School Year 2022-2023 eligibility notifications for the community eligibility provision to the GDOE website by May 1, 2023 as required by the National School Lunch Act (NSLA). GDOE Child Nutrition Program (CNP) division is aware of the requirement and has publicly posted eligibility notifications to ensure compliance to NSLA. GDOE does not anticipate this will be an audit finding moving forward. Plan of action and completion date: The CNP Office has incorporated a calendar reminder within the CNP Office and updated the internal calendar of report due dates to facilitate the timely upload of the required information to the GDOE CNP website. Plan to monitor and responsible officials: The CNP State Administrator, Franklin Cruz, will ensure that CEP eligibility notifications are posted to the GDOE website by May 1 of every year to be in compliance with the reporting requirements of the NSLA.

Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensure accurate USDA food commodities inventory recordkeeping compliance. Further, Coastal Harvest will include specific inventory policies and procedure in the manual discussed in the corrective action for finding 2022-001. Anticipated Completion Date: June 30, 2024