Corrective Action Plans

Reference Number: 2022-006 Prior Year Finding: 2021-003 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 2208A, Quarterly UI Above-Base Report Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Division should review and update its reporting procedures and controls to ensure that ETA 2208A ? Quarterly UI Above-Base Reports are submitted no later than 30 days after the end of each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal department has added to our Policy and Procedures the terms of the reporting period being 30 days after then end of the quarter. It was also posted on a group calendar to begin work on the reports at 20 days after quarter end. Name(s) of the contact person(s) responsible for corrective action: Laurie Wexler Planned completion date for corrective action plan: 01/03/2023

Views of Responsible Officials: The Center has implemented new Grant and Payment Management System (PMS) reconciliation workbooks to track grant expenditures. The Center also engages with consultants to assist with proper reporting and timely filing to avoid audit adjustments. In addition, the Standard Operation Procedures will be updated to ensure that an appropriate protocol and controls for reviewing and approval of documentation prior to submission are in place. The Center will implement a plan that will include revision and approval from the Chief Financial Officer or designee prior to submission, required in the Payment Management System.

Recommendation: We recommend the County management establish internal controls to ensure compliance with federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finance department has met with the IT department to discuss federal procurement requirements and possible checklists. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

Recommendation: We recommend the County management establish internal controls over eligibility. Case files should be reviewed to ensure proper documentation exists to support the eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement additional review procedures. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

RE: Lutheran Social Services of Central Ohio Marion Place II Housing, Inc. Corrective Action Plan Fiscal Year Ended June 30, 2022 Finding Number: 2022-001 Condition: The Corporation used surplus cash calculated at June 30, 2021, to make a payment on a residual receipts note without prior approval from HUD. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management deposited the surplus cash amount of $5,675 into residual receipts on September 23, 2022.

Finding Number: 2022-002 Condition: The Corporation used surplus cash calculated at June 30, 2021, to make a payment on a residual receipts note without prior approval from HUD. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management deposited the surplus cash amount of $22,809 into residual receipts on September 23, 2022.

Response to finding 2022-003 The County will submit the required report as soon as possible and will implement policies and controls to ensure that all required grant reporting is performed in accordance with grant requirements and on a timely basis.

The District?s Indirect costs worksheet to determine allowable costs had an error in the calculation. The District has addressed the cause of the error and future amounts should calculate correctly.

Auditors Finding: 2022-002 (2021-002) Issue: The DREAM Program did not properly document approval on invoices for various expenses. Root Cause: The Organization has not developed a formal documentation procedure to ensure all expenses are accounted for and there are limited staff in our business and finance department. Corrective Action Planned: ? In order to address the capacity challenges of a small nonprofit with limited staffing, we will review our established internal controls for opportunities to better allocate responsibilities across available staff and board members.. ? We will further discuss financial risks, cash disbursements, internal controls, and how to split responsibilities at our quarterly internal audit meetings. Anticipated Completion Date: 8/31/23 Persons Responsible for Corrective Actions: Mike Foote, Executive Director; Christina Cramer, Business Manager; Kayla Brosilow, Operations Director

Responsible Parties: Michelle Lancaster, Deputy County Manager / Human Services Director Beverly Liles, Finance Director Finding 2022-003, Significant Deficiency and Nonmaterial Noncompliance - Special Test and Provisions See Corrective Action Plan for chart / table.

Carver County ? Corrective Action Plan Year Ended December 31,2022 U.S. Department of Health and Human Services Carver County respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: 1/1/2022 to 12/31/2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT None FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-001 Medical Assistance ? Assistance Listing No. 93.778 Recommendation: We recommend the County reviews its procedures for giving timely notice of an individual?s termination to other departments. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will incorporate procedures and controls to ensure timely notice is given to other departments of an individual?s termination. Name of the contact person responsible for corrective action: Mary Kaye Wahl (Assistant Financial Services Director) Planned completion date for corrective action plan: December 31, 2023. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Mary Kaye Wahl at 962-361-1938.

Finding Summary: Southwest completed the Provider Relief Fund reporting requirement without factoring in the amounts of expenses that were reimbursed by other sources. This specifically relates to the amount that Southwest was reimbursed by Medicare as a result of being a critical access hospital that get reimbursed based on cost. Responsible Individuals: Dennis Goebel, Chief Executive Officer; Amanda Loughman, Chief Financial Officer. Corrective Action Plan: Management will ensure to factor in a portion of the Provider Relief Fund expenses that are being reimbursed by other sources when completing the reporting requirements. Anticipated Completion Date: 12/31/2023

November 15, 2022 Oregon Secretary of state, Audits Division 255 Capito! St. NE, Suite #500 Salem, OR 97310 Plan of Action for Multnomah Education Service District The Multnomah Education Service District respectfully submits the following corrective action plan in response to deficiencies reported In our audit of fiscal year ended June 30, 2022. The audit was completed by the independent auditing firm Talbot, Korvola and Warwick, and reported the deficiency listed below. The plan of action was adopted by the governing body at their meeting on November 15, 2022, as indicated by signatures below. Finding 2022.001: Significant deficiency Condition: The provisions for the prevailing wage rates requirements were not included in the construction contracts in excess of $2,000 financed by ESF funds and that the required certified payrolls were not obtained. The related deficiency in internal controls over compliance is considered to be a significant deficiency. As the District does not typically fund construction projects with federal fund, the District's staff were unaware of the $2,000 threshold for construction contacts financed by ESF funds to include prevailing wage rates requirements and used a threshold of $50,000, the Oregon Bureau of Labor & Industries' threshold for prevailing wage rate requirements for public works projects in Oregon. Cause: Effect or potential effect: Without adequate internal controls over wage rate requirements and Including the required provisions in construrtion contracts in excess of $2,000 financed by ESF funds, the District cannot demonstrate compliance with the wage rate requirements of the Davis-Bacon Act requirements. Questioned Costs: Questioned costs, if any, are indeterminable. Out of nine capital projects totaling $123,558, a sample of three capital projects was haphazardly selected. The capital projects were between $9,405 and $14,360 and totaled $26,024. Context; Recommendation: The District should obtain an understanding of all compliance requirements and implement controls to ensure compliance with federal wage rate requirements. Superintendent Dr. Faul Coakley Board of Directors Jessica Ariate ? Mary Botkin ? Kristin Corniielle < Katrina Doughty ? Dr. Samuel Henry ? Deny.se Peterson ? Helen Ying I !611 NE ??ns\?orth Circle ? Portland. Oregon 97220 ? (502) 255-18^1 ? MultnofiialiESD.org p!an ?? action: The Director oi Business & Operations is responsible for implementing the plan of action. All construction projects are managed by the MESD Facilities office. The Director instructed the MESD Contract and Risk Manager, meet with the Facilities office to inform staff of the Davis-Bacon prevailing wage requirements for construction contracts in excess of $ ? 2,00 . Facilities will include the consideration of Davis-Bacon requirements when reviewing a project request that is or has the potential of being federally funded. Facilities will implement the requirements of the Davis-Bacon Act as needed. Timeframe: The meeting took place on November 2, 2022. Facilities has updated their internal procedures. ? ' Multnora ESD Board Chair, Denyse Peterson Superintendent, Dr. Paul Coakley

Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Financial Assistance Listing #93.498 Significant Deficiency Compliance Requirement: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure review and approval of the lost revenue calculation and report submitted to the Department of Health and Human Services for Period 4. Responsible Individuals: Nicole Siegner, CFO Status: Management will enhanced internal controls to ensure lost revenue calculations and reporting submissions to HRSA were reviewed by an individual other than the preparer and documentation of approval was maintained.

Effective immediately, the Chief Financial Analyst has created a schedule for all Westward Heights Care Center monthly financial statements be completed and sent to the Administrator by approximately the 20th of each month. This will allow time to get the quarterly reports completed and sent to the USDA. The annual budget was not completed on time as there was a new administrator. The administrator now has the experience and education to get the budget completed by November 30th and sent to the USDA.

Name of Contact Person: Peter Wetherall, Esq., Executive Director Corrective Action: Nevada Legal Services, Inc. agrees with the finding. Once the issue was brought to Management?s attention, controls were instituted to ensure that a Retainer Agreement is included in a client?s case file when required. Training sessions were provided to new and existing staff related to Retainer Agreement requirements in case management. In addition, a structure was created for cases in the case management system to ensure Retainer Agreement Compliance that requires verification if a Retainer Agreement is needed and that a Retainer Agreement is uploaded to the file for the case before closure, if required in the case.

U.S. Department of Health and Human Services 2022-002 Health Centers Cluster ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization develop a process to address changes in the approved IDCR midway through grant periods where grant expenditures are reconciled to the new IDCR, and additional direct expenditures identified, if needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement processes to review the IDCR used to ensure any changes are incorporated timely and reconciled, as needed. Name(s) of the contact person(s) responsible for corrective action: Jenny Singh, Finance Officer Planned completion date for corrective action plan: December 31, 2023

Finding Number: 2022-001 Program Name/Assistance Listing Titles: Crime Victim Assistance; Family Violence Prevention and Services/Domestic Violence Shelter and Supportive Services Assistance Listing Numbers: 16.575, 93.671 Contact Person: Jessica Bryson, Finance Administrator Anticipated Completion Date: Completed effective October 2022 Planned Corrective Action: During the audited fiscal year, the organization experienced significant staff turnover in the Finance Department. As a result, the methodology of accounting relative to class/customer tracking changed part-way through the year. This resulted in the inability to immediately produce documentation from the financial reporting software that corroborated the grant billings. Although the organization is confident that expenses were billed to appropriate grants throughout the year (due to backup documentation in the grant billing portals), the organization?s financial software did not directly reflect this. To correct this problem, a new class/customer tracking system has been established to ensure that the financial reporting software more accurately tracks expenditures related to Federal Awards and organizational programs. Furthermore, grant billings are regularly reviewed by an independent accounting firm, the organizations Treasurer, and/or the Executive Director to ensure proper coding/tracking.

The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

Finding 2022-001, Payroll Process, Assistance Listing Number 93.224 Health Care Center Program (Direct Health Center Program Cluster). Recommendation: We recommend the Organization follow the documented payroll process and ensure reviews and approvals are documented. Response: NEFHS believes the nature of this finding stemmed from the third-party company being utilized to process payroll. NEFHS has transitioned third-party payroll companies as of January 2023. We have incorporated hard stops within the process to prompt for required approvals of timecards by supervisors before payroll can be processed in full. NEFHS will also incorporate quarterly reviews to ensure the process is being administered as intended.

The District reported what was believed to be transferred into the program by the close of the fiscal year. Unfortunately, those expenses were not moved as the books were closed long after the reporting deadline. The report was adjusted with the CDE at the following reporting period and now reflect the correct expenditures. In the future, all related year-end transfers will be prioritized and completed prior to the reporting deadlines to ensure that they match.

FINDING 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The School Treasurer will complete the Annual ESSER data report. The Grant Director will verify the report(s) for accuracy and completion. The Grant director will sign off on each report and then confirm via email the report(s) is correct and ready for submission to the IDOE. Responsible party and timeline for completion: Contact person responsible for Corrective Action: Patti Kappes, Treasurer Contact phone number: (812)427-4215 Anticipated completion date: April 30, 2023

Finding 2022-011 ? Special Tests and Provisions: Withdrawal Testing (Significant Deficiency and Noncompliance) Information on the Federal Program: U.S. Department of Education, Student Financial Aid Cluster Criteria: 34 CFR Part 668 establishes rules governing the student withdrawal process including the determination of withdrawal date, calculation of earned Title IV assistance and return of unearned Title IV aid within 45 days. Condition: We selected a sample of 12 students who withdrew and were receiving financial aid. Of the 12 students tested, there were two instances in which the College incorrectly calculated the percentage of aid earned. Management?s View: The issue occurred due to a timing difference of the date drop forms being submitted to Student Services and the effective drop date entered into Banner. In this instance, the drop forms were submitted on a Friday when the College operates on a half-day schedule. The form was entered the following Monday, and the entry should have been backdated to Friday. This caused Financial Aid?s Title IV return calculation to be off by two days. Corrective Action Plan: Management is in process of updating Policies and Procedures to incorporate Financial Aid into the student drop process. Financial Aid will receive emailed copies of student drop forms as they are submitted to Student Services. Financial Aid will review the dates in Banner prior to finalizing Title IV return calculations to ensure that the dates the forms were submitted match the date the drop was recorded as in Banner. This will take effect immediately as the policies are formally updated. Anticipated Completion Date: September 30, 2023

2022-001 Reporting and Environmental Reviews ? CDBG Community Development Block Grants/Entitlement Grants ? Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the various compliance requirements of the grant. We also recommend the City document these procedures and internal controls as required by Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Community Development Manager is responsible for the completion of the reports required by the Housing and Urban Development for meeting Community Development Block Grant Funds. The Manger then provides copies to both the Community Development Specialist and the Community Development Director for their review. They make their corrections/changes and returns to the Manager to make those corrections before submitting to HUD. Previously these corrected documents were not kept in the file. We will have all individuals initial and date when they have completed their review and will keep that documentation in the file. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz, Community Development Manager Planned completion date for corrective action plan: 9/26/2023

Finding 2022-001 - Controls Over Cash Management (Significant Deficiency) Criteria: According to Title 2 U.S. Code of Federal Regulations (" CFR") Part 200 , paragraph 305, non-federal entities are required to minimize the time that elapses between the transfer of funds from the federal funding source and the disbursement of those funds by the non-federal entity for the program's intended purposes. Condition and Context: As a part of our testing over cash management of funds received from the federal funding source, we examined information showing the dates on which five program-related disbursement of federal funds were received by the Corporation , and we compared those dates to the dates when the Corporation remitted the amounts for the purposes of covering payroll expenses and paying its various contractors. We noted one draw for $1,184,367 that was received from the federal funding source with no payments made to the contractors for which the funds had been appropriated. This resulted in a period of 16 days between receipt of the federal funds and the corresponding payments to the contractors. We also noted one of the five draws tested were for an incorrect amount. The Corporation submitted a draw for $29,997 in error. The overdrawn funds were repaid to the federal funding source. The Corporation prepared a schedule of draws made during 2022 and it was noted that the Corporation drew or repaid an incorrect amount in four months of the year, of which some were corrected in the next period. Effect: As a result of these matters , the Corporation essentially borrowed money from the federal government and potentially delayed payment to vendors. Cause: The condition was caused by an oversight by management that resulted in invoices not being processed for payment unt i l well after the cash had been drawn by the Corporation and resulted in draws to processed for an incorrect amount. Questioned Costs: From our sample tests , the Corporation overdrew $29,997 for the month of May 2022. Recommendation : We recommend that management designate a specific individual to be responsible for monitoring the receipt of federal funds on a daily basis . This person should be tasked with ensuring that funds that have been transferred from the federal funding source are disbursed to the intended contractors within a short period following receipt of these funds and ensuring that the correct draw amounts are submitted. We also in compliance with Federal statutes, regulations and terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Condition and Context: A summary of allowable charges for the grant was prepared for submission. Differences were noted when comparing the summary to timecards. Within the sample of 45, we noted that 31 timecards did not have a documented review. From the sample, we noted that the pay advice form, which reflects pay rate changes, for 2 employees did not indicate signature by an approver and only indicated the requestor's signature. The employees' new pay rate as indicated on the pay advice form was reflected in the payroll expenditure. Additionally, within the sample of 45, we noted 1 employee that did not have a pay advice form or contract to support the pay rate. We noted the following control items: ? 31 out of 45 timecards tested did not have documented review. ? 2 out of 45 employees tested did not have pay advice forms signed by both the requestor and reviewer. Only the requestor signed the form. ? 1 out of 45 employees tested did not have a pay advice form or other supporting documentation for the pay rate. Effect: Payroll expenditures could be inaccurately charged to the federal grant. Cause: The lack of documented timecard and pay rate approval were an oversight. Questioned Costs: None Recommendation: We recommend the Corporation maintain documented approval of all timecards and pay rate increases. Views of Responsible Officials and Planned Corrective Actions: The Transportation Department provides a spreadsheet that details time operators work by route. This process is used to align FTA funding streams with routes driven. The spreadsheet is kept by the Transportation Manager and reviewed by the Director of Transportation. These two positions approve time prior to submitting it for processing. GPTC is engaging its current payroll provider to assist in finding a technological solution to capturing start and end times of each operator. Until we can get this technical solution, an approval form will be submitted by the Transportation Department along with the allocation spreadsheet. As stated above, GPTC experienced a lot of turnover and personnel changes - the Human Resource Department had many. Pay advices are managed by this department. Our recommend that management prepare a schedule of all claims to determine whether there are additional amounts that have been overclaimed. Views of Responsible Officials and Planned Corrective Actions: In 2022, GPTC experienced a lot of turnover and personnel changes in multiple areas. In reassigning responsibilities, the Finance Department was designated as the area to handle FTA fund requests in June 2023. Absorption of these responsibilities required them to get an understanding of the process, formulate procedures for drawdowns, and develop a method for monitoring these dollars. The first drawdowns by the new team occurred in August 2023. FTA dollars are a major source of funding, so managing this process is highly important. GPTC has implemented a review process, as required by the FTA; and developed a spreadsheet for formulating amounts to be drawn. Iniquities in the spreadsheet were remedied in September 2023, and future processing has been good. GPTC realizes that FTA grants are reimbursable. The process requires prepayment of expenses, proof of payment, and reclamation of the FTA's portion of expended funds. So, future funds will be disbursed in a timely fashion. Large dollar amounts that require FTA funding for payment will be disbursed within three days, as required.