Corrective Action Plans

Management agrees with the finding and recommendation. Management is working with the accounting team to implement a new process to ensure that an internal SEFA is prepared and reconciled on a quarterly basis, at a minimum. Management will review and approve all reconciliations.

FINDING 2022-006 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Reporting for ESSER. After this review, we will implement a system to ensure that all reports are properly reviewed and have the adequate supporting documentation kept on file. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

FINDING 2022-005 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Assessment System Security. After this review, we will implement a system to ensure that all compliance requirements are being met. We will implement a certification process for each building administrator to certify the training completed for their employees. Anticipated Completion Date: We expect this Corrective Action to be implement by August 2023 to allow for a full review of all internal control processes and procedures.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Annual Report Card, High School Graduation Rates. After this review, we will implement a system to ensure that all students that were removed from the cohorts are properly documented and appropriate approvals are obtained prior to student removal from the cohort. We also will implement a process to ensure that the reason for removal is consistent with the documentation. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

Reporting 2022-002 Significant Deficiency in Internal Control over Compliance Condition/context: During the audit of the School's, we noted that the School is maintaining excess reserve levels without an appropriately approved spending plan in place Auditors? Recommendation: Management should perform quarterly reviews of their reserve levels and modify their expenditure patterns to ensure reserves are maintained within approved limits. The required approvals should be obtained from the funder to expend excess funds. Management?s Response: The Organization had earmarked the reserve funds for the purchase of additional kitchen equipment associated with its new high school. Due to permit delays the opening of the high school was delayed by a year. Management anticipates that the excess funds will be spent during fiscal year 2023 and the Organization will be within the 90-day reserve level.

Reporting 2022-001 Significant Deficiency in Internal Control over Compliance Condition/context: During our audit of the School's major programs, we detected certain deficiencies in internal control over compliance. The School submitted vouchers for September 2021 and October 2021 late. The submission exceeded the required 60 days following the last day of the month covered by the claim. The September 2021 voucher could not be accessed and verified by auditors. Auditors? Recommendation: Management should maintain a checklist of all specific due dates associated with Uniform Guidance (?UG?) compliance, including credential renewals, voucher submissions, UG report due date, and other reporting requirements. Management?s Response: Management is aware of the reporting deadlines associated with voucher claims. Unfortunately, a staff member left the Organization and failed to file the annual renewal report, which resulted in the Organization being locked out of the vouchering system. The Organization immediately filed to renew but due to the time it took for the renewal process the September and October vouchers were filed beyond the reporting deadline. This has been rectified and procedures have been implemented whereby the Organization CFO reviews the renewal application to ensure timely filing.

Child Nutrition Cluster ? Segregation of Duties ? Grant Reporting Recommendation: We recommend that the District implement a review process over the reporting requirements related to the Child Nutrition Cluster Explanation of Disagreement with Audit Finding: There is no disagreement with this finding. Action Planned/Taken in Response to Finding: The District will implement a process by which the monthly grant reports are approved by a secondary position prior to submission. Name of the Contact Person Responsible for Corrective Action: Rod Huther, Business Manager Planned Completion Date for Corrective Action Plan: 12/15/2022

Finding # 2022-003 Material weakness over subrecipient monitoring U.S. Department of Agriculture ? Rural Development 10.755 Rural Innovation Stronger Economy Finding: The Organization?s subrecipient agreements did not include the required federal award identification, and the Organization did not provide sufficient financial monitoring of its subrecipients. One subrecipient had a single audit finding, and management did not take actions to resolve the findings with the subrecipient. Recommendation: The Organization should implement a subrecipient monitoring policy that ensure a proper system to monitor, detect and take timely follow-up action on any issues identified in site visits and internal or external audits. Management should evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward and monitor the activities of the subrecipient to ensure that the subaward is used for authorized purposes. The Organization should consider on-site reviews of the subrecipient?s operations and formalizing a monitoring report checklist to ensure that all compliance requirements have been considered and documented. Corrective Action: Spruce Root will review the federal subrecipient monitoring and management guidelines and update its policies and procedures to be consistent with federal requirements. Spruce Root will issue contract amendments for its subrecipient agreements to ensure the proper federal award identification is documented. Anticipated Completion Date December 31, 2023

Finding # 2022-002 Immaterial noncompliance over procurement U.S. Department of Agriculture ? Rural Development 10.755 Rural Innovation Stronger Economy U.S. Department of the Treasury 21.027 Coronavirus State and Local Fiscal Recovery Funds Finding: The Organization should follow the procurement standards set out at 2 CFR sections 200.318 through 200.326 including documentation to justify when a competitive process was not used. The Organization?s procurement policies also should be expanded to incorporate the provisions of the standards referenced. Recommendation: The Organization's procurement policy must have documented procurement procedures, consistent with state, local, and tribal laws and regulations for the acquisition of property or services required under a federal award or subaward. The Organization should maintain records sufficient to detail the history of procurement. Corrective Action: Spruce Root will review the federal procurement guidelines and update its policies and procedures to be consistent with federal requirements. Anticipated Completion Date December 31, 2023

Finding # 2022-001 Noncompliance over allowability of costs U.S. Department of Agriculture ? Rural Development 10.755 Rural Innovation Stronger Economy U.S. Department of the Treasury 21.027 Coronavirus State and Local Fiscal Recovery Funds Finding: USDA?s review of submitted reports, SF-270 and SF-425, identified various adjustments due to disallowed expenses included or insufficient supporting documentation for expenses incurred. Recommendation: The Organization should implement an additional review of expenses when preparing request for reimbursement and expenditure reports. Corrective Action: Spruce Root will enhance its review of expenditures before submitting to funders for reimbursement. Anticipated Completion Date December 31, 2023

"See Corrective Action Plan for chart/table"

"See Corrective Action Plan for chart/table"

Corrective Action Plan: Ohio?s corrective action plan for this finding includes system improvements, additional coordination with the Ohio Department of Job and Family Services (ODJFS) on monitoring the processing of IEVS alerts, and additional monitoring of county caseworkers? processing of IEVS alerts by ODM?s Medicaid Eligibility Quality Control (MEQC) unit. ODM and ODJFS continue to meet to analyze the alerts in Ohio Benefits and the group presents recommendations to our vendor for overall system alert improvements; these recommendations were prioritized and corrected in our normal release cadence. The next alert centered release is scheduled for April 2023. Comprehensive alert reduction efforts reduced overall ~29 million backlog alerts and drove a ~22 million annual reduction in new arrival of alerts. ODM, ODJFS and DAS remain committed to improving the alert functionality. ODM and ODJFS meet monthly to discuss triad reviews completed by ODJFS, that evaluate the counties? IEVS alert processing. ODM County Engagement follows up with the counties after these meetings to discuss action plans for working IEVS alerts. ODJFS also conducted a statewide training in July 2022 that focused solely on IEVS alerts processing. Additionally, some counties have taken part in one-on-one IEVS alerts trainings that have proven to be very beneficial. A system release devoted to IEVS enhancements is planned for R4.6.1 (April 2023) which will streamline the process for county staff to process IEVS matches from the IRS Unearned Income interface. There will be both E-Verify enhancements and a change in the match logic which will result in a reduction in the volume of IRS records that are flagged as IEVS matches. As a result, caseworker time spent on processing IRS IEVS matches is expected to reduce. The resulting time is expected to have more value by allowing caseworkers to focus time on matches with an eligibility impact or potential for benefit recovery. During SFY22, the MEQC unit continued to monitor IEVS alerts during the CMS pilot review process. During the review process, if it was determined that a case was processed with an unworked IEVS alert that resulted in a case processing error, it was cited as a technical deficiency and the county was notified. IEVS alerts will continue to be monitored by the MEQC unit going forward. Anticipated Completion Date for Corrective Action: ? The Ohio Benefits system improvement work and IEVS alert training ? Completed and continuing in fiscal year 2023 ? IEVS enhancement system release - April 2023 Contact Person Responsible for Corrective Action: Nathan Bowers, Program Integrity Audit Compliance Coordinator, Ohio Department of Job and Family Services 50 West Town Street, Columbus, Ohio 43215 Phone Number: 614-705-1049, E-Mail Address: Nathan.Bowers@medicaid.ohio.gov

Corrective Action Plan: ODM has either completed or begun corrective action on all of the following recommendations. CDJFS Caseworker Case Processing Weaknesses AOS cited caseworker reliance as an eligibility process weakness. While Medicaid eligibility systems have been updated to bring efficiencies in the Medicaid renewal and enrollment processes, human intervention is integral to ensure cases are processed accurately and appropriately. The dependence on caseworker knowledge and judgement is ongoing and is not perceived as a weakness, but an expectation for a state supervised county administered program. The federal regulation at 42 CFR ?431.10(c) limits the state?s ability to delegate authority to make eligibility determinations to only a government agency which maintains personnel standards on a merit basis. CMS provided additional information in its response to Q32 in the COVID-19 Public Health Emergency Unwinding Frequently Asked Questions for State Medicaid and CHIP Agencies document dated October 17, 2022, indicating that the merit-based personnel standards apply to all eligibility determination functions that require discretion, whereas contractors may be used to support the administrative functions of the eligibility determination process that do not require discretion. This guidance to states supports ODM?s established process that caseworkers are expected to exercise their own judgement with regard to the eligibility determination. Further, it would not be an effective use of federal or state funds to build an eligibility system in such a way that every possible exception scenario can be addressed by system rules and functionality. There are simply too many permutations of household scenarios and eligibility outcomes to make that a feasible option. As a result, caseworker knowledge, judgement, and discretion are integral to the eligibility determination process. AOS cited caseworker training as an eligibility process weakness. ODM, in collaboration with ODJFS, will continue to conduct a variety of trainings throughout the year as described below. While not yet mandatory, all trainings are offered to all 88 CDJFS agencies and are open to caseworkers and supervisors. In addition, high priority trainings are offered live on various days and times and are made available online to view at any time. At this time, we do not yet have the technology available to assign learning plans to county caseworkers and ensure completion, however ODM continues to consider its options for mandating training for county employees, and the advantages and disadvantages of that approach. ? New Worker Training - In SFY2022, the new worker training program underwent a total overhaul to update materials, improve interactivity, and close information gaps between programs. New worker training sessions are scheduled quarterly in 2023 and are offered to all new workers across the state. A new worker training began on February 27, 2023. ? Regularly Scheduled Webinars - ODM hosts monthly webinars and other targeted trainings throughout the year with all 88 counties. The monthly webinars include policy updates, training material, and general guidance or instruction on recent changes and issues. During SFY2022, ODM provided training updates on over 30 policy or procedural topics. Targeted trainings are scheduled to continue throughout 2023. Recordings for presentations are made available to access online at any time. ODM and ODJFS also host Operational System Release Webinars to review implemented system enhancements and fixes. ? On-Demand Inquiry Assistance - Technical Assistance and System support are provided via email for counties to submit questions and receive ODM guidance on both policy and procedures, as well as how to process within the Ohio Benefits system. During the return to routine eligibility operations period, county ?Ambassadors? have access to a Return to Routine Operations Team channel with real-time Q&A support, as well as training materials and desk aids. ? Future Training Plan - Moving forward, training will be a critical success factor for closing the knowledge gap(s) identified during various audits. ODM County Technical Assistance (TA) will identify the training topics, develop curriculum and training delivery methods for the identified training areas. To ensure successful and timely delivery, ODM TA will develop a 24-36 month training schedule of development, review, and delivery milestones to monitor progress. Calendar year 2023 training will focus on returning to routine case processing outside of the PHE, including revisiting conditions of eligibility, electronic verification processing, and proper discontinuance processes. ODM conducted six live sessions in February 2023, addressing returning to routine eligibility operations and will conduct a variety of trainings in April and May on eligibility basics, considering how many case workers have not determined eligibility outside of the public health emergency continuous eligibility restrictions. Recordings of these sessions are available on the County Resources page and will be converted to the Ohio Benefits Program website. The ODM Medicaid Eligibility Quality Control (MEQC) Unit continually monitors Medicaid case processing accuracy. The MEQC Unit reviews CDJFS eligibility determinations, verifies accuracy of recipient information in Ohio Benefits, verifies information is being maintained to support the eligibility decision, and evaluates timeliness of applications. All MEQC error and technical deficiency findings are shared with the CDJFS agencies for review, appeal, and correction if warranted. The federally mandated MEQC Pilot review is currently underway and is expected to be completed in March 2023, at which time regular case evaluations will begin. ODM promptly notifies the CDJFS agencies of errors, and the root cause analysis and corrective action plans are requested. The communication between MEQC and our ODM partners, ensures potential vulnerabilities in the eligibility determination process are being addressed promptly. In addition to the offered trainings and MEQC monitoring efforts, ODM has made significant improvements to the ex parte renewal process during SFY22, to increase the number of Medicaid renewals that occur in the system without county caseworker intervention. These ex parte updates are expected to greatly assist the CDJFS agencies and decrease the burden of processing cases, while also improving accuracy. The MEQC unit has been reviewing a sample of ex parte cases each month to ensure system modifications were effective. System improvements, CDJFS training, and monitoring will be ongoing as the Medicaid program continues to change over time. System Weaknesses Ohio Benefits generates alerts to notify CDJFS caseworkers of actions to be taken on a Medicaid or CHIP case. These alerts may include potential dates of death, notifications that individuals have moved to another state, and information about changes in income. Alerts are an important feature of the Ohio Benefits system. ODM has worked with ODJFS and DAS to reduce the volume of alerts generated in an attempt to improve the usability of the information for CDJFS caseworkers. ODJFS monitors IEVS alert completion. ODM has implemented automation using bots to help work and clear certain alerts. In 2021, multiple small releases, or `sprints? were implemented as part of the plan to reduce the volume of alerts being generated. Alert reduction efforts reduced overall ~29 million backlog alerts and drove a ~22 million annual reduction in new arrival of alerts. ODM, ODJFS and DAS remain committed to improving the alert functionality. The table below shows the impact in each of the sprints during SFY22 and the beginning of SFY23. Sprint Deployment Interface Projected Backlog Reduction Actual Backlog Reduction Projected Arrival Reduction-Monthly Actual Arrival Reduction Per Month Cumulative yearly Arrival Reduction 3 7.8.21 UCB SDX/SSI 936K 936K 399K 451K 4.7M 4 7.8.21 110K 115K 1.3M R3.8 8.14.21 Healthchek, Verification, LTC, DODD, DRC Incarceration, SVES Prisoner, AVS, Buy-IN 300K 736K 66K 63K 792K 5 9.17.22 SSP Document Upload, Companion EDBC 8.3M 9M 90K 100K 1.2M 6 4.15.23 IRS TBD TBD 33K TBD TBD ODM has plans for additional improvements in 2023 to reduce the volume of alerts generated. A sprint is scheduled in April 2023, after monitoring the impact of the initial five sprints. ODM continues to work with DAS and ODJFS on correcting defects and implementing enhancements to the existing alerts. In release R4.3 (August 2022), eight defects impacting alerts were corrected and in release R4.3.1 (September 2022), two alert enhancements were implemented, along with one additional defect fix. This weakness will continue to be remediated through future system modifications. ODM will continue to work collaboratively with DAS to update Ohio Benefits to bring efficiencies in effort to improve Medicaid eligibility determination outcomes. Several releases are scheduled into 2023 to improve system functionality. ODM will continue to evaluate enhancements to assist DAS in determining if the desired outcome was achieved.

Corrective Action Plan: The Department will review its current control processes over Transparency Act reporting control procedures and update them as necessary to ensure they promote compliance with the Federal regulations, as well as the accuracy and completeness of the information. Since the conclusion of the audit period, the Department has implemented procedures to upload the Transparency Act reports to the FSRS website. However, changes within the FSRS portal and with sam.gov have caused temporary technical challenges to reporting. Once these technical challenges are resolved, we will retroactively upload all outstanding reports and will continue to submit them monthly as required. Anticipated Completion Date for Corrective Action: June 2023 Contact Person Responsible for Corrective Action: Deckard Stanger, Chief Fiscal Officer, Ohio Department of Mental Health and Addiction Services 30 East Broad Street, Columbus, Ohio 43215 Phone: 614-752-8367, E-Mail Address: Deckard.Stanger@mha.ohio.gov

Corrective Action Plan: The Department will expand efforts to monitor and review its current subrecipient monitoring process and will review its current control processes and procedures over subrecipient monitoring, ensuring appropriate risk management monitoring, desk reviews, and Single Audit reviews are being conducted and appropriate level of coverage is obtained for each federal program based on major program testing to ensure compliance with 45 C.F.R. ? 75.352. The Department will conduct periodic reviews of all associated policies and procedures and update accordingly. These procedures will include maintaining all tracking spreadsheets and supporting documentation in accordance with the Department?s record retention policy. The associated spreadsheets and documents will be stored and maintained on a shared Teams channel that can be accessed by the appropriate staff within the Department in the event there is staff turnover in the future. Anticipated Completion Date for Corrective Action: June 2023 Contact Person Responsible for Corrective Action: Deckard Stanger, Chief Fiscal Officer, Ohio Department of Mental Health and Addiction Services 30 East Broad Street, Columbus, Ohio 43215 Phone: 614-752-8367, E-Mail Address: Deckard.Stanger@mha.ohio.gov

Identifying Number: 2022-001 Finding: The Center did not file a FFATA sub-award report for sub-grants greater than or equal to $30,000. The Center did not have a policy and procedures in place to ensure compliance with the FFATA reporting requirement. Corrective Actions Taken or Planned: On June 28, 2023, the Vice President of Finance of the Center filed the FFATA sub-award report for sub-grants greater than or equal to $30,000.

2022-001 Audit Adjustments and Oversight of the Financial Reporting Process Material Weaknesses Name of contact person ? Laura Straw, Director of Finance Corrective action ? Agate hired a new Finance Director during the year who was learning the intricacies of the Organization through year-end. During this she discovered that the entries from the merger were missing but did not have all the necessary information to adjust the financials. By the end of the audit, she had a thorough understanding of the Organization and is aware of what adjustments need to be made going forward. Completion date ? Management and the Board of Directors implemented the above as of December 2022.

Elementary and Secondary School Emergency Relief Fund Wage Rate Requirements Elementary and Secondary School Relief Fund ? Assistance Listing No. 84.425 Recommendation: CLA recommends the District implement controls for monitoring third party contractors when the contractors are responsible for compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: District will obtain all the certified payroll information, confirm review by CESA or whoever the construction manager is and note on the copy of the invoice that certified payrolls for x dates were received by the District and kept in a project folder on the network drive. Name(s) of the contact person(s) responsible for corrective action: Lisa Miller Planned completion date for corrective action plan: Ongoing

Elementary and Secondary School Emergency Relief Fund Segregation of Duties Elementary and Secondary School Relief Fund ? Assistance Listing No. 84.425 Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases when purchase orders are not required, along with adding controls to ensure that the item purchased was received by the District. We also recommend the District review its payroll process and identify payroll tasks that could be reassigned to other district personnel or consider implementing additional review procedures specifically focused on payroll and related fringe benefit costs claimed on federal and state grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We continue to look for ways to segregate duties and will improve on the review process for grants but with the current financial situation, additional staff cannot be added. Name(s) of the contact person(s) responsible for corrective action: Lisa Miller Planned completion date for corrective action plan: Ongoing

Child Nutrition Cluster Procurement Segregation of Duties Child Nutrition Cluster ? Assistance Listing No. 10.553, 10.555, 10.559 Recommendation: CLA recommends the District review its procurement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving micro purchases, along with adding controls to ensure that the item purchased was received by the District. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We continue to look for ways to segregate duties and will improve on the review process for grants but with the current financial situation, additional staff cannot be added. Name(s) of the contact person(s) responsible for corrective action: Lisa Miller Planned completion date for corrective action plan: Ongoing

Child Nutrition Cluster Reporting Child Nutrition Cluster ? Assistance Listing No. 10.553, 10.555, 10.559 Recommendation: CLA recommends the District implement a review procedure over reimbursement requests where someone other than the preparer reviews the claim to ensure counts agree back to supporting documentation prior to the reimbursement request being filed with the granting agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We continue to look for ways to segregate duties and will implement a review procedure for reimbursement requests. Name(s) of the contact person(s) responsible for corrective action: Lisa Miller Planned completion date for corrective action plan: Ongoing

Identifying Number: 2022-002: Special Test ? Wage Rate Requirement Finding: Nonfederal entities shall include in their construction contracts subject to the Wage Rate Requirements (which still may be referenced as the Davis-Bacon Act) a provision that the contractor or subcontract comply with those requirements and the DOL regulations (29 CFR Part 5, Labor Standards Provisions Applicable to Contacts Governing Federally Financed and Assisted Construction). This includes a requirement for the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls) (29 CFR sections 5.5 and 5.6; the A-102 Common Rule (section 36(i)(5)); OMB Circular A-110 (2 CFR Part 215, Appendix A, Contract Provisions); 2 CFR Part 176, Subpart C; and 2 CFR section 200.326). The School Board did not have adequate internal controls in place to verify this compliance requirement for this particular award prior to funds being spent. School Board employees were unaware the Wage Rate Requirement was applicable for this program. Corrective Action Taken or Planned: The policy on the Uniform Grant Guidance for federal grants will be updated to be more clear on the requirements. Also, the CFO will communicate the requirements to ensure all employees responsible for federally sourced funds are adequately trained. Anticipated Implementation Date: March 1, 2023 Responsible person: Cheryl Mast

The Family Health Council of Central PA Inc. sent each provider a confirmation of all state and federal funds paid to them, which included the CFDA number, source of funds, description, contract number, and amount paid. Before finalized the FY 2023 sub-awards, fiscal staff reviewed the sub-awards and met with management and contract compliance staff to ensure that FHCCP?s FY 2023 sub-awards are in compliance with the Uniform Guidance.

Audit Finding Reference: Finding 2022-002 Planned Corrective Action: Easter Seals New Jersey agrees with the auditor?s findings. We are establishing new procedures that will strengthen communication between Finance and Program staff and have adopted controls with regards to obtaining, providing, and reporting subaward reporting requirements in accordance with 2 CFR Chapter 1, Part 170. Name of Contact Person: Aleisha Hart, Chief Financial Officer, ahart@nj.easterseals.com, 732-955-8374 Anticipated complete date: Summer of 2023