Corrective Action Plans

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

FINDING 2022-002 Finding Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The School Corporation had not designed or implemented adequate policies or procedures to ensure that proper procurement procedures for small purchases were followed. There was no oversight, review, or approval process in place and documented at the School Corporation to ensure proper procedures were followed and price or rate quotations were obtained, or documentation to support limited procurement procedures conducted. Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $150,000 per Indiana Code. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micropurchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. The School Corporation did not obtain price or rate quotes for the five vendors tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micropurchase threshold. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. The School Corporation also did not follow procurement requirements for contracted services which exceeded the simplified acquisition threshold of $150,000. The School Corporation did not correctly procure a contract for the one vendor that exceeded the simplified acquisition threshold. Additionally, the School Corporation did not adequately maintain documentation of the procurement history or rationale. Finally, the School Corporation did not verify that this vendor was not excluded or disqualified from participation in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Matthew Miles, CFO Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will obtain 3 quotes or do a bid process in the future. If there is limited availability, we will document the reason 3 quotes are not possible. Additionally, the District INDIANA STATE BOARD OF ACCOUNTS 34 will check for suspension and debarment, create a write-up of our findings, and obtain Board approval for the contract. Anticipated Completion Date: The School District will implement changes described in the Corrective Action Plan February in 2024.

(A) CDHS agrees that it needs to it needs to correct the automated reporting process from the eClearance system used to gather data needed for our FFATA reporting. The department thought that the reports obtained from eClearance were complete and relied on them as the basis of our reporting. Upon investigation we found that an internal process change enacted during the implementation of another system at the start of the pandemic was the cause of the data discrepancy. This occurred because the new system made the routing in eClearance after a certain point unnecessary for internal processing so this stopped. It was unknown that this further routing to archive files in eClearance was the trigger for eClearance to push out FFATA report data. Since the department has been able to identify the cause we are able to immediately remedy the problem and ensure that all processes are in sync to ensure accurate and complete FFATA data is contained in automated reporting processes. The department will catch up on FFATA reporting that was missed during this time frame. (B) The department agrees that it needs to implement procedures to validate that data derived from automated processes used as a basis for FFATA reporting should be periodically validated against another data source. To do this the department will create and implement procedures to use CORE reports of encumbrance data referencing subrecipient object codes and tie this to information received from the automated eClearance report. Doing this will validate that the data provided from eClearance is a complete listing of all FFATA reportable subrecipient awards, and thus is a valid source to base FFATA reporting on. This will also help us monitor the process in case any future inadvertent changes are made to processes that could cause data validity issues. (C) CDHS agrees that a supervisory review is needed over the FFATA reporting process in order to ensure more consistency, accuracy and timeliness in reporting processes and standards. The department is currently developing procedures that will allow for more oversight of the FFATA reporting through supervisory reviews and cross training staff on FFATA reporting duties. Supervisory reviews will help ensure that reporting is completed in line with reporting procedures and timeframes and can be a second set of eyes to ensure that information appears accurate and adds analytical judgement value (example - a supervisor might see that July typically has high volume, but this July volume is low, why). In addition, the department is taking this opportunity to cross train other staff on the process so that more individuals can be involved which leads to more transparency over processes allowing various individuals to notice if something isn't working as designed. These new procedures are being developed and implemented as the department catches up on reporting subrecipient awards that were missed since the automated process stopped working.

(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about the nuances of the program and the reporting requirements as it was being implemented. During implementation we recognized that there are some inherent differences with P-EBT from other benefit programs which caused processes to have to be adjusted slightly. Additionally, timing of federal report filing for the P-EBT program is not in synch with our other processes and associated federal reporting requirements and deadlines. This makes it impossible to ensure reconciliation procedures are performed before filing occurs, which is one of our typical internal controls. As a compensating internal control CDHS will ensure that supervisory review processes are performed over P-EBT reporting, and that P-EBT reporting is reconciled to other sources (CBMS and CFMS) as soon as possible after reporting is available. If changes are discovered CDHS will make adjustments to filed P-EBT reports as needed based on reconciliation findings, and communicate changes to necessary parties. (B) CDHS will work to ensure better coordination between program activities and the accounting section relating to federal reporting changes. Accounting will iterate the importance of timely informing the accounting staff when changes are made to program filed federal reports. This message will be delivered in periodic fiscal meetings and identified on the closing calendar. The P-EBT program will ensure that corrections are communicated to accounting on any updates completed on the FNS-292-B report upon discovery, and no later than 30 days after the reporting period. (C) CDHS will ensure that review and approval processes are occurring as designed at various points in the process leading up to entry into CORE. As part of the Requisition (RQS) approval process program and accounting staff independently approve that the correct direct or subrecipient object code is used. These approved RQS transactions are then transitioned into encumbrance documents that drive which object code future expenditures will be booked to. For CCDF transactions related to this finding, both the OEC and Accounting teams inadvertently approved an incorrect object code in 4 RQS's. Staffing shortages coupled with a large increase in workload related to pandemic funding contributed to this oversight. To correct OEC and Accounting will train new staff, periodically familiarize themselves with the appropriate object codes, and perform quality assurance review over object codes before applying approval in CORE. The K1 is compiled from balances derived from expenditure data recorded in CORE. The compilation of the K1 relies on the fact that expenditure balances are accurate, and that prior reviews and approvals of individual transactions have occurred as designed. The K1 currently goes through various levels of review focusing on balance level validation coupled with analytical procedures. To enhance the review process, CDHS will ensure analytical procedures include line level expenditure comparison at the direct and subrecipient levels.

(A) We agree with this recommendation. In recent years, the Federal Government had multiple continuing resolutions in their budget process, resulting in CDE?s Title I allocations coming in multiple iterations. For the last several years, CDE has received revised allocations from the US Department of Education for the fiscal year as late as early summer; in one example, we received six revisions. With staffing shortages and the administrative burden to continuously revise, research issues and update FFATA for each allocation change, CDE took the step to report only the final allocation to FFATA, which was reported as of the month the awardee was awarded. However, the report was submitted later in the fiscal year. CDE will take a two-fold approach to rectify the issue related to the required FFATA reporting for Title I. First, we will report to FSRS the initial awards within 30 days following the date the awardee was provided final approval on their award. This is consistent with CDE?s approach to all other federal awards. Second, we will monitor the continuing resolutions and changes in allocations, and report only the net changes to each awardee, in the month those changes occur from the US Department of Education. Thereby, FSRS will represent the total revised award. In addition to this approach, all Title I awards will continue to be a part of our regular FFATA reconciliation process. (B) We agree with this recommendation. CDE identified its own failure to report two ESSER subawards to FFATA within 30 days as part of the successful development and implementation of a FFATA-specific reconciliation process in Summer 2022. CDE will continue to refine and improve its FFATA reconciliation process.

By the implementation date, the Department of Labor and Employment (CDLE) will complete a review of grant agreements for reporting requirements, including the Federal Funding Accountability and Transparency Act of 2006. By the implementation date, the CDLE will develop and implement appropriate controls and processes to come into compliance with the reporting requirements and submit FFATA reports for the 10 entities identified in the audit.

Management agrees with the recommendation. Due to hiring of new staff and an internal audit with similar findings, these actions were in process and implemented as of November 2022. These actions are part of the Sub Team?s standard operating processes and will continue. The proposed corrective action plan is as follows: - The hiring of new team members in 2022; all team members trained on subcontracting processes and documentation requirements with an emphasis on following standard baseline procedures. - New Subcontract Administrator (SCA) position tasked with compiling final packets for each sub, which includes a quality check to ensure all documents and signatures required are included. - Use of subcontract checklist and risk assessments required and consistently done by the team.

Federal Program Name: ? Block Grants for Community Mental Health Services ? ALN 93.243 ? Section 223 Demonstration Programs to Improve Community Mental Health Services ? ALN 93.958 Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on the incurred date, rather than paid date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: Management concurs with the audit finding. As the previous process for grant salary, fringe, and indirect billings was based on salary paid date this resulted in expenses on certain grants being allocated prior to the period of performance. While this was at least in part offset by eligible grant expenses not being billed at the end of the grant period, it was not in compliance with 2 CFR 200.1 for period of performance. The CFO, supported by the Controller and Grants Manager, will immediately update the controls and grants billing processes to be based on incurred date rather than paid date. Name(s) of the contact person(s) responsible for corrective action: CFO, Controller, and Grants Manager Planned completion date for corrective action plan: Will implement in fiscal year 2023.

FINDING 2022-010 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: June 2023

FINDING 2022-004 Contact Person Responsible for Corrective Action: Sue Hart Contact Phone Number: 812-752-8921 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Each vendor who has received payment from the school district from federal Child Nutrition funds, or is expected to in the future, shall be required to have at least one of the following filed with the school district each year: 1) SAM Exclusions without the vendor being listed as excluded or disqualified; or, 2) Certification of the vendor not being excluded or disqualified; or, 3) Including a clause or condition on any and all contracts or invoices confirming the vendor is not excluded or disqualified. The Director of Food Services shall maintain files with evidence of the above documentation and it shall be updated at least annually and no fewer than once per calendar year. In addition, the Director shall ensure price or rate quotes are acquired from all vendors the Director reasonably expects to pay more than the micro-purchase threshold and contracts shall be executed with vendors when purchases are between $50,000 and $150,000. Such contracts shall also be Board approved with copies uploaded to the Gateway system for ease of access by SBOA or the district in the future. Anticipated Completion Date: June 2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Greg Hopkins Contact Phone Number: 812-967-3926 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Small Purchases The Food Service Director of the local School Food Authority will work with the Food Service Management Company to ensure all items purchased are procured properly using the correct thresholds set by the state and federal government. Suspension and Debarment The Corporation is now contracted with a Food Service Management Company (Aramark). The Food Service Director reviews all agreements/contracts related to Food Service to ensure that they meet the requirements related to suspension and debarment. Once contracts/agreements are reviewed, the Food Service Director signs off. Anticipated Completion Date: Effective Immediately

Finding Number: 2022-008 Federal Program, Assistance Listing Number and Name: , Department of Health and Human Services, HIV Emergency Relief Project Grants Condition: Original Finding Description: Based on review of subrecipient agreements, we noted that the City?s contractor entered into a subaward agreement with the City?s subrecipients. Based on the definition of a subaward as defined by Uniform Guidance (UG), a subaward is provided by a pass-through entity to a subrecipient for the subrecipient to carry out part of a Federal award received by the pass-through entity. Further, a pass-through entity is defined as a non-Federal entity that provides a subaward to a subrecipient to carry out part of a Federal program. A contractor is not a pass-through entity. Contact Person Responsible for Corrective Action: Denise Fair Anticipated completion date: July 2023 Planned Corrective Action: The City will implement controls to ensure that the City Health Department provides oversight of the WIC participant eligibility process. The Health Department has hired a WIC Program Director who will monitor participant eligibility compliance and ensure that eligibility policies and procedures are maintained and followed. In addition, the city will perform a review of the contract and scope of service to confirm exclusion of subrecipient responsibilities.

Finding Number: 2022-012 Federal Program, Assistance Listing Number and Name: ALN 21.027, Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) Condition: Original Finding Description: The CSLFRF subrecipient agreements did not include the CSLFRF assistance Listing Number (ALN) as required per 2 CFR 200.332 (a)(1)(xii). Contact Person Responsible for Corrective Action: Sandra Yu Stahl and Terri Daniels Anticipated completion date: July 2023 Planned Corrective Action: The City has implemented a process to ensure that all subrecipient agreements contain the Federal ALN as required by 2 CFR 200.332. All subrecipient agreements will include a new exhibit as an attachment in the agreement that will include the ALN and any other required grant elements.

Program: AL 21.026 ? COVID-19 Homeowner Assistance Fund ? Subrecipient Monitoring Corrective Action Plan: N/A Contact: Major General Daryl Bohac Anticipated Completion Date: N/A

Program: AL 20.205 ? Highway Planning & Construction ? Subrecipient Monitoring Corrective Action Plan: NDOT will review all current active subaward agreements and verify federal subaward identification information is included. If information was not previously included in the original agreement or a supplement agreement, NDOT will provide a supplemental award notice to notify the subrecipient of the subaward identification information as required by 2 CFR ? 200.332. Contact: Khalil Jaber Anticipated Completion Date: September 2023

View of Responsible Officials The Department acknowledges the misinterpretation of the agreement as a subaward has led to a failure to comply with 2 CFR section 200.332(a). Underlying this misinterpretation was the Department?s failure to differentiate between entering into agreements with other state agencies and entities recognized as component units of state government such as the NH Business Finance Authority; noting agreements between state agencies would not require such compliance. Accordingly, the Department will review existing policies and procedures related to subawarding and subrecipient monitoring to ensure agreements with component units of state government are properly considered. Additionally, the Department will amend the existing agreement to ensure required award information is communicated and ensure all other subrecipient monitoring protocols are applied to the subaward. Anticipated Completion Date: June 30, 2023 Contact Person: Taylor Caswell

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have complete and accurate information for the P & E report. In addition to the policy and procedure, an added person will assist with these reports by creating the reports through our financial software and reviewing before giving the reports to the Auditor who will prepare the P & E reports and then the Commissioner?s will review before the Auditor submits the report to the Treasury. The Bartholomew County Auditor?s Office is continually designing and implementing a proper system of internal controls so that any errors are detected and corrective measures are made as needed, Anticipated Completion Date: December 31, 2023

Condition: For all four subawards selected for testing, the identification of the award being Research and Development (R&D) was not noted. Further, for two of the four subawards selected for testing, there was missing information from the subaward including (1) Recipient DUNS number (2) Unique Federal Award Identification Number (FAIN) (3) Assistance Listing number (4) Indirect Cost Rate. Lastly, one subaward did not include the following information: (a) Period of Performance of subaward (b) Amount of federal funds obligated and awarded (c) General terms and conditions of subaward (d) Federal award project description (e) Name of Federal awarding agency. Corrective Action Plan: EA recognizes that this required information must be provided to subrecipients. To prevent this error in the future, EA will design a cover page template including all required information. EA will confirm with Sikich that the form covers all requirements. EA will use this template for all subawards related to our grants. Responsible Person for Corrective Action Plan: Betsy Spore, Director of Finance and Accounting Implementation Date for Corrective Action Plan: 09/01/2023

FINDING 2022-004 Contact Person Responsible for Corrective Action: Auditor Contact Phone Number:812-265-8936 Views of Responsible Official: We Concur The Auditor will retain documentation and present to the Commissioners before submitting annual financial reports. Jefferson County will now also prepare a checklist for every preparation of all future ARPA reports due. Anticipated Completion Date: May 2024

We are working with our fiscal agent to review the requirements of the Uniform Guidance to ensure that the MTDC base is properly applied in future federal grants.

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Jamie Arce, Controller Contact Phone Number: 574-322-4863 Views of Responsible Official: Management agrees with the finding. Description of Corrective Action Plan: The City will review its existing policies and procedures surrounding adequate supporting documentation and will update policy as required. Training on this requirement will be provided to all City Staff involved in procurement. Anticipated Completion Date: October 31, 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: Mary K. Kaczka, Assistant Director, Community Development Contact Phone Number: 574-322-4472 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will take the following steps to address the period of performance weakness that have been identified: Staff involved with posting or reviewing of claims in both the city ledger and IDIS will be trained on the requirements of 2 CFR 200.343(b) regarding allowable costs during the period of performance. Changes to the claims process has been implemented in which CDBG staff includes the grant number and program year on the face of the invoice or claim sheet in addition to general ledger account number. Invoices are processed for claim packets by department office service staff and reviewed for accuracy and completeness by management. This change in process will assist in reconciliation between the City Ledger and IDIS. Anticipated Completion Date: August 31, 2023

Reference Number: 2022-029 Prior Year Finding: 2021-027 Federal Agency: U.S. Department Homeland Security State Department Name: Department of Safety and Homeland Security, Federal Emergency Management Agency (FEMA) State Division Name: Delaware Emergency Management Agency (DEMA) Federal Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters), COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Award Number and Year: 4526-DR-DE (2022), 4566-DR-DE (2022), 4627-DR-DE (2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: DEMA should review and enhance internal controls and procedures to ensure that all required information is included in all subawards, that subrecipients are properly monitored, and that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A contractor has been assigned to develop and implement internal controls to ensure all required information is included in all subawards, that subrecipients are properly monitored, and that evaluation of independent audits is performed. Subaward letters were updated in September 2022 and a monitoring protocol implemented to begin monitoring all subrecipients to date to include an evaluation of independent audits that is documented as part of the monitoring visit. Name(s) of the contact person(s) responsible for corrective action: Tramaine Childs Disaster Recovery Specialist Innovative Emergency Management Inc. 318.278.2813 (Mobile) Tramaine.Childs@iem.com Planned completion date for corrective action plan: September 26, 2022

CORRECTIVE ACTION PLAN JANUARY 10, 2023 The Brevard Health Alliance, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Carr, Riggs, and Ingram, LLC 215 Baytree Drive Melbourne, FL 32940 Audit Period: Fiscal Year October 1, 2021 - September 30, 2022 The finding from the January 10, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. 2022-001 PROCUREMENT PROCEDURES COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care For Homeless and Public Housing Primary Care) ? American Rescue Plan Act Assistance Listing Number: 93.224, Contract Numbers- H8F41284 Department of Health and Human Services (HHS) 2022 Funding Pursuant to 2 CFR ?200.1, Simplified Acquisition Threshold (?SAT?), acquisitions which exceed the SAT of $250,000 must use one of the following procurement methods: the sealed bid method, the competitive proposals method, or the noncompetitive proposal method (sole source). The Alliance did not utilize the sealed bid method or competitive proposals method for a purchase of computer hardware, which exceeded the $250,000 SAT. The Alliance?s procurement policy was not updated to be in compliance 2 CFR 200.1 until April 2022. This purchase began in fiscal year 2021, but the remaining items under the contract were procured in fiscal year 2022. Perspective: The purchase made at the beginning of the year was procured under the old purchasing policy. The policy was updated in April 2022, and the additional purchase exceeding the bid threshold made subsequent to the new purchasing policy was procured under a competitive process. Recommendation: The Alliance should continue to follow its updated procurement policy. Responsible Party: Shannon Wherry, Controller Corrective Action: Management updated the procurement policy April 2022 to comply with the provisions of 2 CFR ?200.1, 2 CFR ?200.67, and 2 CFR ?200.214. The updated policy has been implemented since this occurrence and will continue to be followed.

Finding # 2022-007 Title of Finding Subrecipient Monitoring Contact Person Brook Hinzman Anticipated Completion Date June 2023 Corrective Action planned to be taken: Will comply and monitor subrecipient spending going forward.