Corrective Action Plans

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.

Finding 2022-003 Contact Person Responsible for Corrective Action: Rhonda Morgan, FSD Contact Phone Number: 765-240-2386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Procurement: Frontier School Corporation will have the Food Service Director prepare contacts to all possible food & drink vendors asking for Vendor Bids for the following school year. Any email correspondence will be CC?d to the Corporation Treasurer and Superintendent when contacting the Vendors. A phone call log will also be kept by the Food Service Director. After receiving Vendor Bids, all Vendor Bids or Vendor Declining to Bid will be presented to the School Board for their approval. The Food Service Director will also give a recommendation at that time on who they would like to award the Vendor Bid to. After the School Board vote on Vendor Bid Awards, e-mail correspondence will be sent to all vendors with Corporation Secretary and Superintendent CC?d. All email data, phone logs, and School Board notes will be filed in the Food Service Director?s office. This internal control system will ensure compliance with the state Procurement agreements and requirements. Anticipated Completion Date: The CAP will be in place by March 24, 2023 in preparation for the Vendor Bids for the School Year 2023-2024 to be prepared and sent out in April 2023. Suspension and Debarment: Frontier School Corporation Food Service Director will check SAM Exclusions, collect a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. This information would then be kept in the Vendor?s file. Anticipated Completion Date: The CAP will be in place by March 17, 2023 in preparation for the Vendor Bids for the School Year 2023-2024 to be prepared and sent out in April 2023. The Food Service Director will have current vendors checked on SAM Exclusion or have a certification from that vendor, or adding a clause or condition to the covered transactions with the current vendors by March, 17, 2023.

The Authority is in the process of working with Illinois Department of Revenue to obtain an agreement for fiscal year 2023. Unless extraneous circumstances prevent the Authority from obtaining an agreement in a timely manner, the Authority will ensure intergovernmental agreements exist before commencing new program administration. The Authority will implement new policies and procedures to strengthen control.

FINDING 2022-001 Contact Person Responsible for Corrective Action: Kelli Keith Contact Phone Number: (812) 438-2655 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will maintain communication with the Wilson Education Center to ensure that they comply with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. In the event that the Wilson Education Center does not comply with the above requirement, the school corporation will look at the federal website to ensure that all vendors are on the approved list. If the Wilson Education Center fails to meet the above criteria, the school corporation would advertise to solicit bids for milk and bread. Anticipated Completion Date: January 13, 2023

Corrective Action Plan: The following actions will be taken: ? Work with the Ohio Department of Rehabilitation and Correction to obtain more accurate incarceration dates. Currently we are not receiving the dates the claimant is incarcerated in a facility. We are currently receiving their expected release date which does not meet the needs of the office. ? We do not believe there is a need to work with the Department of Health as there has been no discrepancy with the accuracy of the data provided. ? We will create a process to create a weekly review file and save those results for review and evaluation purposes for both death and incarceration records. ? We will create a procedure to investigate the results of the death and incarceration files consistent with our existing procedures to investigate similar situations. Anticipated Completion Date for Corrective Action: January 2024 Contact Person Responsible for Corrective Action: Carl Prideau, Section Chief-BPC, Ohio Department of Job and Family Services 30 East Broad Street, 38th floor, Columbus OH 43215 Phone Number: 614-644-5164, E-Mail Address: Carl.Prideau@jfs.ohio.gov

FINDING 2022-006 Contact Person Responsible for Corrective Action: Judy Brooks, Food Service Coordinator Contact Phone Number: 812-274-8001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Service Coordinator will follow our procurement procedures for all purchases. Food Service Coordinator will document that vendors for the BID are not suspended or debarred from participation in federal programs before purchasing also vendors used through the Wilson Center. The Deputy Treasurer will verify procurement and suspension and debarment documentation is on file before payment is made. When we are checking the vendors on the sams.gov website and there are no results founds then we will also request the vendor to submit a suspended and debarred form. Anticipated Completion Date: 2/13/2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Tammy Breedlove, Food Service Director Contact Phone Number: 765-569-4308 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The following internal control process has been added to the Business Office Handbook Effective February 1, 2023. It is the responsibility of the Food Service Director to ensure compliance and comply with the grant agreement and the Procurement and Debarment compliance requirements. Each School year, the Food Service Director & Superintendent will present the West Central IN ESC Food Service Bids & any Food Service Small Purchase quotes to the School Board for review and approval. Audit Evidence will be the Board packets and Board Minutes. Food Service Small Purchases- The Food Service Director will obtain quotes directly from the vendors or use the vendor?s website/catalog to compare products and prices. The Food Service Director attends WCIESC procurement meetings to get the most up-to-date pricing information. It is the responsibility of the Food Service Director to keep all documentation. The Food Service Director will present the documentation to the Business Manager for review. Small Purchase Vendors will be approved by the School board each School Year. Audit Evidence will be the quote documentation as well as the Board packets and Board Minutes. Anticipated Completion Date: March 15, 2023

FINDING 2022-006 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Todd VanDerWeele Contact Phone Number: 574.223.2159 Views of Responsible Official: We concur with the finding. The Special Education Director will obtain pricing when cumulative costs are projected to exceed the micro purchase threshold an adequate number of qualified sources. The Special Education Director will document and communicate the results of this process with the Business Manager and Superintendent. Anticipated Completion Date: July 31, 2023

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Amanda Bilbrey, Food Service Assistant Contact Phone Number: 574-831-2188 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Food Service will review bid packets to ensure documentation was provided as proof that the vendors were not suspended or debarred. If such evidence is not provided, the Food Service Director will verify and request appropriate documentation. Anticipated Completion Date: March 24, 2023

2022-055 Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $47,942 (known) Criteria: 2 CFR 200.1(1); 2 CFR 200.400(a); 2 CFR 200.404; 42 CFR ? 433.32(a) Federal regulations only allow the Medicaid program to charge allowable program expenditures at the federal financial participation rate for various program costs at the time of payment for services provided. The Department of Human Services (department) and the Oregon Health Authority (authority) make payments to vendors other than providers through the state?s accounting system. We judgmentally selected payments to 28 vendors for our review. We identified the following 2 errors, which were not identified during their review process, that resulted in improper payment of Medicaid expenditures: Payments to one vendor charged expenditures related to a specific project unrelated to the Medicaid program, resulting in known federally funded questioned costs of $1,361. For one payment management was unable to provide a contract or support for bids collected for the project charged to the Medicaid program, resulting in known federally funded questioned costs of $46,581. The above issues occurred due to human error and inadequate record maintenance which could lead to unallowed activities/costs being charged to the Medicaid program. We recommend department and authority management strengthen controls over review to ensure transactions are adequately supported and reviewed. Additionally, we recommend the authority reimburse the federal agency for unallowable costs. MANAGEMENT RESPONSE: We agree with this recommendation. ODHS Facilities Management Response for Finding #1: The Office of Facilities Management (OFM) is committed to providing accurate coding for payments. Communications have been made with staff responsible for coding invoices and the need to conduct thorough reviews to ensure coding is accurate and charged to the appropriate funding source for the goods or services the agency is being invoiced for. OFM will be communicating with the programs that provide coding to confirm that the information provided appropriately aligns with the intended use of the funds. The department will review current processes and forms to ensure there is sufficient detail to verify accuracy. Questioned costs of $1,361 in Federal Funds (and $2,722 in Total Funds) paid with invoice number VP815455, was corrected on 4/26/2023 with document BTCL1412. ODHS, Aging and People with Disabilities (APD) Response for Finding #2: The department is committed to storing and retaining supporting documentation for all authorized payments. The processes and procedures on contract bidding and approval associated with payment authorization for 1915k services and support are being reviewed and improvements such as central repositories are being explored. Once analysis and improvements are complete, they will be documented and communicated to staff within the department and to the Office of Financial Services for awareness. Additionally, as part of succession plan development, the department will create intentional opportunities for knowledge transfer, shared document storage, and increased transparency amongst work teams, which will assist with document location in the context of unexpected personnel changes. The department will reimburse the federal agency for any unallowable costs. Anticipated Completion Date: June 30, 2024 Contact: Jennifer Stallsworth, Chief of Staff or David Hawkins, Construction and Facility Maintenance Manager

2022-054 Department of Human Services/Oregon Health Authority Improve controls over payments for Medicaid clients Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.777 and 93.778 Medicaid Cluster Federal Award Numbers and Years: 2105OR5MAP, 2021; 2105OR5ADM, 2021; 2205OR5MAP, 2022; 2205OR5ADM, 2022 Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.1(1); 2 CFR 200.400(a); 2 CFR 200.404; 42 CFR ? 433.32(a) Federal regulations only allow the Medicaid program to charge allowable program expenditures at the federal financial participation rate for various program costs at the time of payment for services provided. The Department of Human Services (department) and the Oregon Health Authority (authority) make payments to service providers through the Jsystems system. We randomly sampled 61 clients and one Medicaid service payment associated with each client using a statistically valid sample. We reviewed agency documentation to test compliance with the Activities Allowed or Unallowed & Allowable Cost requirements. For 1 client, we found the issues described below. The claim selected as our sample item did not have mileage accurately calculated, which resulted in an overpayment. Further review of payments for this client identified additional inaccurate payments during the fiscal year for mileage to this provider. Questioned costs identified for our sample item resulted in an overpayment of $6.00 and other identified questioned costs resulted in an underpayment of ($5.27). The above issues occurred due to human error when entering mileage into the state payment system from the home care worker mileage tracking software (OR-PTC), which lead to improper payments. Phase 1 of the OR-PTC system was implemented in September of 2021. During this phase of the implementation branches must run a report of mileage claims and enter these claims manually into the payment system. Due to the exceptions noted above, we reviewed all clients within our sample for the fiscal year which had mileage entered into the OR-PTC system and identified multiple additional underpayments and overpayments that resulted in an overall underpayment of ($49.07). Due to the systemic nature of this issue, we are unable to reasonably estimate or quantify remaining potential questioned costs outside of our sample population. We recommend department and authority management strengthen controls over the OR-PTC system to ensure transactions are adequately supported and reviewed. MANAGEMENT RESPONSE: We agree with this recommendation. The department is engaged in ongoing efforts to mitigate this risk through continued communications with local offices and their leadership around the importance of correct data entry and reviewing changes to our KPI?s that we report quarterly to CMS. Regional Readiness Coordinators (RRCs) provide training, reinforce best practices, review business processes, and provide feedback on issues we are seeing to reduce incidences of human error. The department will also continue to review and research authorizations for Mileage and Time entries that do not align with existing claims to determine where additional RRC support is needed. Several system enhancements and changes slated for June 2023 are intended to help providers claim time accurately and reduce local office workload associated with reviewing pending entries. This will not fully resolve the issues noted by SOS, however, implementation of phase 2A of the Provider Time Capture System, which is scheduled to go into production July 12, 2024, will eliminate the need for local offices to manually enter mileage or hours into the mainframe payment systems and will automatically flag discrepancies between OR PTC DCI and the Mainframe. The department has corrected all identified issues discovered through the audit process. Anticipated Completion Date: July 31, 2024 Contact: Jennifer Stallsworth, Chief of Staff

FINDING:2022-003 Contact Person Responsible for Corrective Action: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 Views of Responsible Official: We concur with the findings Description of Corrective Action Plan: In the future the Food Service Director will check on Sam.gov for any Disbarment on any purchases that is over $10,000.00. She will print it out and initial and keep on file. In the future the Food Service Director will include in their Service Agreement form #1048, for Disbarment, Suspension. The School Corporation will seek Bids/Quotes for anything over $10,00.00 in the future. If the school is not asking for Bids/Quotes for repairs, we will use the company that we have a Maintenance Agreement with. Anticipated Completion Date: February 2023

CORRECTIVE ACTION PLAN FINDING 2022-004 Contact Person Responsible for Corrective Action: Region 8/Heidi Sprunger Contact Phone Number: 260-589-3133 Views of Responsible Official: We concur with the finding. The district is working with Region 8 to obtain the corrective action plan that was submitted previously. Description of Corrective Action Plan: We will monitor this with Region 8 to ensure that the corrective action plan that was submitted is followed. Anticipated Completion Date: Immediately

ALLOWABILITY OF EXPENDITURES Department of Health and Human Resources (DHHR) Assistance Listing Number 93.767 Microdyn OPPS quarterly updates for Pricer and Editor Dynamic Link Libraries (DLLs) are commonly received mid-month of the first month in the quarter after the Centers for Medicare and Medicaid Services releases quarterly updates. During 2022, releases occurred on January 15, April 16, July 16, and October 19. Although updates to the DLL were completed timely throughout the year, claims sampled for the audit fell into the periods of delay between the first day of the quarter and the updates to the DLL. Procedures are in place to reprocess any affected claims once the quarterly updates have been uploaded into the system. However, there was an interruption in the procedure to reprocess claims after the quarterly updates were uploaded to the claims processing system. Corrective action has already been implemented that includes automatically opting and populating the "reprocess claims" flag in the Request Management System (RQMS) when the Microdyn OPPS updates are entered to work. (The RQMS is the system used to enter and manage work orders for the Medicaid Management Information System.) Claims processing staff at the fiscal agent have also entered calendar reminders to reprocess claims as necessary after the OPPS quarterly updates are processed. All affected claims including claims sampled for the Single Audit were reprocessed and paid from mid-December 2022 through mid-January 2023.