Corrective Action Plans

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Significant Deficiency Contact Person Responsible for Corrective Action: Ann Hathaway Contact Phone Number and Email Address: 317-852-1126 ahathaway@brownsburg.org Views of Responsible Officials: We concur with the finding that there was not a review in place prior to submitting the report for 3/31/2023. The rules, dates and requirements were quickly changing for the reporting of the Coronavirus State and Local Fiscal Recovery Funds. With there being only one project and a relatively small amount spent, the report was filed with no errors. Description of Corrective Action Plan: The 3/31/2024 report was reviewed and further reports will be going forward. Anticipated Completion Date: Immediately

ALN: 84.425, 84.425F, Corrective Action Plan: Controls and Compliance - HEERF - MSU - The Montana State University - Bozeman will enhance internal controls to comply with federal regulations surrounding cash management and reporting requirements for new Federal programs, including those through the Higher Education Emergency Relief Fund (HEERF), and intends to use existing resources and controls within the university to strengthen the review and reporting requirements for new programs. The university is corresponding with the United States Department of Education to resolve the use of outstanding HEERF monies. Person(s) Responsible for Corrective Measures: Aaron Mitchell, Associate Vice President for Financial Services, Montana State University - Bozeman, Target Date: 12/31/2024

Corrective Action Plan: The Institute implemented the recommendations in the fourth quarter of fiscal year 2024.

FINDING 2023-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County did not have procedures in place to prevent, or detect and correct, errors on Project and Expenditure (P&E) reports submitted to the U.S. Department of the Treasury. The report submitted during the audit period included projects with current period obligations and cumulative obligations totaling $3,319,955 that had not yet been obligated by the end of the reporting period. It was recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight of federal reports are taking place and to ensure the County provides the Treasury with complete and accurate information for the P&E report. Contact Person Responsible for Corrective Action: Amy Copeland Contact Phone Number and Email Address: acopeland@ripleycounty.com; 812-689-6311 INDIANA STATE BOARD OF ACCOUNTS 21 Ripley County Auditor Amy Copeland – Auditor 102 West 1st North Street, PO Box 235 Versailles, IN 47042 Ph: 812-689-6311 Fax: 812-689-3006 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: I, Amy Copeland, Auditor, plan to have the county attorney sit with me when I fill this report out from now on. I will also have one of my employees look over it before it is submitted. Anticipated Completion Date: April 30, 2025

Finding 2023-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Anita Fuller, Finance Director Corrective Action Plan: Proposed Completion Date: Immediately

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2023-005 Child and Adult Care Food Program – Assistance Listing No. 10.558 Action taken in response to the finding: The Office for Food and Nutrition Programs (FNP) has moved from a paper based permanent agreement to a web form that exists on the DESE Security Portal. All existing and new Child Nutrition Sponsors will continue to sign off on the document via the web-based portal allowing for a more efficient collection and document retention process. A change will be made in the portal to automatically apply a DESE signature upon submission of the permanent agreement to avoid a late DESE signature. Name of the contact person responsible for corrective action: Rob Leshin, Director of FNP Planned completion date for corrective action plan: July 1, 2024

Condition: Obligations were overstated by approximately $650,000 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: The Town of Pepperell mis-stated $650,000 as obligated based on intended uses. $300,000 of those funds have been re-directed to real obligations and the Select Board will be authorizing additional spending in the next 10 weeks. Anticipated Completion Date: October 31, 2024 Contact: Andrew MacLean, Town Administrator, Pepperell amaclean@town.pepperell.ma.us, 978-650-1621

The City will use the contract start date (7/1) as the Obligation date, and will submit the FFATA report accordingly.

All Final Expenditure Reports will include the appropriate expenditure amounts associated with the grant year.

Condition: The District recorded a duplicate deposit of $133,868 in federal funds to the general ledger. Corrective Action Planned: The Central Office will ensure that the general ledger transactions are reconciled to the final financial reports before submission to DESE. Anticipated Completion Date: June 30, 2025 Contact: William Plunkett, Director of Finance

Finding 2023-002 – Preparation and Maintenance of Equipment Population The single audit report included the following recommendation: To address the Condition identified above, we recommend Amtrak to continue integration of the systems in such a way that appropriate funding source would be tagged to each asset automatically and that required property records would automatically be consolidated into one system of record and updated in that system. Ensure that adequate IT interface and business process application controls over the completeness, accuracy, validity, confidentiality, and availability of transactions and data during application processing (input, processing, output, etc.) are in place. Additionally, management should consider breaking out large purchase orders containing multiple items of equipment and tools under one purchase request, by creating separate level 2 WBSE codes in order to distinguish between different types of items being acquired, in order to be able to provide more appropriate classification. Identification as a repeat finding: Not a repeat finding Management Response/Status of Action Plans: Amtrak will implement the following to mitigate the finding related to the equipment population. 1. To prevent errors regarding the mapping of grant funding to equipment, the Capital Accounting Department will be implementing additional procedures and validations in the preparation and approval of the equipment review population file. This will include additional cross checks to validate mappings from fund sources to equipment and an additional review by EAMDT. The additional review and approval steps will be formalized with documented steps before September 2024. 2. To prevent errors related to missing asset numbers, the Capital Accounting Department, in coordination with EAMDT, has implemented an additional review of the single audit eligible indicator and inclusion of an asset unit number at the time the equipment asset is recorded in the fixed asset ledger. Additionally, EAMDT and Capital Accounting are now utilizing automated reporting that allows real time review of single audit equipment additions and data fields from the Company’s systems. This reporting allows for a timely view of key data fields from the related systems including Asset Equipment Description, Asset Unit Number, Single Audit Flag, Last Audit Date and Conditions. All equipment with missing asset unit numbers will be investigated and corrected. If any equipment marked as single audit eligible appears as not being eligible, Capital Accounting will investigate and resolve. The contacts for this item are Carol Hanna, VP Controller and Michele Millsaps, Assistant Controller, Capital and Inventory Accounting. Amtrak anticipates that changes above will remediate this finding in the fiscal year ending September 30, 2024 and beyond.

Finding 2023-002 Condition: The Town reported its entire award on the March 31, 2023 Project and Expenditure report as fully obligated and expended in error. Corrective Action Planned: Accounting will review all expenditures and amend the Project and Expenditure report to reflect the trial balance as of March 31, 2023. We will also ensure that reporting due April 30, 2024 is completed accurately based on the guidance of the Treasury. Anticipated Completion Date: By April 30, 2024 Contact: Caroline Burke, Town Accountant

Finding: The Office of Superintendent of Public Instruction improperly charged $42,265 to the Special Education Cluster. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 84.173 COVID-19 Amount $42,265 Status: Corrective action complete Corrective Action: As stated in the finding, the Office has adequate internal controls to comply with period of performance requirements. To address the allowable periods for journal vouchers (corrections), the Office will ensure the correction cycle will align with federally established liquidation periods. In response to the finding, the Office has updated procedures to strengthen internal controls, as follows: • Monitor monthly expenditures to ensure the Office stays within the allowable pre-determined threshold and grant award limit. • Complete expenditure corrections within the grant liquidation period. • Liquidate obligations charged to the grant on the last business day of January (or 120 days after the budget period ends). • Request prior approval of late liquidations from the federal grantor as needed. The Office will communicate the corrective action plan with internal stakeholders to ensure compliance with updated process/procedures. The Office will consult with the federal grantor to discuss whether the questioned costs identified in the audit should be repaid. Completion Date: January 2024 Agency Contact: Amy Kollar Director of Agency Financial Services PO Box 47200 Olympia, WA 98504-7200 (360) 725-6283 Amy.kollar@k12.wa.us

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with requirements to ensure it met the earmarking requirements for the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 84.173 COVID-19 Amount $378,206 Status: Corrective action complete Corrective Action: When the Special Education program underwent a fiscal leadership transition in 2021, the incoming director identified necessary changes in agency procedures for closing out fiscal year (FY) 2021. The director and budget analyst have been maintaining weekly check-ins since May 2022 to discuss the implementation of proper internal controls. Beginning in FY 2023, the Office has fully implemented processes to ensure spending plans do not exceed the maximum allowable amounts earmarked for administration and other state-level activities. The updated procedures require the director of Operations and the budget analyst to perform the following: • Review criteria for spending plans at the beginning of the fiscal year. • Review the Grant Award Notice and Grants to States Summary Table and Preschool Grants to States Summary Table. • Review spending plans and update the maximum allowable amounts earmarked for administration and other state-level activities in the spending plan throughout the fiscal year. • Meet weekly to review spending plans and update plans as requests are received. • Review monthly expenditure reports during weekly meetings. These updated procedures have contributed to increased communication and partnership between the director of Operations and the budget analyst. These internal controls provide assurance that the Office will meet earmarking requirements and compliance with federal rules. The Office will consult with the federal grantor to discuss whether the questioned costs identified in the audit should be repaid. The conditions noted in this finding were previously reported in finding 2022-025. Completion Date: March 2024 Agency Contact: Tania May Assistant Superintendent, Special Education PO Box 47200 Olympia, WA 98504-7200 (360) 725-6075 Tania.may@k12.wa.us

Finding: The Department of Social and Health Services did not have adequate internal controls over and did not comply with requirements for monitoring subrecipients to ensure payments were allowable, properly supported and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $312,659,850 Status: Corrective action in progress Corrective Action: The Department partially concurs with the finding. The Department’s Office of Refugee and Immigrant Assistance (ORIA) administered this funding through the Washington COVID-19 Immigrant Relief Fund program and contracted with a subrecipient organization to conduct eligibility determinations to approve and disburse funds to undocumented immigrants. This program is now closed, with all subrecipient contracts ended and the final payments sent in early 2023. The Department is taking action to strengthen internal controls over subrecipient monitoring for ORIA’s contracts. By July 2024, the Department will: • Complete a review of all active contracts utilizing federal funding to ensure subrecipients are accurately identified. • Explore the feasibility of increasing ORIA and Economic Services Administration accounting staff resources to support the workload increase associated with monitoring subrecipients. By October 2024, the Department will convene a work group with contracts and accounting staff to create effective internal controls and written procedures for fiscal and program monitoring of ORIA’s subrecipient contracts. This will include the following: • Verify the subrecipient status for each contract is correctly determined and recorded in the Agency Contracts Database. • Include the required subrecipient language in the contract. • Obtain a copy of the indirect rate certification or cost allocation plan from the subrecipient. • Complete risk assessments. • Create appropriate monitoring plans for each subrecipient. • Conduct fiscal monitoring of each subrecipient to obtain assurance that the use of federal funds complies with federal laws and regulations. • Create corrective action plans when required. By January 2025, the Department will ensure all ORIA program staff responsible for monitoring receive training on the updated procedures. In addition, the Office of the Secretary will request the Department’s Internal Audit and Consultation office conduct an internal audit of ORIA to ensure the program implements strong internal controls, properly accounts for federal funds, and materially complies with federal requirements. The Department does not concur with the questioned costs. The funds were used to assist Washington workers/families who were affected by the COVID-19 pandemic but were unable to access federal stimulus programs and other social support due to their immigration status. Repayment of these funds would only hinder the state’s ability to provide critical services to our clients. If the grantor contacts the Department regarding the questioned costs, the Department will discuss this with the Department of Health & Human Services and will take additional action as appropriate. Completion Date: Estimated January 2025 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with requirements to monitor subrecipients and to ensure payments were allowable, properly supported, and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $75,251,225 Status: Corrective action in progress Corrective Action: Completion Date: Agency Contact: The Legislature appropriated Coronavirus State and Local Fiscal Recovery Funds (SLFRF) to the Department’s Energy Division to award assistance to utility service providers to eliminate customer account arrearages. Payments for the program ended in 2022 and the program is no longer funded by the Department. The Department will implement procedures to strengthen internal controls for future programs managed by the Energy Division to ensure payments to subrecipients are adequately supported, allowable, and only reimburse costs incurred during the grant period of performance. As part of the audit resolution process, the Department will: • Work with utilities to obtain official client arrearage reports to verify the amounts paid and the period in which they were incurred. • Verify all households served were eligible per U.S. Treasury guidance. • Reconcile all allowable and unallowable expenditures. • Consult with the grantor to discuss the resolution of any questioned costs identified. Estimated July 2024 Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with requirements for monitoring subrecipients to ensure payments were allowable, properly supported and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $95,560 Status: Corrective action complete Corrective Action: The Department’s Eviction Rental Assistance program which was funded with the Coronavirus State and Local Fiscal Recovery Funds ended in June 2023. During the audit period, the Department implemented procedures to strengthen internal controls to ensure expenditures were allowable, properly supported, and in compliance with the subrecipient fiscal monitoring requirements. The Department’s Homelessness Assistance Unit implemented the following corrective actions: · Updated unit reimbursement procedures to include a requirement for supporting documentation that details transaction level expenditure information for direct expenses that reconciles to payment requests. · Provided training to staff on reviewing transaction level supporting documentation to ensure expenditures reconcile with reimbursement requests and are within the period of performance. · Added a review note to each reimbursement request to document the grant coordinator’s review of documentation and reconciliation to payment requests. · Worked with the Department’s internal control officer for review and feedback of the updated procedures. The Department is currently working to standardize a reimbursement documentation process that is in compliance with federal requirements. The Department will discuss any repayment of questioned costs through the normal audit resolution process with the Department of Treasury. The conditions noted in this finding were previously reported in finding 2022-019. Completion Date: April 2024 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with requirements to ensure payments to subrecipients of the Emergency Rental Assistance program were allowable and properly supported. Questioned Costs: Assistance Listing # 21.023 COVID-19 Amount $4,123,486 Status: Corrective action complete Corrective Action: The funding for the Emergency Rental Assistance program ended on June 30, 2023. The Department is no longer funding this program. To address the control deficiencies reported in the prior year’s finding, the Department improved internal control processes, resulting in improved compliance. The Department strives to meet all federal requirements and any repayment of questioned costs will be determined through the normal audit resolution process with the U.S. Treasury. The conditions noted in this finding were previously reported in finding 2022-016. Completion Date: July 2023 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

Finding: The Washington State Department of Transportation did not have adequate internal controls over and did not comply with cash management requirements for the Formula Grants for Rural Areas program. Questioned Costs: Assistance Listing # 20.509 Amount $41,555 Status: Corrective action complete Corrective Action: The audit identified a payment that was entered into the Electronic Clearing House Operation (ECHO) system with incorrect project information. The Department has since implemented additional controls to help ensure the draws of program funds are timely and accurate and are drawn for the correct program. To address the audit recommendations, the Department: • Assigned Project Support and Receivable (PS&R) staff to submit Public Transportation ECHO draws. Two additional staff have been identified as backup in this process to ensure draws are processed timely. • Rescheduled the entry of draw information into the ECHO system to the morning to allow for timely corrections as needed. • Updated the ECHO system to allow automatic confirmation email for payments entered into the system. Additionally, • The PS&R Manager will automatically receive draw confirmation emails and conduct a review and check as the draws are being submitted. • Additional checks and balances will be performed by the person entering information into the ECHO system. • The Public Transportation division has a validation process in place for staff to check the amounts with the project. The Department will continue to review procedures regularly and update as required to ensure compliance. The questioned costs identified in the audit have been reimbursed to the incorrectly charged federal program. Completion Date: October 2023 Agency Contact: Jesse Daniels External Audit Liaison PO Box 47320 Olympia, WA 98504-7320 (360) 705-7035 danielje@wsdot.wa.gov

Finding: The Employment Security Department made improper payments to ineligible beneficiaries of the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $603 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The State Auditor’s Office (SAO) made the assertion that the Department incorrectly interpreted guidance in the Unemployment Insurance Program Letter (UIPL) No. 16-20 requiring claimants to provide proof of employment to receive Pandemic Unemployment Assistance (PUA) payments. However, the section cited by SAO was paragraph b(ii) which only lays out the requirements for establishing the respond-by dates for providing documentation for review. The deadline for responses is different depending on whether the PUA claim was filed before January 31, 2021, or on/after that date. This paragraph does not establish the requirements for payment or non-payment of PUA weeks. In our finding response, the Department cited section C.2 of the UIPL, which states: If, in that timeframe, the individual fails to provide documentation or fails to show good cause to have the deadline extended, an overpayment must be established for all of the weeks paid beginning with the week ending January 2, 2021. This is because the individual cannot be deemed ineligible for a week of unemployment ending before the date of enactment solely for failure to submit documentation. Therefore, the three cases identified by SAO should not be exceptions under this guidance. Further, the Department received guidance from the U.S. Department of Labor on January 11, 2021, which confirmed the proper methodology used by the Department. Completion Date: Not Applicable Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

The Department of Community Affairs (DCA) has reviewed and enhanced internal controls and procedures to ensure that all required information, as per the federal Uniform Guidance pass-through entity requirements, is included in all new LIHEAP subaward contracts. These subaward agreement control enhancements have been implemented effective with the fiscal year 2024 contracts. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

The Division of Aging Services (DoAS) will comply with the pass-through entity and subrecipient monitoring requirements under the federal Uniform Guidance as per CFR § 200.332(a). The DoAS will provide all required information to the subrecipient at the time of award issuance. This subaward notice will be posted as a miscellaneous attachment to contracts in the Division's System for Administering Grants Electronically (SAGE), or via mail, fax or email to those subawards not administered in SAGE. DoAS plans to complete and update this information on SAGE within 60 days. COMPLETION DATE/ CONTACT PERSON May 31, 2024 Hetal Bhatt (609) 438-4586 Hetal.Bhatt2@dhs.nj.gov Dennis McGowan (609) 438-4739 Dennis.McGowan@dhs.nj.gov

Staff members have received updated training to become more familiar with the inventory process to ensure equipment is properly tracked.

2023-024 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program MANAGEMENT RESPONSE: We agree with this recommendation. The ODHS Office of Facilities Management coordinates care of a 168-building portfolio. Part of this work is coordination of furniture reconfiguration, minor and major remodels of office spaces and other building maintenance work. For these projects we rely on program staff with understanding of their funding sources to provide us with accurate coding to support the project related costs. Our office does not work directly with funding source management only coding and billing. To better track who is providing us the coding and maintain a record of payment approval we have revised our workorder form to include who from the program is providing the coding and what authority they have to provide the coding. This will allow us to assure that important details are captured regarding funding application and coding for billing and protect from funds being drawn from sources that do not support and/or are not appropriate for a given project. The questioned costs of $3,849 were corrected and refunded to CMS using document BTCL1485 with a April 17, 2024 effective date. The refund will be reported on the Q3 FFY 2024 CMS 64 which will be submitted by June 30, 2024. Anticipated Completion Date: June 30, 2024 Contact person: Karuna Thompson, Construction and Facilities Maintenance Manager; Travis Labrum, Grant Accounting Manager

Condition: Obligations were overstated by approximately $800,000 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: Will adjust on March 31, 2024 Project and Expenditure report. Anticipated Completion Date: April 30, 2024 Contact: Nicole Pearsall, Town Accountant