Corrective Action Plans

Auditor’s Recommendation: The Organization document internal control over compliance procedures and document written procedures to ensure compliance with 2 CFR 200.305. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

Eastern Carolina Human Services Agency, Inc. Corrective Action Plan For FY Ending June 30, 2023 Section II. Financial Statement Findings. 1. Finding 2023-001 - U.S. Department of Health and Human Services, Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: Internal control processes over financial accounting did not ensure that all transactions were properly recorded. Internal control processes over financial accounting did not ensure that key accounts were reconciled or received on a periodic basis. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director. Action Plan: After review/monitoring of the previous Finance Officers duties and responsibilities, it was determined that the internal control processes of the finance department were not carried out properly to meet the requirements of 2 CFR Part 200 Section 200.302. Therefore, the agency terminated the Finance Officer. The agency immediately began the search for a new Finance Officer via Indeed and other employment hiring agencies. This process took much longer than expected which left an unexperienced Accounting Technician to operate the Finance Department along with limited finance knowledge of the Executive Director. After several advertisements for the vacant position the agency interviewed numerous applicants and was finally able to hire the current Finance Officer. The Finance Officer has worked continuously to insure that the internal control process of the department is implemented by making sure all accounts are reconciled and reviewed with supporting evidence of each review. With this process back in place, management and the Board of Directors will review and sign off on each account's financial statements. Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-002 - U. S. Department of Housing and Urban Development Voucher Cluster, Assistance Listing #14.871/14.879 Statement of Condition: For the year ended June 30, 2022, the Organization did not submit their audited financial statements to HUD by the required deadline. For the year ended June 30, 2023, the Origination did not submit their unaudited or audited financial statements to HUD by the required deadline. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: The submittal of the GAAP-based unaudited and audited report for FY ending June 30, 2022, was a management oversight due to the lack of a Finance Officer in place. The agency currently has a Finance Officer in place who will submit timely GAAP-based unaudited and audited financial information electronically to HUD via the Financial Assessment Sub-System (FASS-PH). Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-03 - U.S. Department of Health and Human Services Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: The origination did not submit the data collection form and required reporting package to the Federal Audit Clearinghouse (FAC) for the year ended June 30, 2023, by the required due date. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: Management will ensure that the audit and data collection forms are completed timely and the data collection form and required reporting package are submitted electronically to the FAC each fiscal year going forward. To further ensure this finding is resolved, training for the Finance Officer/Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Section II - Findings relating to the financial statements which are required to be reported in accordance with generally accepted government auditing standards. 1. Finding 2022-001 Statement of Condition: Controls over the vendor payment process were not properly followed. Action Plan: Submitted previously with Financial Statements and Independent Auditor's Report FY Ended June 30, 2022. Current Status: Corrected The Management Department (Finance Officer and Executive Director), with the supervision of the Board of Directors Finance Officer, will continue to make every effort necessary to meet all HUD submission as required, in order to be in compliance with all HUD rules and regulations. Respectfully submitted, Trudy Murray Executive Director

Description of Finding: The Foundation was unable to accurately support the amount of federal dollars reimbursed during the fiscal year for one grant. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the requirements of the compliance requirements. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by March 31, 2025.

Catholic Charities of Central and Northern Missouri agrees with this finding and as of July 1, 2024 has altered procedures so that invoices and documentation related to expenditure of federal funds are now scanned and attached to the accounting entry recording the payable.

We are working with our Net Suite consultants to correct the historical transactions and on-going system procedures and processes to insure that the accounting software provides that all financial transactions are properly allocated to programs/properties funded with federal funds. Anticipated Completion Date-12/31/2024 . Responsible Contact Person-Kathleen Boyce, CFAO

Corrective Action: The district will ensure that all supporting documents will be stored electronically first and stored physically as a secondary option. Each department will be responsible for maintaining a copy of all supporting documentation. All checks and contracts will be included in the procurement packets for all expenditure. We are currently implementing this process and strengthening internal controls. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: October 31, 2024

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

Finding 2023-006 – Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: MSD Warren will submit a revised ESSER data report to DOE. Anticipated Completion Date: Completed as of the date of this report.

CONDITION: The District did not properly record its federal program expenditures for the ESSER and ARP ESER federal grant programs using the various funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations and well as Section 2 CFR 200.302(a) of the Uniform Guidance. CRITERIA: The financial management system of the District must provide for 1) identification in it’s accounts, of all Federal awards received and expended and the Federal programs under which they were received, and 2) accurate, current and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements set forth in sections 200.328 and 200.329 of the Uniform Guidance. 74CORRECTIVE ACTION PLAN: The School District concurs with the above noted finding. The School District has employed a new Business Manager whose responsibilities include the oversight of the financial management system and the posting of all transactions into that system. Procedures will be put into place during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for ensuring federal program expenditures are properly coded within the District’s financial management system so as allow for proper reporting related to those expenditures.

Contact Person LeAnn Littlewolf, Executive Director Corrective Action Plan We are in the process of updating the Organization’s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2024

U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes Auditee’s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD’s fiscal team enters the drawdown request into the Federal Payment Management System (PMX). An invoice is then created within Workday. When the City’s Department of Treasury receives the funds, the funds should be matched to the invoice and cash posted to the general ledger. One of the challenges with the City’s migration into Workday was billing and invoice matching for grant sponsors. This resulted in no posting of cash received from drawdown request to the general ledger. The Department of Finance has recently developed a process to resolve this issue. BCHD’s fiscal team will work with DOF to develop a reconciliation process for cash draws received after the City’s fiscal year end. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes Auditee’s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD’s fiscal team enters the drawdown request into the Federal Payment Management System (PMX). An invoice is then created within Workday. When the City’s Department of Treasury receives the funds, the funds should be matched to the invoice and cash posted to the general ledger. One of the challenges with the City’s migration into Workday was billing and invoice matching for grant sponsors. This resulted in no posting of cash received from drawdown request to the general ledger. The Department of Finance has recently developed a process to resolve this issue. BCHD’s fiscal team will work with DOF to develop a reconciliation process for cash draws received after the City’s fiscal year end. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.767 Children’s Health Insurance Program (CHIP) Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: No Auditee’s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD’s fiscal team enters the drawdown request into the Federal Payment Management System (PMX). An invoice is then created within Workday. When the City’s Department of Treasury receives the funds, the funds should be matched to the invoice and cash posted to the general ledger. One of the challenges with the City’s migration into Workday was billing and invoice matching for grant sponsors. This resulted in no posting of cash received from drawdown request to the general ledger. The Department of Finance has recently developed a process to resolve this issue. BCHD’s fiscal team will work with DOF to develop a reconciliation process for cash draws received after the City’s fiscal year end. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.044, 93.045, 93.053 Aging Cluster Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2023-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted, had approved and has implemented the new Internal Controls Policy that addresses this deficiency. This policy will includes sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: This was completed February 20, 2024.

Condition: As a precondition to receive federal awards, prospective recipients must have effective internal controls over the federal award. As described in 2 CFR, Part 200.303, nonfederal entities must have certain written policies and procedures surrounding the management of their federal awards. Such policies should include procedures for collecting payments of federal funds per 2 CRF 200.305, cash management (i.e., minimizing the time between draws and actual disbursing of federal awards) per 2 CFR 200.302(b)(6), allowable cost per 2 CFR 200.403, and conflict of interest per 2 CFR 200.318. Per 2 CFR 200.319(d), the non-Federal entity must have written procedures for procurement transactions. Recommendation: The Authority should adopt written policies and procedures over cash management and allowable costs required under the Uniform Guidance. Planned Corrective Action: The Authority implemented these policies during the FY 2024 (BA054 Cash Management Policy and BA059 Authorization of Purchases). Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

Name of Responsible Individual: Brenda Willis, Senior Executive Director of Financial Grants & Contracts Corrective Action: The internal control procedures for federal expenditures will be reviewed and updated to ensure that they comply with federal regulations such as the Uniform Guidance (2 CFR 200) and the Federal Acquisition Regulation (“FAR”). The roles and responsibilities of staff involved in managing and reviewing federal expenditures will be explicitly defined. All personnel handling federal funds will be trained on policies, compliance requirements, and how to detect red flags in grant activity. The approval workflow for federal expenditures will be assessed and updated by adding Sponsored Programs Office to the approval path to assist in preventing fraud and ensure compliance with regulations. The internal controls will be updated by December 2024 and training will commence in early 2025 Anticipated Completion Date: December 31, 2024

FINDING 2023-007 Finding Subject: COVID-19 – Education Stabilization Fund – Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance for the reporting requirement. Not all EESER reports submitted by the School Corporation during the audit period were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Description of Corrective Action Plan: We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Moving forward we will ensure all ledgers are attached to the reports that have been submitted. Anticipated Completion Date: The anticipated date of correction for this finding is January 1, 2025.

FINDING 2023-004 Finding Subject: Twenty-First Century Community Learning Centers – Cash Management, Program Income and Reporting. Summary of Finding: The School Corporation had not established an effective system of internal controls related to the grant agreement and the Cash Management, Program Income and Reporting compliance requirements. Cash Management The school submitted reimbursement requests without taking into considering the program income or reducing the request by the program income earned due to the lack of adequate program income. Program Income Controls had not been designed or implemented adequately to ensure that the proper fees were assessed and that the cash collections remitted were accurate. Additionally, the school-maintained program income in a separate fund and comingled with other non-grant funded program revenues. The unit did not deduct program income from allowable costs prior to claiming reimbursement. Reporting The total requested reimbursements for the audit period were understated by $32,605 when compared to the ledger. Of the two End of Year reports selected for testing neither properly included program income that was received during the year due to inadequate tracking of program income. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a system of internal controls to strengthen our policies and procedures and ensure the proper tracking of Program Income is reported and submitted accurately for Twenty First Century Learning center grant funds. Description of Corrective Action Plan: We have reached out to our liaison at the Department of Education to determine if program income should be reported monthly or annually. Management will be working with the Safe Harbor Director to implement a system to ensure separation of the Twenty first Century grants and other funds that are under the Safe Harbor program. Anticipated Completion Date: The anticipated date of correction for this is January 1, 2025.

Finding 2023SA-003 Insufficient Grant Monitoring Comments on the Finding and Each Recommendation: The County agrees with the finding. Action(s) Taken or Planned on the Finding: The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to grant reports that are filed. Name of Contact Person: Judi Pollock, County Clerk Projected Completion Date: Unknown