Corrective Action Plans

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.

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2023-001 Coronavirus Local Fiscal Recovery– Assistance Listing No. 21.027 Recommendation: We recommend that the Authority implements a control to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please contact Hector Ordonez, Vice President of Finance and Administration at (817) 333-3421 or hordonez@fwhs.org.

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree with the data submitted in the Reports, therefore we could not determine their accuracy. Contact Person Responsible for Corrective Action: Matt Miles 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 work to ensure the ESSER report amounts tie to the accounting records and will improve record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs / Cost Principles, Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Any transfers that happen, will be reviewed, and will have better documentation of what claims made the transfer happen and make sure supporting documentation is attached to the claim to prove the use of the transferred funds. Anticipated Completion Date: Immediately

Significant Deficiency in Internal Control over Compliance, Other Matters 2023-002 Reporting Recommendation: We recommend the County review its processes and implement controls to formally review these quarterly reports and that they are compared and reconciled to the general ledger. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County is planning a more in-depth checklist of accounts to be reconciled and journal entries to be made along with regular check in and team meetings to meet the deadlines. Name(s) of the contact person(s) responsible for corrective action: Michelle Uitenbroek, Finance Director Planned completion date for corrective action plan: December 31, 2024 If the granting agencies have questions regarding this plan, please call Michelle Uitenbroek, Finance Director at 920-832-1674.

Internal Controls over Grant Management (Significant Deficiency and Noncompliance) Recommendation: We recommend the City develop a grants manual or additional written policies that comply with the requirements of 2 CFR 200 and ensure compliance. Response to 2023-005: Internal Controls over Grant Management Significant Deficiency and Non-Compliance In response to the Deficiency in the City of Tallassee’s corrective action plan, the City is in the process of establishing a written financial management system in accordance with 2 CFR 200.302 to include written procedures to implement requirements for payment methods and determine allowability of costs in accordance with subpart E. Due to the City of Tallassee being a small town, we did not have the staff available prior to receiving the grant monies to complete the task due in part to the lack of individuals looking for work in a rural sparsely populated area. Because of our lack of personnel the project was not completed. The City of Tallassee has financial management internal controls in place. All of the City’s grant activities (Federal and State) are tracked in funds under unique assigned general ledger numbers for each grant awarded to the City. All 2019-CWSRL-DL funds are deposited into a dedicated bank account and are not co-mingled with other funds of any kind. The City also contracts out grant management to certified and approved grant management commissions and engineering firms for required tracking and reporting to the appropriate state and federal agencies.

SECTION III – FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 Material Weakness Reporting Criteria and Condition: While the Organization has some written financial management procedures documentation, it does not meet all the recent specific requirements under 2 CFR 200.302 in the Uniform Grant Guidance. Context: The financial management requirements under 2 CFR 200.302 require each non-federal entity maintain effective control over, and accountability for all funds, property, and other assets, including having written procedures in place. Key changes which effect the Organization include: • Increased documentation • Time and effort reporting for payroll • Specific purchasing consideration Cause: The Borough did not implement adequate controls to ensure compliance with this reporting requirement. Potential Effect: Errors could occur in financial reporting. Recommendation: We recommend the Organization update its existing policies to comply with the requirements under 2 CFR 200.302. Views of Responsible Officials and Planned Corrective Actions: Management understands the importance of defining and following the necessary policies and procedures to remain in compliance with the requirements under 2 CFR 200.302. Borough of Yardley will implement these policies and procedures to ensure that the organization will comply going forward. Repeat: Repeat finding from 2017-002 Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.

2023-002 U.S. Department of Environment Protection – Assistance Listing # 66.468 Capitalization Grants for Drinking Water State Revolving Fund (Drinking Water State Revolving Fund Cluster) Lack of Required Written Policies & Procedures – Compliance Condition & Criteria: The Authority does not currently have all the written policies and procedures in place as required by the Uniform Guidance as it relates to financial management and determining allowability of costs for the federal program (Title 2 U.S. Code of Federal Regulations (CFR) 200.302 & 200.305). In addition CFR sections 200.318, 200.319, and 200.320 require there to be written policies and procedures regarding procurement and conflicts of interest. Planned Corrective Action: The water systems improvements federally funded project is the Authority’s first time subject to the requirements of the Uniform Guidance as we have not had any significant grant funding since 2004. The Authority does have a set of informal policies and procedures that are followed as it relates to financial management, allowability of costs, procurement, and conflicts of interest, and have been very careful to carry out all federal program activities in accordance with established regulations; however, the Authority was simply not aware of the requirement that these polices and procedures be documented in writing. The Authority has been working over the past year to draft and develop these policies and procedures as they relate to federal programs, and to get them documented in writing. The Authority is currently working with their attorney to have the written polices established and plan to have this completed within the next fiscal year. Once the required policies are written, the Board of the Authority will review the policies, revise as appropriate, and adopt the policies for the Authority to comply with the federal funding requirements.

The finding arose due to conditions created as a result of turnover experienced by the Center within the finance department, expense reimbursement requests were inadvertently completed incorrectly using incorrect allocation percentages and information. Additional preventative internal control procedures will be implemented, including an additional level of review of the reimbursement request prior to submission.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2023-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations

Finding Number: 2023-003 Planned Corrective Action: The accounts payable clerk will double check all claims submitted to the state for accuracy. Anticipated Completion Date: 08/30/2024 Responsible Contact Person: Stacy Bolden

FINDING 2023-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Kosciusko County Sheriff's Office applied for the Indiana Local Body Camera Grant (ILBC). The sheriff’s office was awarded this grant on January 1, 2023, with a grant cost amount of up to $31,920. This grant is a reimbursable grant through the Indiana Department of Homeland Security. The period of performance was from January 1, 2023, to December 31, 2023. The Kosciusko County Sheriff's Office ordered body-worn cameras and equipment on April 26, 2023. The invoice for the cameras and the camera equipment was paid on July 14, 2023. The Kosciusko County Sheriff's Office then submitted a Reimbursement Claim Form on September 11, 2023. The Reimbursement Claim Form shows the Sheriff's Office incorrectly requested the full $31,920. They received $31,920 from the Indiana Department of Homeland Security on September 27, 2023. However, the county had only spent $9,581 of the grant money towards the body camera purchase. Therefore, there is a remaining balance in the fund of $22,339 as of December 31, 2023. Due to the period of performance, the county should have reimbursed the Indiana Department of Homeland Security $22,339. On May 9, 2023, the Sheriff's Office grant administrator submitted a Program Report for the ILBC grant. This report was filed without an implemented internal control or evidence of a review. The report was completed and submitted by the Sheriff's Office grant administrator. The report incorrectly indicated that all expenditures had been completed. As of the date of the submission, the county had not purchased the bodyworn cameras and all federal funds had not been expended. Contact Person Responsible for Corrective Action: Alyssa Schmucker Contact Phone Number and Email Address: 574-372-2325 aschmucker@kosciusko.in.gov View of Responsible Officials: We concur with the findings identified. Description of Corrective Action Plan: The Kosciusko Sheriff’s Office, grant coordinator will contact IDHS for instruction on how to return the $22,339.00 and prepare a claim to be processed by the Kosciusko County Auditor’s office. The grant balances are submitted each month by departments these are checked and confirmed by the Auditor’s Office this one was overlooked in the review process. The person who applied for the grant no longer works for the county. It is believed the new person handling the grants was not aware that this grant even existed. The Grant Administrator(s) will have someone sign off on the grant report submissions and forward all reports to the Auditor’s Office. Anticipated Completion Date: It is anticipated that this will be completed as soon as the information to return the funds is received from the state and the claim is submitted to the Auditor for payment. This claim will be paid as soon as it is received. On or before 12/31/2024.

U.S. DEPARTMENT OF THE TREASURY COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) – Federal Assistance Listing Number 20.027 Corrective Action Plan – Internal Control over Compliance Finding Condition: The County has inadequate controls over approving and disbursing funds for the Coronavirus State and Local Fiscal Recovery Funds program. Plan: The County will assess why the established controls over approving claims and signing checks were not followed in the approval and disbursement of Coronavirus State and Local Fiscal Recovery Fund program funds. Anticipated Date of Completion: 11/30/2024 Management Response: Management will follow its established controls over approving and disbursing Coronavirus State and Local Fiscal Recovery Fund program funds.

Will review all salary charges for ESSA

ALN: 10.542, 10.551, 10.561, Corrective Action Plan: Inadequate Accounting Records - SNAP - P-EBT - DPHHS - The Montana Department of Public Health and Human Services conditionally concurs with this recommendation. Expenditures were tracked separately by program and records were adequate to trace funds in accordance with federal regulations. The department will continue to improve its processes related to ensuring new federal program activity is not co-mingled with other programs, especially when closely related. Person(s) Responsible for Corrective Measures: Corinne Kyler, Administrator, Montana Department of Public Health and Human Services, Target Date: Completed

ALN: Various R&D, Corrective Action Plan: Equipment Inventory Controls - MSU - Montana State University - Bozeman will enhance the internal controls surrounding the capital asset inventory and tagging process, including accessing research space to count and tag new assets. The university had a difficult time over the pandemic in retaining employees and hiring replacements. There were also difficulties accessing space on campus due to social distancing requirements. The university has been able to hire employees in Property Management and expects the pandemic-related challenges to be minimal moving forward. Person(s) Responsible for Corrective Measures: Aaron Mitchell, Associate Vice President for Financial Services, Montana State University, Target Date: 12/31/2024

ALN: Various R&D, Corrective Action Plan: Equipment Inventory Controls - UM - The University of Montana - Missoula has strengthened internal controls by hiring an Account Analyst to manage asset tagging and to conduct comprehensive reviews to ensure all assets are tagged and accounted. The Account Analyst will be assisted by an intern to conduct a thorough review to verify and update the status of all assets. Person(s) Responsible for Corrective Measures: Rachel Buswell, Controller, University of Montana - Missoula, Target Date: 09/30/2024

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.

2023-007 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control and Instance of Non-Compliance Corrective Action Plan: The city is in the process of updating its Purchasing Policy and will include language on allowable costs and cost principles that are compliant with 2 C.F.R. 200. The Purchasing Policy requires updates at least every five years and will be taken to City Council before the end of 2024 for approval by Resolution. Responsible Individual(s): Lincoln Bogard, Administrative Services Director; A’ja Wallace, Deputy Finance Director; and Barbara Mason, Purchasing Manager Anticipated Completion Date: December 2024

2023-003 - REPORTING Recommendation: We recommend that the Council implement controls and policies and procedures over financial reporting to ensure compliance with federal reporting requirements. Action Taken: The Executive Director will review and approve all financial reporting documents before submission. Since identified in the report, the Fiscal Officer has provided the Executive Director all previous fiscal year 2023 and 2024 financial reports for review and approval, if needed.

CONDITION: The District did not properly record its federal program expenditures for the ESSER and ARP ESSER federal grant programs using the various federal 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. This is a repeat finding (2022-005) from the previous fiscal year. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

Management will implement the necessary changes to WHCA's policies and procedures.

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority review their process and internal controls over HQS inspections to ensure compliance with HUD requirements and their administrative plan. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Housing Choice Voucher department is addressing inspection controls in multiple ways. The Department has added additional staffing and also has created new tracking that makes it easier to review and identify units that have not passed inspection and not been abated. The Department has also instituted an ongoing process that has the inspections manager conducting a monthly review of units moving through the abatement process to ensure timely processing and cessation of HAP payments as needed. As part of this review the Department is also conducting a comprehensive review of units that have prior failed inspections to ensure abatement occurred. Name of the contact person responsible for corrective action: Mark La Brayere Planned completion date for corrective action plan: Three elements are continuous with no final completion date. The singular comprehensive review is scheduled to be completed within three months.