Corrective Action Plans

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting details.

The Treasurer will review both the elementary and the jr high/high school lunch and breakfast counts prior to the claims being submitted to CRRS.

The Hospital recognizes the importance of having a methodology in place for estimating  the allowance for contractual adjustments in accounts receivable and the estimate for third‐party payor settlements.   The  Hospital  will  work  on  strengthening  procedures  for  the  allowance  for  contractual  adjustment  estimate and develop an estimate for the Medicaid lump sum payments. Our goal will be to use our Medicare cost report model to estimate the Medicare cost report settlement on a quarterly basis. In addition, our goal is to have the model tested against the most recently submitted Medicare cost report on an annual basis. An accountant was hired on February 13, 2024, to assist the Chief Financial Officer (CFO)   in the monthly accounting duties. The accountant immediately began reconciling cash accounts and is caught up on  all  prior  month  reconciliations.   The  accountant  is  working  with  CFO  to  post  activity  and  corrections  to  the  general ledger. The accountant will ensure that cash and investment accounts are reconciled monthly in a timely manner going forward. Now that the cash reconciliations are caught up, the accountant will begin reconciling all other balance sheet accounts. Responsible Individuals: Stephani Tipton, Accountant and Ken Fisher, CFO Anticipated Completion Date: Ongoing

The migration to a new general ledger financial reporting system is an isolated incident and given the improved reporting capabilities the change in product provided a positive impact. UWGC experienced turnover for the program manager position that created a learning curve that was addressed but resulted in audit completion delay. UWGC has an experienced manager currently overseeing the program who will follow policies and procedures as prescribed and on a timely basis to allow for prompt reporting submission.

UWGC experienced a staffing turnover during the 2024 fiscal year of the manager responsible for the reporting on the SEFA. The manager tracked financial reports on a cash basis causing a timing difference with not recognizing accounts payable. The finance team accounted for expenses in the appropriate period, therefore the Finance team will crosscheck reports for timing difference prior to submission to governing agency.

Finding 2023‐001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Melissa Quintero, Director, Sponsored Programs Administra􀆟on and Peter D. Friedmann, Chief Research Officer, Baystate Health. Views of Responsible Officials: Management agrees and acknowledges that well‐defined roles, responsibili􀆟es, processes, and monitoring are necessary. Management wishes to highlight that no unallowable charges were incurred as a result of the iden􀆟fied deficiencies. Correc􀆟ve Ac􀆟on Plan and Expected Comple􀆟on Date Roles and Responsibili􀆟es—Management has engaged Huron Consul􀆟ng Group (Huron) to review roles and responsibili􀆟es across Sponsored Programs Administra􀆟on (SPA), Research Accoun􀆟ng and other affected areas to ensure adequate defini􀆟ons and clarity across control owners. Huron’s recommenda􀆟ons should be available by April 11, 2024. Once Huron’s recommenda􀆟ons are received and reviewed by management, posi􀆟on descrip􀆟ons will be revised, new posi􀆟ons created, and training implemented to ensure personnel understand their role and responsibili􀆟es related to internal controls, including controls over compliance and documenta􀆟on requirements. Policies and Procedures—Management maintains policies and procedures that govern the conduct of grantrelated ac􀆟vi􀆟es. Policies and procedures will be updated following Huron’s review of the roles and responsibili􀆟es, and management will con􀆟nue to make addi􀆟onal updates as necessary. Personnel will be trained on relevant updated policies and procedures. Documenta􀆟on and Document Maintenance—Management has ini􀆟ated implementa􀆟on of ServiceNow to improve the consistency and accessibility of documenta􀆟on evidencing review over research and development (R&D) compliance requirements and performance of internal control procedures. ServiceNow is a cloud‐based pla􀆞orm that will allow for the opera􀆟on of 􀆟cket‐based help desk func􀆟onality for SPA. This system will replace the large volume of email communica􀆟ons that currently documents a significant propor􀆟on of internal control ac􀆟vity and solve the problem of such emails lost to incomplete archiving and Baystate’s email reten􀆟on policy. SPA has a Microso􀅌 Teams central repository for all award‐related documents, as well as any legacy email and other documenta􀆟on related to compliance requirements and internal controls over compliance. Salary Cap—Management will re‐emphasize to end‐users via wri􀆩en communica􀆟on that the quarterly Excel summary report of salary cap is a courtesy report only, and that end‐users should rely on Infor Lawson as the system of record and its (1) Labor Cost by Ac􀆟vity report for labor cost and (2) Ac􀆟ve 10.2 report for salary cap distribu􀆟on and valida􀆟on. Prior to the quarterly mee􀆟ngs with the Departments and Service Lines to review award ac􀆟vity and expenditures, SPA and Research Accoun􀆟ng will compare the Excel summary with the two Infor Lawson reports for accuracy, inves􀆟gate and resolve differences in a 􀆟mely manner, and document evidence of review in SPA’s Microso􀅌 Teams site. Indirect Cost and Fringe Benefit Review—Due to the manual nature of entering and maintaining award data in the financial system, complete accuracy in data capture con􀆟nues to be an ongoing goal and objec􀆟ve. Management will develop and implement a checklist to enhance the review of internal controls associated with the SPA form maintained in IRBNet prior to submission to Finance. Documenta􀆟on of this review will be maintained in the Microso􀅌 Teams central repository. SPA has ac􀆟vated in IRBNet a system‐generated email alert that will be sent to Research Accoun􀆟ng on the comple􀆟on of the SPA form to enable the account set up step to be ini􀆟ated or revised, as required. SEFA Review—An enhanced monthly Infor Lawson report and a quarterly schedule of expenditures of federal awards (SEFA) report from Research Accoun􀆟ng has been added to the SPA’s quality assurance process to ensure 􀆟mely review of the SEFA data to improve accuracy. All quality assurance reports are available monthly a􀅌er the month end close. These reports will be reviewed by SPA and Research Accoun􀆟ng for accuracy and retained in SPA’s Microso􀅌 Teams site with evidence of review. Management expects to complete the above ac􀆟ons by December 31, 2024.

March 27, 2024 2023-003: Material weakness in Internal Control / Material Noncompliance – Cash Management (repeat comment) Condition: 1) The Condition requested funds in advance of when the related distributions were made, 2) the basis for the advance (requests) were not supported by appropriate documentation, and 3) authorization for requesting funds in advance was not obtained. Corrective Action: We agree with the finding. The Consortium has carefully reviewed our policies and procedures and have made the necessary changes to ensure that cash draws are based on expenditures already incurred and they are supported by transactions recorded in the books and records of the Consortium. We believe the updated procedures will result in the reduction over time and ultimately the complete elimination of this issue. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: December 2024 Respectfully, Shamar Herron

Additional preventive internal control procedures will be implemented, including an additional level of review of the Schedules and reconciliation. These procedures and internal controls have been implemented as of the date of this report.

The Public Works Department shall consult with the Finance Department to revise the reimbursement process to ensure future requests reconcile the specific amount expended by the grant. The revised process will include preparation of the reimbursement request using the City's financial system of record, and an independent review prior to submission to the grantor.

The Auditor-Controller’s office will provide additional training to applicable departments to educate staff on appropriate records maintenance related to grant files and the importance documented review and approval processes. This training will provide additional education over appropriate supporting documentation to verify internal controls and compliance requirements are being reasonably followed

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

Corrective Action With the organization of the Business Office under the new Business Administrator, the Charter School has implemented a system that utilizing docuware support to ensure that supporting schedules and documents for claims are readily available and ensure proper safekeeping of pertinent documents. In addition, this supports that the Charter School maintains supporting documentation for seven (7) years and making it available to the NJDOE, the U.S. Department of Education, and/or their authorized representatives upon request. Person(s) Responsible Bernadette Pinto, Interim School Business Administrator Planned Completion Date June 30, 2024

Dear Mr. Waguespack, The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 4, 2024, regarding a reportable audit finding related to controls over reporting and other Federal compliance requirements for the Medicaid and CHIP programs at the LDH. The LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Controls over Reporting and Other Federal Compliance Requirements for the Medicaid and Children's Health Insurance Programs Recommendation: LDH management should strengthen controls over preparation and review of the quarterly federal expenditure reports to ensure Federal expenditures are accurately reported and should ensure all quarterly checklist reviews are completed. LDH Response: LDH partially concurs with the finding and recommendation. LDH disagrees that the quarterly checklist is intended to demonstrate compliance with the federal reporting requirements. The quarterly checklist is used to document and track the receipt of source documents from other departments so the fiscal staff can develop work papers for the federal expenditure reports. The checklists do not track the accuracy of the work papers. Additionally, the quarterly reconciliations purpose is to reconcile expenditures in the state's accounting system (LaGov) to the Medicaid and Children's Health Insurance Program Budget and Expenditure System (MBES/CBES). During this audit period, LDH was in the process of reviewing the reconciliation procedures to transition from previous methods of reconciliation utilizing the old accounting system (ISIS) to LaGov. Although the duplication was identified through this Single State audit, LDH maintains it would have identified the duplicative entries during the annual grant award reconciliation process which would have been within the federal reporting timelines Corrective Action Plan: LDH will continue to build on the improvements already implemented to prevent Medicaid expenditure misstatements from recurring. As discussed with the Single State auditors, measures to increase operational accuracy were being worked on during the audit or are in the process of being developed. LDH management has already taken steps to implement a corrective action plan to strengthen the internal controls that will enhance the State Agency's preparation and review of the quarterly federal expenditure reports which includes a more thorough review of procedures to collect and review data from program offices and incorporate more cross training amongst the fiscal staff responsible for federal reporting. The anticipated completion date of this corrective action plan is April 30, 2024. You may contact Helen Harris, LDH Fiscal Director, by telephone at 225-342-9568 or by e-mail at helen.harris@la.gov with any questions about this matter.

FINDING 2023-005 Finding Subject: COVID‐19 Education Stabilization Fund ‐ Reporting Summary of Finding: Reports were not supported by underlying accounting records. Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: (812)254-5536 calford@wcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Washington Community Schools like all other school corps across the state, got the requests for these reports with very little to no instruction of how to complete them. We weren’t told they would be part of the audit and therefore didn’t retain reports used to complete some of the reports. Going forward we will ensure reports proving numbers reported are available to SBOA. Anticipated Completion Date: 06/30/2024

FINDING 2023-003 Finding Subject: Child Nutrition Cluster - Allowable Activities and Allowable Costs Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to allowable activities and allowable costs. The School Corporation purchased two pieces of equipment that were over $5,000 each in Fiscal Year 2023 without approval from the Federal awarding agency or pass-through entity. The first piece of equipment was a liftgate in the amount of $6,906, and the second piece of equipment was a vehicle in the amount of $7,500 for a combined total of $14,406. The financial management system of each non-federal entity must provide written procedures for determining allowability of costs in accordance with the federal regulations and the terms and conditions of the Federal Award. The policy should provide clear guidance as to what costs constitute appropriate direct and indirect charges to federal awards as well as provide for consistency in charging practices across the School Corporation. The School Corporation did not have an allowable costs policy outlining the School Corporation's processes and policies with regards to costs charged to federal grants. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Retrain Food Service Director and Assistant Food Service Director on the process for purchasing equipment. The district will also develop and pass an Allowable Costs Policy. Anticipated Completion Date: To be completed by July 1, 2024

Assistance Listings number and program name: 10.691 Good Neighbor Authority Contact person: Lucinda Andreani, Deputy County Manager and Flood Control District Administrator Anticipated completion date: June 30, 2024 Concur. The Coconino County Flood Control District (FCD) acknowledges the annual financial and performance reports were not filed in accordance with the contract. The cash draw reports were completed for the award according to the contractual requirements. Therefore, the federal agency was aware of all expenditures made under the award. The FCD will submit all missing annual financial and performance reports. With assistance from the Finance Department, the FCD will develop procedures to ensure all reporting requirements are met. These procedures will include internal timelines, designated roles and responsibilities, and a tracking mechanism. Additionally, fiscal capacity will be created through the training of an additional staff member in reporting to serve as backup so contractual reporting requirements can be fulfilled when unforeseen challenges arise such as declared emergencies and flood events.

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance

2023-005 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 Wetumpka’s previous corrective action plan, the City was 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. Before the current audit was performed, the staff member writing these procedures separated from our organization. Due to the City of Wetumpka being a small town, we did not have the staff available to complete the task due in part to the lack of individuals looking for work in a post COVID world. Because of our lack of personnel and the fact we did not feel we would meet the $750,000 threshold required for a Single Audit, the project was abandoned. The City of Wetumpka has financial management internal controls in place. All of the City’s grant activities (Federal and State) are tracked in a separate fund from the general operating funds under unique assigned general ledger numbers for each grant awarded to the City. All grant funds are deposited into a dedicated bank account and are not co-mingled with other funds of any kind.

Federal Agency Name: Department of Education Pass-through Entity: State of Iowa Department of Education Federal Financial Assistance Listing #84.287 Program Name: Twenty-First Century Community Learning Centers Program Cash Management Material Weakness in Internal Control over Compliance Finding Summary: No support could be provided for the third quarter draw requests to substantiate a secondary level of review was completed prior to submission of the draws. Documentation to support the review of draw requests prior to submission was not retained during the transition period in the Finance Director role. Corrective Action Plan: SHIP had a one-month period of transition in 2023 in which there was no one in the Finance Director role. The Executive Director took over those duties and also contracted for higher level review and approval from a third-party accounting firm during the transitional period. All draws were reviewed, approved and even supported by the Executive Director and the contractors. SHIP did provide current auditors with the time tracking from the contracted accounting firm that they did review the 3rd quarter report, the report was just not officially signed off on. Staff requesting the draw forgot to get one approval signature for quarter three, all others were signed. Moving forward, SHIP will re-train staff to ensure all draws are signed off on. Responsible Individuals: Mindy Baylor - SHIP Finance Director Anticipated Completion Date: September 2023

Finding 2023-010 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and one ESSER III report, for a total of five reports. A single employee prepared and submitted each annual data report without a review or oversight process in place to prevent, or detect and correct, errors. All five reports were selected for testing, two of which were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Another individual will start to review the information entered into the required ESSER reports prior to submission and supporting documentation will be retained. Anticipated Completion Date: April 1, 2024

FINDING 2023-006 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: During the audit period the School Corporation submitted three final expenditure reports. The final expenditure reports were completed and submitted by the Treasurer without an oversight or review process in place to prevent, or detect and correct, errors. In addition, the final expenditure report for the Title I School Improvement for program year 2021, due December 30, 2021, was submitted March 7, 2024. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 39 Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Another individual will start reviewing the final expenditure reports prior to submission to IDOE. Anticipated Completion Date: April 1, 2024

Department: Health and Human Services Title: Internal control over ELC program reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Financial Reporting: Quarterly financial reporting will be emailed to the reviewer by Maine CDC. Financial Reporting: Reviewer corresponds corrections/findings via email to Maine CDC. Financial Reporting: Maine CDC inputs financial reporting into CAMP. Performance Reporting: Quarterly meetings with each team to update progress will be recorded. Performance Reporting: All milestones that have progress in the last quarter will have a note describing how we determined the progress level entered into CAMP. Performance Reporting: A note about who reviewed the progress report and who submitted it will be entered into the Monitoring Notes section in CAMP. Completion Date: June 10, 2024 (first item), June 18, 2024 (second item), June 20, 2024 (third item) and June 30, 2024 (last three items) Agency Contact: Sara Robinson, Infectious Disease Program Manager, DHHS, 207-287-4610

Department: Administrative and Financial Services Title: Internal control over ICA program cash management needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will review estimated revenue amounts for the CDC ICA appropriations and request the establishment and/or increases related to an analysis of ICA transactions. Completion Date: March 31, 2024 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626

Department: Economic and Community Development Title: Internal control over CSLFRF expenditures needs improvement Questioned Costs: Known: $591,845 Likely: $591,845 Status: Corrective action in progress Corrective Action: The Department will review internal processes and procedures to ensure that they properly address questions of compliance and allowable expenditures for similar programs that may arise in the future. The Department will identify the appropriate allowable expenditure categories and create business cases that will address the questioned costs by placing them into the proper expenditure categories. Completion Date: June 30, 2024 Agency Contact: Denise Garland, Deputy Commissioner, DECD, 207-624-7496

Department: Health and Human Services Administrative and Financial Services Title: Internal control over WIC cash balances needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will contact the Federal Awarding Agency to identify steps needed to resolve cash discrepancy. Completion Date: December 31, 2024 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626