Corrective Action Plans

Finding 2023-001 Federal Agency Name: US Department of Health & Human Services, California Department of Social Services Program Name: Child Care and Development Fund Cluster CFDA #93.575 Finding Summary: The Commission has not established written procedures for determining allowability of costs in accordance with Subpart E- Cost principles or the conditions of the Federal award. Responsible Individuals: Debora Dickerson-Sims, Chief Financial Officer Corrective Action Plan: Review current policies and procedures to revise or develop new procedures for determining allowability of costs in accordance with Subpart E – Cost principles or the conditions of the Federal award. Anticipated Completion Date: June 30, 2024

The Hannibal School District received millions of one-time federal grant monies to assist with expenditures incurred as a result of the effects of the coronavirus pandemic. Although these funds were hugely helpful, minimal guidance was available. This is not a finding that has been presented to us in the past. The school district has received federal and state grants annually that are reconciled to the appropriate project codes and this process will be diligently followed as in prior years. For example, the district was awarded the Immediate Responses Services grant in Fall 2023. The expenditure project codes for this grant have been provided by grant guidance and any and all expenditures will be coded using these expenditures codes. This should prevent any need for future journal entries moving forward. This process is an example of the systematic process that will be followed for all grants.

This following is submitted as our management response to the audit finding regarding Allowable Costs Reporting in the District’s FY23 Audit. At the close of Fiscal Year 2023, the District submitted a payment request for federal ESSER reimbursement, encompassing eligible employee expenses spanning multiple years in accordance with ESSER guidelines. However, an administrative oversight became apparent, as the expense codes and ASBRs for the relevant years had not been amended to align with the represented expenditures. To address this, the District is undertaking a meticulous correction process through adjusting journal entries. This corrective action will ensure that the expense codes accurately reflect the corresponding project codes and Fiscal Year expenditures. Simultaneously, the ASBRs for the affected years will be resubmitted, aligning with the requisite financial standards. Looking ahead, the District is instituting a proactive measure to prevent recurrence. The superintendent, or a designated district representative, will verify that the District's accounting software records, as compiled by the District Bookkeeper, impeccably mirror the accurate totals for expense codes, incorporating the requisite accounting codes, including project codes. This validation will be a prerequisite before any future reimbursement request for federal funds is submitted, ensuring a heightened level of precision and compliance in financial reporting. These measures underscore the District's commitment to fiscal accountability, rectifying oversights, and fortifying internal controls to uphold the integrity of financial processes. The district will begin immediately implementing the revised proactive measures and is in the process of rectifying the noted issues with corrective journal entries. This process will be updated prior to January 15, 2024. Should you need anything further from the district, please do not hesitate to contact me.

Background: One repeat finding from the 2022 fiscal year audit was identified on the Schedule of Expenditures and Federal Awards during 2023 fiscal year end audit conducted by Aldrich CPAs + Advisors LLP (Aldrich). For fiscal year 2022, Aldrich performed an audit on the major program Disaster Grants – Public Assistance (Presidentially Declared Disasters) for the monies received from the Department of Homeland Security passed through the Oregon Office of Emergency Management awarded to the City for the February 2021 Ice Storm. Management recognizes the importance of adequate procedures and internal control oversight and has rectified this finding. Management’s response and corrective plan of action for the finding follows. Finding 2023-001: 21.027 Coronavirus State and Local Fiscal Recovery Funds Criteria: 2 CFR Part 200.302(b)(7) requires the financial management system to include written procedures for determining the allowability of costs. Condition: City of Oregon City has not developed written procedures for determining the allowability of costs. Cause: Administration did not have written procedures for determining the allowability of costs. Effect: Unallowable costs could be charged to the program. Questioned Costs: None   Perspective: Written procedures for determining the allowability of costs is integral to the proper design of internal controls. However, the results of audit procedures did not detect any costs which are not allowable charged to the program. Recommendations: Management should develop written procedures as required by 2 CFR Part 200.302(b)(7). Responsible Official: Matt Zook, Finance Director Views of Responsible Officials: Management understands the requirement for written procedures for determining the allowability of costs. A formal policy and procedure was approved and adopted August 22, 2023. The opportunity to identify this finding arose due to new management staff and a new audit firm engage with the June 30, 2022 audit, and we appreciate the opportunity to improve compliance.

Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited for not having submitted general ledger evidence submit additional support for the reconciliation they submitted. 3) Should a similar tranche of funds become available in the future, AlaHA will ensure disbursements are not made before receipt of general ledger evidence to support the amount reported by the hospital. Target Date: For items 1 & 2 in the corrective action plan, November 6, 2023.

Albuquerque Health Care for the Homeless, Inc.’s Finance Team will work to ensure that Policy and Procedure 4011 regarding the use of corporate credit cards is followed. All management staff that have organizational corporate cards will be retrained by the Accounting Manager on the importance of obtaining itemized receipts. In the event a receipt is lost, regardless of verifying the legitimacy of the purchase with the direct supervisor, the finance team will ensure that the expense is not charged to any federal funding. Persons Responsible: Leon Paboucek, Accounting Manager Estimated Completion Date: October 25, 2023

I am acknowledging the finding of the Federal Audit team in which an error in my spreadsheet was documented resulting in requesting a recurring expenditure on two different pay requests. The correction was made the day of the audit through coding other expenditures matching the qualifying expenditures. In the future, the district spreadsheets will include review by the bookkeeper and superintendent to ensure the fund pay requests are correct and not repeated. By multiple review and the addition of PO number and date of pay request this will easily define a possible "doubling up" of items for a pay request. This was one finding and all other accounts reviewed were correct and accurate. Additional expenditures were corrected and easily matched the grant funds obtained through reimbursement. The new procedure will begin immediately. Tara Lewis Superintendent

Management is currently confident with the abilities of the accounting staff to prepare interim financial statements. The District has also accepted the additional risk associated with the auditor drafting year-end financial statements including the notes to the financial statements. Management will review, approve, and take responsibility for the financial statements.

Findings: Major Federal Program Audit Significant Deficiency Written Uniform Guidelines Policies and Procedures Recommendation: We recommend Crowhaven Apartments, Inc. draft and adopt written procedures in accordance with Uniform Guidance requirements. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and are in process of developing and implementing the appropriate policies and procedures.

FINDINGS- MAJOR FEDERAL AWARD PROGRAMS AUDIT Material Weakness U.S. Department of Education- Education Stabilization Fund Under the Coronavirus Aid, Relief and Economic Security Act- AL 84.425 Finding No.: 2023-007 Condition: The District did not maintain adequate financial reocrds in accordance with 2 CFR 200.302(b)(3). Recommendation: The District should maintain adequate financial reocrds capable of adequately identifying the source and application of grant funds in accordance with 2 CFR 200.302(b)(3). Action Taken: The District concurs with the recommendation. The District will work to maintain records capable of adequately identifying the source and application of grant funds.

Management will enforce existing internal control procedures and train staff to maintain appropriate documentation.

Will have a policy for FEMA allowable expenditures in the future

Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.

Management will ensure that all nongrant expenditures are kept to a minimum until the cash balance of NVT is in excess of the unearned grant revenue and restricted fund balance. A large part of this problem in the current year was the amount of money paid to the Village’s accountants/consultant in prior years. This has been resolved and the new accountant’s fees are much more in line with reasonable amounts.

2022‐009 Cash Disbursements (Material Weakness) Recommendation: We recommend policies and procedures over the segregation of duties between the accounting and banking functions be strengthened. In addition, policies and procedures should be implemented to ensure support for expenditures is retained and includes evidence of approval. Additional oversight should be provided by those charged with governance. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. Implementation of updated policies was completed November 2024. Accounting and banking functions are segregated.

2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be established to allocate indirect costs in accordance with federal regulations. Policies and procedures are also needed to provide appropriate oversight of all grant accounting including reporting. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. A review process and coding within the accounting system was completed in January 2025. All invoices and staff time are evaluated for the level of effort towards each grant.

2022 – 005: Reporting (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory. Without these reports, we were unable to perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly so this should take care of this issue. Management has worked on procedures and training to assure financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory are completed.

2022 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide sufficient documentation to support compliance with federal procurement and suspension and debarment requirements for purchases made under the Title V program. The general ledger did not allow for sufficient identification of transactions related to the Title V program as all expenditures were recorded through journal entries without supporting transaction-level detail. Due to this limitation, we were unable to select procurement transactions for testing or verify whether vendors had been screened for suspension and debarment before contracts were awarded. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software uused,and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. The following are updated procedures that are now in place. All purchases must come with a purchase order request and be signed by the supervisor prior to purchase. All purchases over $1000 must be CEO approved too. All purchases over $5000 must have 3 bids and be Board approved. All purchase orders must be completed completely in all fields to know what grant/funding source is covering the cost for draw downs. Anyone who uses the SDUIH credit cards must sign a credit card statement

2022 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly.

The funds from the project came from several different grant sources. Bills were due and our consultant DLZ advised us on how to pay these bills even if they were paid from grants other than from the correct grant sources.

View of Responsible Officials and Corrective Action Plan The excess drawdown may have occurred due to the carry fund balance being included as a debit balance on the trial balance during review of drawdown expenses and not adjusted to reduce the amount of the drawdown(s). The error was discovered when the Accounting Manager was in the process of preparing the SEFA schedule. The Accounting Manager disclosed this error to the auditor during the course of the audit. Corrective Action Plan Timeline AAIHB will consult with the Program Manager and awarding agency to determine the appropriate resolution of the excess drawdown within 30 days. AAIHB finance office has a process in place of reviewing drawdowns and monitoring expenses as grants approach the end of the project funding period. Designation of Employee Position Responsible for Meeting Deadline Accounting Manager and Finance Director

Management concurs with the finding and will implement a proper expenditure reporting process, reconciled monthly, to avoid recurrence during future audits.

Management will work with their consultant and develop written policies and procedures over their federal awards in accordance with the requirements of the Uniform Guidance.

FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Significant Deficiency Condition: The City did not have proper controls in place to ensure that the annual report was accurately filled out and agreed to underlying detail. Context: Variances to key line items were noted when comparing the Form RD442-2 and Form RD442-3 to supporting documents. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that reports agree to underlying detail. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

Management’s Planned Corrective Action: Disagree: We have established a cost center or “Department” for each federal program that clearly identifies federal expenditures. Our funders request monthly copies of receipts and payment issued to verify expenses. Responsible Party: Beaulieu Accountancy Corporation, Accountant Completion Date: 9/25/2024