Corrective Action Plans

FINDING 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The School Treasurer will complete the Annual ESSER data report. The Grant Director will verify the report(s) for accuracy and completion. The Grant director will sign off on each report and then confirm via email the report(s) is correct and ready for submission to the IDOE. Responsible party and timeline for completion: Contact person responsible for Corrective Action: Patti Kappes, Treasurer Contact phone number: (812)427-4215 Anticipated completion date: April 30, 2023

Finding 2022-003 ? Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Mr. Patrick Culp, Superintendent Contact Phone Number: 219-279-2418 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Tri-County School Corporation will ensure someone other that the preparer of the report perform a documented review prior to submission to validate the accuracy and completeness of the data submitted. Anticipated Completion Date: March 29, 2023

INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE OUT AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START PROGRAMS LOW-INCOME HOME ENERGY and WATER ASSISTANCE PROGRAM CFDA # 93.600, 93.568 and 93.499 (Questioned Costs - Undetermined) Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the agency?s financial funding sources, the agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst?s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and uniform guidance regulations. The new automated financial system, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 2023.

Finding Number: 2022-002 Condition: The College did not retain underlying support related to the student emergency grants information reported by the College on the annual and quarterly basis. Planned Corrective Action: Support used for reporting will be retained for all future reports moving forward including the fourth quarter 2022 report and the 2022 annual report. Contact person responsible for corrective action: Tom Reynolds, Associate Vice President of Business Services and Deputy Treasurer Lakeland Community College Anticipated Completion Date: As soon as possible moving forward for future quarterly and annual reports starting 12/19/2022

FINDING 2022-003 Contact Person: Jo Ann Treon Phone Number (765)948-4632 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Forms RD 442-2 & RD Form 442-3 will be completed in August 2023. Anticipated Completion Date: Immediately

FINDING 2022-007 Subject: COVID-19 ? Education Stabilization Fund ? Reporting Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425U200013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. The amounts reported as expended on the second report did not agree to the underlying expenditure records of the School Corporation. Per discussion with the Treasurer, the amounts reported on the second report were the appropriated amounts, not the actual amounts expended during the period. Therefore, the amounts on the report were overstated by approximately 25% for ESSER I and 280% for ESSER II compared to the correct amounts on the School Corporation?s records. Additionally, for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Description of Corrective Action Plan: The NJ-SP School Corporation will implement effective internal controls to oversee that the federal grant information prepared and submitted is accurate and reviewed. This will be done in order to detect and correct errors that may be entered prior to submission. This will be done by having an employee prepare the Annual Data Report information while another employee reviews and approves the information before submitting. These controls will be implemented by July 1, 2023. Responsible Party and Timeline for Completion: Dalton C. Tunis ? Corporation Business Manager/Treasurer Anticipated Completion Date: July 1, 2023

FINDING 2022-003 Information on the federal program: Subject: Education Stabilization Fund - Annual Data Report Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: The School Corporation did not have a documented review control in place to ensure the annual data report was reviewed by someone other than the preparer and that the report was submitted timely. Context: The Annual Data Report for the period of October 1, 2020 to June 30, 2021 was due to the Indiana Department of Education (IDOE) by May 13, 2022. The School Corporation submitted the report on May 16, 2022. In addition, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action. Dr. Barry Stone, Director of Curriculum will prepare the Annual Data Report in a timely matter and the reports will be reviewed by Mrs. Berry, Superintendent and then signed off before submitting the report. Responsible party and timeline for completion: Federal regulation requires name and title of person overseeing corrective action plan and anticipated completion date. Dr. Barry Stone, Director of Curriculum will compile the report and Mrs. Berry, Superintendent will approve and sign off when the report is due.

FINDING 2020-002 Contact Person Responsible for Corrective Action: Shelly Harrison, Corporation Treasurer Contact Phone Number: 765-492-5102 Views of Responsible Official: We concur to the findings; however, while completing the ESSER Reports, some formatting errors of the provided spreadsheet created some questions by the North Vermillion officials prompting a clarification email to the DOE. Since the formatting errors were not addressed and all completed boxes on the North Vermillion ESSER Report spreadsheet turned green (indicating the correct amounts on the spreadsheet), the North Vermillion officials felt the ESSER report submitted was correct. Description of Corrective Action Plan: To correct the internal control issue, the Superintendent and Corporation Treasurer will work independently as well as collaboratively on the ESSER Reports. Prior to submitting any future report, the corporation officials will document their work by signing off and dating the report prior to submission to the DOE. To rectify the incorrect dollar amount on the Yearly ESSER Report Spreadsheet, the corporation treasurer and superintendent will work collaboratively to correct the amounts on either the ESSER I Year End Report and the ESSER II Year 2 and/or Year End Report. Anticipated Completion Date: Both the Internal Control and ESSER I corrective actions have been corrected, with the ESSER I Final Expenditure Report being completed and signed off on. The ESSER II corrective actions will be completed on the upcoming ESSER III Year End Report when that report is due.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Jennifer Barcus, Corporation Treasurer. Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will begin reviewing all annual data reports completed by the Superintendent, prior to submission of the reports, to verify that all expenditures are reported in the correct reporting period. Anticipated Completion Date: Immediate review will begin of all annual data reports.

COVID-19 Provider Relief Fund ? AL No. 93.498 Recommendation: Our auditors recommended the Organization evaluate its financial reporting processes and controls to determine whether additional controls over the preparation of any Provider Relief Fund reports are needed to ensure the reports are prepared in line with the Provider Relief Fund guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: The Organization missed reducing the costs claimed against PRF by the amounts reimbursed through the Medicare cost report. The Organization did have additional lost revenues though that would offset these costs claimed and wouldn?t result in a repayment of the funds. We would look to HRSA for guidance on how you would like us to update our Phase 1 PRF report or how you would like to see this corrected. Also, the CFO will listen to webinars to receive education for Phase IV funds that were received by the Organization to ensure compliance with the reporting requirements. COVID-19 Provider Relief Fund ? AL No. 93.498 (Continued) Name(s) of the contact person(s) responsible for corrective action: Connie Prewitt, Interim CFO Planned completion date for corrective action plan: Will implement in fiscal year 2023.

Rural Health Care Services Outreach, Rural health Network Development and Small Health Care Provider Quality Improvement ? AL No. 93.912 Recommendation: Our auditors had the following recommendation related to FFATA reporting: ? They recommended the Organization review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete and timely. ? Specific to special reports for FFATA, they recommended the Organization provide training on the requirements to those employees responsible for reporting the action in FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: The Organization was unaware of the FFATA reporting requirement. The Organization will register and submit the FFATA. Also, the Organization failed to report the indirect costs on the FFR. The Organization has notified the responsible parties to avoid future occurrences. The FFR?s have been completed to report indirect costs separately in fiscal year 2023. The FFATA was submitted in fiscal year 2023 and will be updated yearly. Name(s) of the contact person(s) responsible for corrective action: Connie Prewitt, Interim CFO Planned completion date for corrective action plan: Will implement in fiscal year 2023.

FINDING 2022-008 Contact Person Responsible for Corrective Action: Danica Houze, Chief Financial Officer Contact Phone Number: 812-274-8001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Documentation will be kept to ensure evidence of preparation, review, and approval of the Grant Reporting. Two individuals will sign off on all future reports and documentation will be kept on file. Anticipated Completion Date: 2/13/2023

2022 ? 008 Reporting (Significant Deficiency and Noncompliance) Management Response: The City agrees with the finding. The City will implement controls to ensure compliance with federal financial management regulations. The City recognizes that it needs to improve its procedures for preparing quarterly report for Treasury funds. Going forward, the Family and Community Services Department will work with the Grants Section to develop and implement standardized procedures for identifying and documenting expenditures, and for reviewing quarterly reports prior to submission. Timeline and Responsible Position: June 2023 ? City Controller/DFAS Deputy Director and Director of Family & Community Services

Contact Person Responsible for Corrective Action: Tina Gross Contact Phone Number: 317-945-4327 Views of Responsible Official: We concur with this finding, but would like to offer the following explanation: When ESSER funds first become available, there were no guidelines or restrictions that were made available. Instead, the districts were assigned swift deadlines in getting their spending plans submitted. The advice was, if you can link the request to COVID, and IDOE approves the request, then ESSER funds can be used. Months later, in an attempt to tighten things up, the school districts were presented with guidelines. This took place after all of the planning had already been done for all three grants and costs had already been incurred. The renovation cost in question was included in our spending plan submitted to IDOE through the Title Application Center. The following narrative was also submitted with the budget to IDOE as follows: ?We are also requesting $472,962.87 for a renovation project at our local Career Center, Central Nine in Greenwood. Franklin High School is one of eight sending schools for this career center. These renovations will add necessary classroom and lab space for the Diesel, Welding, and Dental programs. The renovations also include meeting space and restrooms. The total cost of Franklin Community Schools? portion of the project is estimated at $652,400, however, we are only requesting a portion of that in ESSER III funds and will cover the difference using district funds? IDOE approved the budget submitted, including this specific transaction. There was no reason for the district to think that this was an unallowable transaction. Description of Corrective Action Plan: The district is willing to transfer this expense to rainy day or operating funds if necessary. Anticipated Completion Date: 2-22-23

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Monica Kegerreis, Assistant Superintendent Contact Phone Number: 574-831-2188 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The ESSER reports requested by IDOE will follow the same procedures of all FER reports. The ?data collection? for the ESSER grants was not identified as a financial report, and thus did not follow these processes. Now that we know this is a financial report, the steps below will be followed. The grant was initially not set up correctly and expenses were expended to and then transferred to the correct accounts once the grants were set up correctly. These changes were in flux when the report was requested, so what was reported at the time of the report is no longer what is reflected in grants? ledgers. The corrective action will require that the program director gathers the initial data, the data will be reviewed by the administrative assistant to the grants? director, and then reviewed by the Treasurer. All three employees will sign/initial a printed copy of the report before it is submitted. Data regarding students served by programs and staff reports will be reviewed by the program director and the data specialist and signed off on by both parties to ensure accuracy. Anticipated Completion Date: March 24, 2023

Finding 2022-001: The Alabama Statewide 9-1-1 Board (the Board) will develop a grants manual or additional written policies to incorporate all the requirements of 2 CFR 200 and ensure compliance with grant requirements.

2022-051 Oregon Health Authority Correct expenditures charged to the incorrect program Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (COVID-19) Federal Award Numbers and Years: 6 NU50CK000541 (COVID-19) Compliance Requirements: Activities Allowed or Unallowed Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: $356,050 (COVID-19) Criteria: 2 CFR 200.302 To address the COVID-19 pandemic, the Center for Disease Control (CDC) awarded the Oregon Health Authority (department) over $495 million in additional funding beyond the normal funding levels for the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program. The funding was awarded for specific purposes such as enhancing detection, reopening schools, and enhancing detection expansion. The purposes of these awards generally do not allow for expenditures directly related to operating the COVID-19 vaccine clinics. In our testing, we identified two payments totaling $356,050 relating to emergency medical technicians attending vaccine clinics to assist if those receiving the vaccine had adverse reactions and required medical attention. Per department management, the transactions should have been charged to a different grant provided by the Federal Emergency Management Agency (FEMA). The error was caused by incorrect account coding when the invoice was processed. Other transactions under this contract were properly charged to the FEMA grant. We recommend management correct the accounting error and ensure the expenditures are charged to the correct programs. We also recommend the department determine if there are additional questioned costs relating to the advanced cash draw as the federal programs have different timing for federal reimbursements. MANAGEMENT RESPONSE: We agree with this recommendation. Corrective action plan: ? Adjust the two identified payments charged to the grant in error ? Adjust the erroneous charges to the Federal Emergency Management Agency (FEMA) grant ? Complete internal audit of expenditures and adjust any non-grant compliant expenditures out of this grant prior to federal financial reporting and close-out. Anticipated Completion Date: June 30, 2023 Contact: Kim Riddell, Program Support Coordinator and Jeff Cartwright, ACDP Lead Fiscal Analyst

Condition: The subsidiary ledger for community development rehabilitation loans maintained by the Department did not agree to the City?s general ledger. Corrective Action Planned: A thorough review of the Grants Division?s loan files was conducted by the City?s Fiscal Analyst in 2018/2019. Corrections and notations from that analysis will be included when the loan data is imported into the current grant management software. Once the import has been completed, the Grants Division will provide the relevant City Offices with the most current loan data. Ideally, loan balances will also be managed using the accounts receivable module in MUNIS. Anticipated Completion Date: June 2023 Contact: Jaimie Corliss, Grants Administrator

FINDING 2022-017 Contact Person Responsible for Corrective Action: Tricia Malone Hudson, District Curriculum Specialist Contact Phone Number: 812-279-3521 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: The school corporation will develop a protocol for ensuring that all documentation and records regarding Federal Grants will be maintained for a period of three years. Anticipated Completion Date: North Lawrence Community Schools implemented this procedure beginning in September 2022.

FINDING 2022-014 Contact Person Responsible for Corrective Action: Tricia Malone Hudson, District Curriculum Specialist Contact Phone Number: 812-279-3521 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: The school district has established a process for reviewing reimbursements and district expense records to ensure alignment. Anticipated Completion Date: North Lawrence Community Schools implemented this procedure beginning in January 2023.

FINDING 2022-003 Education Stabilization Fund-Internal Controls Contact Person Responsible for Corrective Action: Michele Fleck, Treasurer Contact Phone Number: 812-882-4844 Description of Corrective Action Plan: Effectively immediately, the Vincennes Community School Corporation will include the Federal Programs Coordinator when preparing any annual reports to confirm accuracy of the reporting. This will provide more internal controls. Anticipated Completion Date: 07/01/2023.

Finding 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action?Argos Community Schools will ensure that going forward, all documents will be overseen by at least two parties in the Business Office, with signed documentation. Responsible party and timeline for completion: Federal regulation requires Kelli VanDerWeele, Corporation Treasurer/Director of Business Services and Ned Speicher, Superintendent, will be overseeing and putting corrective action plan in place immediately.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Kyle Zahn Contact Phone Number: 765-883-5576 ext. 5112 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As ESSER reports and reimbursements are completed the supporting documents will be kept with the reports. Prior to submission, reports completed and documentation compiled by the Director of Finance will be reviewed by the Director of Exceptional Learners and Testing and vice versa. Anticipated Completion Date: February 2023

REPORTING Recommendation: We recommend the Department review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete and timely. We recommend the Department implement effective processes and procedures to maintain the submitted reports and the documentation used to prepare the reports in the files of the Department. Corrective Action: The Department understands the issues and is taking corrective action to improve reporting. Due to the New Mexico emergent events that took place in FY22, the Department made the emergent events the Department?s priority and onboarding became a secondary focus for the Department. In FY23, the Department has shifted its priority to onboarding across the Department, and we have onboarded a Grants Unit Manager to oversee the reporting requirements of all federal grants. A procedural checklist will be implemented to ensure that: 1. the recipient share section is completed, 2. that financial reports are submitted to the Department timely, and 3. all Performance Progress Reports as submitted. Due Date of Completion: June 30, 2023 Responsible Person(s): Chief Financial Officer

ALLOWABILITY OF EXPENDITURES Department of Health and Human Resources (DHHR) Assistance Listing Number 93.767 Microdyn OPPS quarterly updates for Pricer and Editor Dynamic Link Libraries (DLLs) are commonly received mid-month of the first month in the quarter after the Centers for Medicare and Medicaid Services releases quarterly updates. During 2022, releases occurred on January 15, April 16, July 16, and October 19. Although updates to the DLL were completed timely throughout the year, claims sampled for the audit fell into the periods of delay between the first day of the quarter and the updates to the DLL. Procedures are in place to reprocess any affected claims once the quarterly updates have been uploaded into the system. However, there was an interruption in the procedure to reprocess claims after the quarterly updates were uploaded to the claims processing system. Corrective action has already been implemented that includes automatically opting and populating the "reprocess claims" flag in the Request Management System (RQMS) when the Microdyn OPPS updates are entered to work. (The RQMS is the system used to enter and manage work orders for the Medicaid Management Information System.) Claims processing staff at the fiscal agent have also entered calendar reminders to reprocess claims as necessary after the OPPS quarterly updates are processed. All affected claims including claims sampled for the Single Audit were reprocessed and paid from mid-December 2022 through mid-January 2023.