Corrective Action Plans

2023-001 – ALN 14.850 – Public & Indian Housing – Allowable Costs Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the requirements of the compliance requirements. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by March 31, 2025.

We are in process of submitting the required operating budget and self-certification letter to the USDA. Anticipated Completion Date- 12/31/2024 Completed.Responsible Contact Person-Kathleen Boyce, CFAO

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

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

Finding 2023-005: Internal Control Deficiency and Noncompliance Over Procurement Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: AdviseWell, Inc. did not have internal controls in place throughout the audit period to sufficiently document the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price or sole source justification if warranted. Additionally, management did not have evidence of internal controls being in place throughout the audit period to document that vendors were not suspended or debarred prior to entering into a procurement transaction. AdviseWell, Inc. did not have or use documented procurements procedures throughout the audit period. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-04 finding, to ensure that sufficient documentation of history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection of, and the basis for contract price; ensure vendors are not suspended or debarred prior to entering into the procurement process; and document these procurement procedures with an annual review of these with staff. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

Finding 2023-002: Internal Control Deficiency and Noncompliance over Activities Allowed/Allowable Costs Principles, Period of Performance Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: Management did not have adequately designed internal controls in place over expenses charged to the federal program. Management also did not consistently retain evidence to support the existence of certain expenditures and thus the expenses were not adequately documented. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-01 finding, to ensure expenditures are appropriately reviewed and approved prior to entering into the expenditure or requesting reimbursement from the federal program. Documentation will be maintained to support that expenditures were reviewed for appropriate period of performance. Management will ensure all duties are appropriately segregated. In addition, following the October 2023 implementation, care will be taken to ensure that invoices for vendors using electronic invoicing systems will be downloaded in a timelier manner to ensure electronic invoices do not expire within those systems. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

The SAU Grant's Coordinator will be responsible for ensuring the annual grant certification form for salary employees is completed and maintained.

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and submitted each report without a review or oversight process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-003, the Chief of Staff to the Board of Commissioners will have the Controller to the Board of Commissioners review the P&E Reports and the Recovery Plan Performance Report prior to being electronically submitted to the Department of Treasury via its State and Local Fiscal Recovery Funds portal. If errors are discovered by the Controller, the Chief of Staff will correct the electronic entry prior to submission. Anticipated Completion Date: This CAP will be completed by October 31, 2024, the deadline for submitting the third quarter 2024 P&E Report.

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury 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 purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. 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. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… 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: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. 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 primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

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

Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that Provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. Planned Corrective Action: County management will develop written policies and procedures for grants. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with CFR Section 200.502(a) and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Planned Corrective Action: County management will develop a closing process to ensure all federal expenditures are identified, recorded, and reconciled on the SEFA. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

Finding 2023-007 – Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: MSD Warren has construction projects at two sites payable out of ARP. MSD Warren’s contracts for those projects contain Davis-Bacon provisions. MSD Warren will collect payroll data to verify compliance with Davis-Bacon. Anticipated Completion Date: 12/15/24

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

Finding 2023-005 – Special Education Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: MSD Warren will seek competitive quotes for these services prior to the 24-25 school year. Anticipated Completion Date: 6/30/24

Finding 2023-003 – Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The CFO will send a memo to all administrators identifying quote and bid thresholds. The school district will obtain at least 3 quotes or use an alternative acceptable procurement method for large purchases. Anticipated Completion Date: 6/30/24

Finding 2023-002 – Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Business Office and Payroll staff will review a Labor Distribution Report to verify that the staff is only paying appropriate personnel from the Food Service Fund. Anticipated Completion Date: 6/30/24

Assistance Listing No. 93.567 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review and update existing controls. Document approvals throughout the process. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2024

Assistance Listing No. 93.576 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review and update existing controls. Document approvals throughout the process. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2024

Assistance Listing No. 93.659 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review and update existing controls. Document approvals throughout the process. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2024

Assistance Listing No. 93.576 Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review and update existing controls. Document approvals throughout the process. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2024

Audit Ref. #2023-001 Federal Awards: Special Test & Provisions – Use of Project Funds-Payroll Disbursements Name of Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Corrective Action: New Employees responsible for sorting and filing timesheets will be monitored more closely. Proposed Completion Date: September 30, 2024 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Telephone Number: (340) 772-4099 ext. 45

Finding No. 2023-006: Inaccurate Reporting on the Supplementary Schedule of Expenditures of Federal Awards ALN and Program Expenditures: 97.036 ($5,258,177) Program Name: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Corrective Action: Process Improvements: - The University will establish a Supplementary Schedule of Expenditures of Federal Awards (SEFA) controls narrative to formalize preparation and reconciliation processes of SEFA data. - The central University Research Administration team (URA), in coordination with Finance and Administration, will review SEFA preparation and data collection processes and establish a formalized reconciliation process. - Biannually, URA will conduct third party searches to verify funding received at each entity. Expected Implementation: August 2024 – December 2024 Contact: Jennifer A. Ponting (Associate Vice President, Research Administration)