Corrective Action Plans

FINDING 2023-003 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jessica Thome, Controller Contact Phone Number and Email Address: (812) 244-2360 and Jessica.thome@terrehaute.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We have utilized an outside consulting service to assist in the reconciliation of expenditures. Quarterly P&E Reports will be completed by the Controller and reviewed and approved by the Mayor. Anticipated Completion Date: Qtr3 P&E report required by end of Oct 2024

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jessica Thome, Controller Contact Phone Number and Email Address: (812) 244-2360 and Jessica.thome@terrehaute.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Controller will review any previously entered contracts that are paid from our federal grants including ARP to ensure we are in compliance. Anticipated Completion Date: October 2024

FINDING 2023-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County did not have policies or procedures in place to verify that an entity that the county would do business with was not suspended, debarred, or otherwise excluded from participating in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: (812)268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will require, from all vendors that the county will spend $25,000 with in a calendar year using federal funds, a certificate stating that they are not suspended, debarred or otherwise excluded from participating in federal assistance programs. The County Auditor will maintain a copy of the certification in their office. Anticipated Completion Date: October, 2024

FINDING 2023-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County entered into an interlocal agreement with the City of Sullivan to procure services for a Sewer Lift Station Improvement/Line Extension to the New County Jail project. The County could not provide any documentation required to verify compliance with the procurement and Suspension and Debarment requirements for the SWIF funds spent on the project. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: (812)268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will adopt a procurement policy. In addition, the County will work with the City of Sullivan to obtain the necessary documentation related to the interlocal agreement and maintain the documentation for future audit periods. Anticipated Completion Date: October, 2024

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Allowable Costs/Cost Principles Summary of Finding: The County Council did not have an Allowable Cost policy in place during the audit period and supporting contracts for agreements with recipients of the grant funds could not be provided for the audit. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: 812-268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We concur with the finding. The County will adopt an allowable cost policy and the County Auditor will review all supporting documentation with claims to ensure that proper contracts or interlocal agreements are included with the claims for of the grant. Anticipated Completion Date: October, 2024

The Garden is in the process of reviewing its policy surrounding the review process for federal expenditures. The Garden will be implementing an approval process for all expenses on credit cards and other federal charges. Accounting will only charge the expense to the grants once it has verified the expense has gone through the proper approval channels.

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Summary of Finding: The County elected to receive the standard revenue loss allowance, allowing them to claim their total State and Local Fiscal Recovery Funds (SLFRF) allocation of $6,293,126 as revenue loss to use for government services. As such, all SLFRF program funds to date were expended under the revenue loss eligible use category. The U.S. Department of the Treasury (Treasury) determined that there are no subawards under this eligible use category, and that recipients’ use of revenue loss funds would not give rise to subrecipient relationships as there is no federal program or purpose to carry out in the case of the revenue loss portion of the award. Prior to entering into subawards and covered transactions with federal award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include but are not limited to contracts for goods or services awarded under a non-procurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. Verification is to be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person, or adding a clause or condition to the covered transaction with that person. Due to the Treasury's determination that the revenue loss eligible use category does not give rise to subawards, the County was only required to comply with suspension and debarment requirements, related to covered transactions. Covered transactions in the amount of $1,730,492 were made during the audit period to three vendors. Of the three vendors used by the County, one vendor contract included a suspension and debarment clause. However, for the two remaining vendors, the County did not check the ELPS, nor was a certification collected from the vendors, nor was a clause in the agreements. Although the County had a policy to include a clause in vendor contracts related to covered transactions, the County did not have effective internal controls to ensure that the suspension and debarment clause was added to all the contracts. The lack of effective internal controls and noncompliance were isolated to the two vendors noted above. Contact Person Responsible for Corrective Action: Britt Ostler Contact Phone Number and Email Address: (765) 659-6330 INDIANA STATE BOARD OF ACCOUNTS 31 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Suspension and Debarment clause will be added by the Commissioners/County Attorney to all contracts and/or the Commissioner’s Administrative Assistant will check Sam.gov to make sure the vendor is in good standing before the Commissioner’s enter into any contracts for federal grants. Anticipated Completion Date: December 31, 2024

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the U.S. Department of the Treasury (Treasury). The reporting periods, as well as the respective due dates, are based on the type of recipient and the recipient’s population, as well as the recipient’s allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The County was classified as a metropolitan county with a population below 250,000 residents that received an allocation of less than $10 million in State and Local Fiscal Recovery Funds. As such, the initial P&E report, covering the period from March 3, 2021 to March 31, 2022, was required to be submitted to the Treasury by April 30, 2022. The subsequent annual reports are to cover one calendar year and must be submitted to the Treasury by April 30 each year. The County submitted one P&E report during the audit period, which was obtained from the Treasury's website. Although one employee prepared the P&E report and another reviewed the entries, the system of internal controls was not effective in preventing, detecting, or correcting errors. The data submitted included amounts which should not have been included and amounts which were not supported by the County’s records. Errors identified included the following: • Total Cumulative Obligations were overstated by $907,630. • Total Cumulative Expenditures were overstated by $4,332,524. The lack of effective internal controls and noncompliance were isolated to the P&E Report submitted during the audit period. Contact Person Responsible for Corrective Action: Britt Ostler Contact Phone Number and Email Address: (765) 659-6330 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 29 The County received guidance from a consultant in regards to reporting the SLFRF. The consultant had advised “if the County planned to spend $5M, then the total cumulative “obligations” would be $5M. Per review of the SBOA, two figures in the 2023 P&E Report were miscalculated: Cumulative Obligations and Cumulative Expenditures. The Cumulative Obligations reported should be the amount contracted for the project plus any change orders. The Cumulative Expenditures should be the amount expended in prior years, if any, plus the amount expended until March 31st of the year the P&E Report is dated. The current period for the 2023 P&E Report covered April 1, 2022 to March 31, 2023. Future P&E Reports submitted for this grant will use this understanding of Cumulative Obligations and Cumulative Expenditures and will be prepared by the County Auditor and reviewed by a second individual prior to submission. Anticipated Completion Date: April 1, 2025

In response to this finding, it is important to note that the proposed measures were already considered upon the transition of the CFO. ElderSource will continue to follow policies and procedures in place, which include the CFO or a designee in their absence reviewing the payroll journal, along with a written confirmation of approval. According to this letter, the corrective action has been completed. It will be monitored by the CFO, James Lee.

FINDING 2023-004 Finding Subject: COVID 19 Coronavirus State and Local Fiscal Recover Funds – Reporting Federal Agency: Department of the Treasury Summary of Finding: Material Weakness – The P&E report submitted in April 2023 was prepared and submitted by one employee without evidence of an oversight or review process to ensure accuracy. Contact Person Responsible for Corrective Action: Elizabeth J Billue Contact Phone Number and Email Address: 574-583-1515 libby.billue@whitecounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All annual reporting will be reviewed as previously planned, prior to submission. However, a coversheet has also been created and will be completed for all future annual reporting has been created for use. The form includes documentation of the preparer, reviewer, and date of submission. This information will be kept in files within the Auditor’s office. Anticipated Completion Date: This plan will be implemented by April of 2025.

FINDING 2023-003 Finding Subject: COVID 19 Coronavirus Stat and Local Fiscal Recover Funds – Procurement and Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion – Subawards and covered transactions for federally provided award funds are required to verify that vendors are not suspended, debarred, or otherwise excluded. Two contracts using SLFRF funds were found to have not included a clause to certify that they were not suspended or debarred. Contact Person Responsible for Corrective Action: Elizabeth J Billue Contact Phone Number and Email Address: 574-583-1515 libby.billue@whitecounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor has met with the County Attorney to put a plan in place to make sure that this clause in included in all federally funded projects at a minimum. If the clause is not included within the contracted presented for approval, the County will require that a signed statement certifying that the vendor is not suspended or debarred be attached to the contract. Anticipated Completion Date: This plan will be implemented by 12/31/24.

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County did not have effective internal controls in place to ensure that P&E reports submitted were accurate. This allowed errors on P&E reports to remain undetected and uncorrected. It was recommended that policies and procedures be put in place to ensure that all reports were complete and accurate. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County implemented an additional procedure to ensure we have complete and accurate information for the P & E report. Beginning with the 3rd Quarter P&E report, the County had added a person to assist with these reports by creating the reports through our financial software and reviewing the figures and information before giving the reports to the Auditor. The County Auditor prepared the P & E reports and then the Commissioner’s reviewed before the Auditor submitted the report to the Treasury. Due to the financial software (Software Solutions), there were reporting issues between quarters. The Bartholomew County Auditor’s Office continuously strives to improve upon our process and during 2024, changed financial software to LOW Financial to help with reporting and will implement an additional check and balance prior to the Treasury. Anticipated Completion Date: December 31, 2024

FINDING 2023-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County had not implemented procurement policy or procedures for procuring goods and services paid with Federal funds. The County did not have policies or procedures in place to verify that the entities which they entered into covered transactions were not suspended, debarred, or otherwise excluded. Four out of seven covered transactions were selected for testing, and none of the contractors’ suspension or debarment statuses were checked prior to payment. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will continue to work with the Commissioner’s Office and other county departments to improve upon the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Fund. The County implemented a Procurement, Suspension and Debarment Policy; however it did not specifically reference federal funds. The County will amend the current policy to include the necessary verbiage and information related to the federal funds. By establishing this system of Internal Controls and developing the proper policies and procedures, this should help ensure contractors and sub recipients, as appropriate are not suspended, debarred or otherwise excluded prior to entering any contacts or sub awards. Anticipated Completion Date: December 31, 2024

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.

Corrective Action Plan: The Corporation will enhance internal control procedures to ensure that all cash disbursements are reviewed and approved by management before issuance. The procedure will involve: 1. Voucher Review Protocol: A checklist will be created to ensure that all disbursements are accompanied by documented approvals. This checklist will include verification of the approval by both management and legal counsel when necessary. 2. Management Approval: Disbursements, particularly those over $500,000, will require formal sign-off from the Chief Executive Officer and review by the Legal Department. 3. Training & Compliance: Staff will be trained on the updated process, and compliance will be regularly reviewed by the internal audit team. A report on adherence to these new procedures will be made available to the Board quarterly. 4. Verification of Prior Disbursement: Regarding the specific instance cited, management will review the process followed to verify that the review by Albanese and LDC counsel, as referenced in the email, was correctly documented. If this was indeed the case, a follow-up with the auditors will be initiated to clarify the discrepancy. Responsible Individual: Joseph Ninomiya - Chief Executive Officer Planned Date of Implementation: October 15, 2024

1)The duplicate invoice for $92,880.00 was removed from the Tracker worksheet which was submitted in 11/27/2023. 2)The duplicate invoice for $91,511.66 will be removed from the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024. 3)The discounts taken for early payment of contract labor invoices for a certain vendor will be corrected on the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024.

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward design controls to ensure formal documentation of approval of comparables is in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Home Forward will add clarifying language in our Shelter Plus Care (Continuum of Care) Program operating manual indicating need for staff to document who completed rent reasonableness reviews including signatures from program supervisors or department staff responsible for approving comparables when necessary as part of the rent reasonableness review. Additional staff training will be conducted during Shelter Plus Care and department team meetings. Name(s) of the contact person(s) responsible for corrective action: Ian Slingerland, Director of Homeless Initiatives and Supportive Housing Planned completion date for corrective action plan: 10/1/2024

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend Home Forward implements a process to ensure exclusion checks are done prior to the execution of a contract. This process should include a system to ensure documentation is maintained in the files evidencing the date of the exclusion check as well as documented review and approval of the results of the exclusion check by program staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement has updated the Contract Request form to include a section for attesting yes or no for federal funds, also allowing for free form entry. After a discussion with DCR on situations where they are unsure if there will be HUD funding it was determined to treat all their Public Improvement projects as Davis Bacon projects and include all applicable steps throughout the solicitation process. We are doing a full background check on all contracts, which includes a sam.gov check. When the contracts come to the Contracts and Procurement Manager for final signature, a check will be made in the file to confirm the documents are present showing the sam.gov screen print was made and the Contracts and Procurement Manager will sign both the background check and the Contract at that time. Example attached. Name(s) of the contact person(s) responsible for corrective action: Celeste King Planned completion date for corrective action plan: June 1, 2024

Finding Number: 2023-001- Schedule of Expenditures of Federal Awards (SEFA) Preparation – Material Weakness Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the federal award to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. This includes properly identifying all federal awards subject to the Uniform Guidance and fairly presenting the required information in the schedule of expenditures of federal awards. Condition: Subsequent to the issuance of the Audit Report on the Consolidated Financial Statements and Supplementary Information for the year ended September 30, 2023, it was discovered that there was an omission of two federal grants with expenditures totaling $1,591,715 from the schedule of expenditures of federal awards. Cause: The Organization did not communicate with Care 1st Health Plan regarding the details of certain contracts to determine the amounts were subject to the Uniform Guidance and were to be included on the schedule of expenditures of federal awards. In addition, Care 1st Health Plan became the Regional Behavioral Health Authority for the Northern Arizona region effective October 1, 2022. Due to this transition, various changes occurred causing uncertainties with classifications of certain types of federal awards as subrecipient awards versus as contractor payments. Effect: The schedule of expenditures of federal awards was understated by $1,591,715, which resulted in the restatement of the previously issued schedule of expenditures of federal awards to correct the omission. Questioned Costs: Not applicable. Recommendation: We recommend that all funding contracts are carefully reviewed to determine whether amounts awarded should be classified as contractor payments or as subrecipient payments. If there is any uncertainty, we recommend that the Organization contact the funding source for clarification. Name of Contact Person: Mike Fett, CFO Phone Number: 602-265-8338 Anticipated Completion Date: September 30, 2024 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish procedures to review all contracts and to if necessary, to communicate with funding sources to ensure that receipts of federal funding are properly classified as being subrecipient versus contractor arrangements to ensure completeness of the Schedule of Expenditures of Federal Awards.

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 and July 10, 2024. Explanation: National CASA/GAL has consistently maintained policies and procedures to ensure FFATA reports are filed timely. Documentation of review/approval from a person separate from the person filing the FFATA report was not readily available in some instances, so procedures were updated to include maintenance of such review/approval. FFATA reports are required to be filed “by the end of the month following the month after the subaward obligation date”. National CASA/GAL filed FFATA reports to adhere to this deadline in compliance with what it understood to be the obligation date, understanding an obligation date could not occur prior to the grant period. This finding was noted in the 2022 audit which was issued August 13, 2024. The 2023 audit, completed in September 2024, included in its scope, the same FFATA reports from the same federal grant that had been reviewed in the 2022 audit and OJJDP/OCFO monitoring visit. National CASA/GAL did not have an opportunity between the 2022 and 2023 audits to cure this finding in practice until the issuance of new subrecipient awards in 2024.

Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement. Responsible Party: Vice President Finance Completion Date: November 30, 2024

Finding: Akron Children’s screening for suspension and debarment through the third-party vendor results does not include controls to ensure file completeness or accuracy. Corrective Action Plan: Akron Children’s implemented a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. Completion Date: December 31, 2023 Corrective Action Plan: Akron Children’s developed a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including independent review of the accuracy of file submissions. Completion Date: October 31, 2024 Corrective Action Plan: Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements. Completion Date: December 31, 2023 Resposible Party: Chief Legal Counsel