Corrective Action Plans

Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for, and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 4 reporting required an organization to illustrate how PRF and ARP funds received were used. An organization was allowed to include eligible expenditures from January 1, 2020 through December 31, 2022 depending on the period reporting. Condition: During the process of identifying expenses that were incurred to prevent, prepare for, or respond to the coronavirus pandemic, management properly incurred and reported reflected expenses within the period of availability; however, the quarterly expenses reported on the portal submission did not reflect the actual quarter in which the expenses were incurred. Planned Corrective Action: Management will continue to refine its processes to more diligently review expenditures to ensure accurate reporting of expenses by quarter in future reporting. Planned Completion Date: December 31, 2023 Person Responsible: Chase Dudzinski, Chief Financial Officer

FINDING 2022-002 Material Weakness ? Procurement , Suspension, Debarment Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s office will continue to check the System for Awards Management quarterly to verify Tran Services is not debarred. Further, the office will now check for contracts that exceed the $25,000 threshold that require such inquiry. Anticipation Completion Date: 09/30/23

FINDING 2022-001 Material Weakness - Reporting Contact Person Responsible for Corrective Action: Julie Flores Contact Phone Number: 765-382-3779 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Controller?s Office will send the monthly appropriation reports for transportation to the Administrative Assistant (AA) and to the Transportation Manager to review and reconcile. After the monthly report has been reconciled by the transportation Administrative Assistant, it will be initial and dated by the AA, the work will be forwarded to the grant administrator, transportation manager and controller?s office. The Controller?s Office will review to ensure accurate information was forwarded to the grant administrator. These changes will be reflected in the City of Marion?s Internal Control Policy. Anticipation Completion Date: 09/01/23

Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Criteria: 2 CFR section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Title 2 CFR Section 200.214 of the Uniform Guidance states that the County must comply with 2 CFR part 180, which implements Executive Orders 12549 and 12689. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The 2022 Compliance Supplement states: Non-Federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. ?Covered transactions? include contracts for goods and services awarded under a non-procurement transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000 or meet certain other criteria as specified in 2 CFR section 180.220. All non-procurement transactions entered into by a pass-through entity (i.e., subawards to subrecipients), irrespective of award amount, are considered covered transactions, unless they are exempt as provided in 2 CFR section 180.215. When a non-Federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at https://www.sam.gov/SAM/, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). Condition: During our testing of the Orange County Public Works (OCPW) and the County Executive Office?s (CEO) provisions for procurement requirements under the COVID-19 Coronavirus State and Local Fiscal Recovery Funds, we noted the following instances where there was no evidence that the OCPW or CEO departments verified the entity was not suspended or debarred or otherwise excluded from participating in the transaction, prior to entering the contract, in accordance with County policy ? Three (3) of three (3) contracts through the OCPW department selected for testing. ? Two (2) of six (6) contracts through the CEO department selected for testing. Cause: The OCPW and CEO departments did not follow their policy to verify the information described in the condition prior to entering the transactions. Effect: The County?s control and compliance were not consistently followed, which required verification of suspension or debarment prior to entering the contract. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of three (3) out of eight (8) procurement contracts were sampled from OCPW and six (6) out of fourteen (14) procurement contracts were sampled from the CEO department for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds. The condition above was identified during our testwork of the OCPW and CEO departments? internal controls over procurement and suspension and debarment. Repeat Finding from Prior Years: No. Recommendation: We recommend that the OCPW and CEO departments adhere to their procurement procedures requiring the suspension or debarment verification is performed prior to entering into a covered transaction. Management Response and Corrective Action: County Executive Office: 1. Person Responsible: Selina Chan-Wychgel, Fiscal Services Manager 2. Corrective Action Plan: The County Executive Office will adhere to the Contract Policy Manual (CPM) and internal policy and procedure of ensuring the suspension or debarment verification of a contractor is performed and documented prior to awarding a contract. The County Procurement Office will continue to provide trainings and reminders to County-wide procurement staff of this guideline to ensure compliance with Federal Award protocol. 3. Anticipated Implementation date: June 30, 2023 OC Public Works: 1. Person Responsible: Joseph Sly 2. Corrective Action Plan: On October 21, 2022, OCPW Procurement updated the Department?s policy and procedure to include an additional requirement for the submission of the Alternative Funding Procurement Acknowledgement Form when utilizing non-County funding sources. The contracts selected in this audit were awarded prior to October 21, 2022. 3. Anticipated Implementation date: October 21, 2022

Program: COVID-19 Emergency Rental Assistance Program Federal Financial Assistance Listing Number: 21.023 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.01 of the Uniform Guidance states that the County may report charges on a cash or accrual basis, as long as the methodology is disclosed and consistently applied. Condition: During our testing of the HCA?s provisions for reporting requirements, we noted the following instance where reports were prepared on the cash basis, but reports indicated that the costs were reported on the accrual basis of accounting: ? Two (2) out of the three (3) reports for the HCA. Corrective action of prior year finding was implemented mid-year. Cause: The HCA department reported amounts on cash basis, but the form identified the basis for the report as ?accrual?. The HCA department review process and certification of the report did not identify the discrepancy. Effect: The County?s control was not consistently followed, which applies the basis of accounting on a consistent basis. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of three (3) reports were selected for report testing. Repeat Finding from Prior Years: Yes, Finding 2021-005. Recommendation: We recommend the HCA adhere to their policies and apply the same basis of accounting on a consistent basis for the program. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Cindy Wong, HCA Accounting Services Division Manager 2. Corrective action plan: Once identified during prior year?s Single Audit, HCA Accounting has ensured the appropriate basis of accounting is reported correctly and applied consistently for the ERAP program. 3. Anticipated Implementation date: Fully Implemented

Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award No. and Year: 2022 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing of the Social Services Agency?s (SSA) provisions for reporting requirements, we noted the following instance where reports were prepared, reviewed, and approved by the same individual: ? Two (2) of four (4) reports for the SSA Cause: The SSA department did not have a segregation of duties over the preparation and review and approval of performance reports. Effect: The County?s control was not consistently followed, which requires reports to be reviewed and approved by a separate individual. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A non-statistical of four (4) out of twelve (12) reports were selected for reporting testing from SSA. The condition above was identified during our testwork of the SSA?s internal controls over reporting. Repeat Finding from Prior Years: No. Recommendation: We recommend the SSA adhere to their policies and ensure segregation of duties over the preparation and review and approval of performance reports. Management Response and Corrective Action: Social Services Agency: 1. Person Responsible: Silvia Fuller, Administrative Manager II, Research 2. Corrective action plan: SSA has normally adhered to policy of segregation of duties over the preparation and review and approval of performance reports. However, during 2021 the assignment of the CA 237 FC report fell to one individual due to staff vacancies caused by the COVID Pandemic. Effective August 2022, the report has been assigned to the Research Unit which is following and adhering to the policy of segregation of duties. 3. Anticipated Implementation date: Fully implemented as of August 2022

Program: Immunization Cooperative Agreements Federal Financial Assistance Listing Number: 93.268 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 17-10336 A02 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.334, Retention requirements for records, states that financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a federal award must be retained for a period of three years from the date of submission of the final expenditure report, or, for Federal awards that are renewed quarterly or annually, from the date of submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. Condition: During our testing of the HCA?s provisions for reporting requirements, we noted the following instances for two (2) out of two (2) reports: ? The performance reports were not reviewed or approved prior to submission to the State. ? The department did not retain any supporting documents for the performance reports. Cause: The HCA department personnel prepared program required performance reports and submitted to the State without retaining evidence that the reports were reviewed and approved by a separate individual prior to submission. The HCA department did not retain any supporting documents for the performance reports submitted. Effect: The County?s control was not consistently followed, which requires reports to be reviewed and approved by a separate individual prior to submission to the State. Additionally, the HCA department did not adhere to their policies and procedures in place requiring record retention of supporting documentation. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) performance reports were selected for report testing for the Immunization Cooperative Agreements program. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA adhere to their policies and ensure the review and approval of reports are clearly documented prior to the report?s submission and adhere to their policies of record retention of supporting documents for the performance reports submitted to the State. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Joshua Jacobs, HCA Public Health Services - Communicable Disease Control Division Director 2. Corrective action plan: HCA Public Health Services Communicable Disease Control Division will ensure retention of proper documentation supporting the performance reports and substantiating the review/approval prior to report submission to the State for the Immunization Cooperative Agreement. 3. Anticipated Implementation date: March 27, 2023

Management concurs and will revisit policies and procedures relating to grant administration to ensure that supervisory review procedures are performed.

Finding Number: 2022-007 Federal Program, Assistance Listing Number and Name: ALN 14.241, Department of Housing and Urban Development, Housing Opportunities for Persons With Aids (HOPWA) and COVID-19 HOPWA Condition: Original Finding Description: In conjunction with eligibility testing, instances of noncompliance specific to the rental assistance calculation were identified. Contact Person Responsible for Corrective Action: Denise Fair and Angelique Tomsic Anticipated completion date: July 2023 Planned Corrective Action: In FY23, the City implemented a review of 100% of clients who received subsidy services. The intensive review is being performed to help ensure all required documents are saved and accurate. A corrective action plan will be documented and further reviews put in place to help ensure compliance and consistency for all rental calculations. The city will also continue to work with its contractor on process improvements. In addition, as part of the AFCAP process, the City will work with the department to perform internal reviews to help ensure processes are being followed

Finding Number: 2022-010 Federal Program, Assistance Listing Number and Name: ALN 20.507 and 20.526, Department of Transportation, Federal Transit Cluster, including COVID-19 ALN 14.231, Department of Housing and Urban Development, Emergency Solutions Grant Program, including COVID-19 Condition: Original Finding Description: A contract selected for testing within Emergency Solutions Grant Program that was procured in August 2021 was not communicated to City Council until October 2022. A contract selected for testing within the Federal Transit Cluster that was procured in November 2021 was submitted for City Council approval within the prescribed 4 weeks; however, OCP did not notify City Council in writing of the basis for the emergency contract within one week of the procurement. Contact Person Responsible for Corrective Action: Sandra Yu Stahl Anticipated completion date: July 2023 Planned Corrective Action: The city will review its current procurement non-competitive policy ensure the required review, controls and checklist are in place to ensure compliance and all policy steps are followed by staff.

Finding Number: 2022-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City of Detroit did not have adequate controls in place to exercise its oversight responsibility of eligibility determinations that were performed by a contractor for the program. Contact Person Responsible for Corrective Action: Denise Fair Anticipated completion date: July 2023 Planned Corrective Action: The City will implement controls to ensure that Health Department provides oversight of the contractor and the participant eligibility process. The Health Department has hired a WIC Program Director who will monitor participant eligibility compliance and ensure that eligibility policies and procedures are maintained and followed. Through the AFCAP project process, the City will also review the contract in detail to help ensure full compliance

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalispell Regional Medical Center d/b/a Logan Health Medical Center (LHMC) as of December 31, 2020. When LHMC calculated their lost revenues, they included HC's revenue for both 2020 and 2021 instead of only the 2021 information. This resulted in LHMC reporting higher lost revenue than the detailed reports supported in Period 1. This also affected the lost revenues reported in Period 2 for LHMC. HC filed its own report for Period 1, which included their revenues for 2019 and 2020. Zeros were entered for 2021, which resulted in reporting higher lost revenues than the detailed reports supported in Period 1. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO. Corrective Action Plan: The lost revenue calculation will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: 3/31/2023

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expenses were higher than revenues, creating a negative revenue for the quarter. As the HHS reporting portal would not allow negative amounts to be entered, a zero was entered into the HHS reporting portal. These negative amounts should have been offset to other quarters or other revenue line items, but were not, which resulted in higher revenue amounts being reported than the detailed reports supported. Responsible Individuals: Craig Lambrecht, CEO, and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation for these three locations will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: 3/31/2023

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: There was no formal documentation of review and approval for overall expenses claimed, calculation of lost revenue, or the Corporation's special report by a separate individual outside of the preparer at two entities. Responsible Individuals: Craig Lambrecht, CEO, and Cole Turner, CFO. Corrective Action Plan: All tracking documents and reports will be reviewed by someone other than the preparer at all locations. The reviewer will sign off by email or by physical signature that they have reviewed and agree with support. Anticipated Completion Date: 3/31/2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Susan Sleeper Contact Phone Number: 260-925-2362 Views of Responsible Official: I concur with the finding. Description of Corrective Action Plan: New Internal Controls will be implemented, with review of the COIVD-19 annual report prior to submission with email correspondence kept as documentation. Anticipated Completion Date: 06/30/2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Susan Sleeper Contact Phone Number: 260-925-2362 Views of Responsible Official: I concur with the finding. Description of Corrective Action Plan: New internal controls will be implemented for the suspension and debarment requirements. Auditor Sleeper has all conversed with County Attorney Kruse on the issue. Anticipated Completion Date: 06/30/2023

Finding 2022-003 ? Child Nutrition Cluster - Reporting Contact Person Responsible for Corrective Action: Tracy Wilson Contact Phone Number: 317-936-5444 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: All claims submitted for federal reimbursement will be reviewed prior to submission. Control will be put in place to verify entries to sales reports through CNC website and initialed by two parties to confirm accuracy over the process. Anticipated Completion Date: Effective Immediately

2022-004 Allowable Costs/Costs Principles Recommendation: We recommend the organization charge compensation for personnel services to the federal grant based on approved hours worked in the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Plainfield Community School Corporation will implement practices to ensure compensation for personnel services to the federal grant is based on approved hours worked in the program. Temporary employees will document hours worked by signing in and out each day worked. Name(s) of the contact person(s) responsible for corrective action: Elizabeth Shepperd Planned completion date for corrective action plan: April 2023

2022-005 Child Nutrition - Reporting Recommendation: School Corporation needs to update its policies and procedures related to the administration of the Child Nutrition Cluster to include a system of internal control that will mitigate the risk of noncompliance with the stated criteria related to recordkeeping. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Plainfield Community School Corporation will implement a policy that mitigates the risk of noncompliance with the required recordkeeping for the Child Nutrition Cluster. Name(s) of the contact person(s) responsible for corrective action: Kelly Collins Planned completion date for corrective action plan: April 2023

Concur: Departments are responsible for the operational compliance of their grant awards. The Aviation Department is in the process of reclassifying a position to a contract compliance specialist which will help ensure future compliance. Financial Management Services (FMS) will establish a process to assist departments in meeting compliance requirements. A contract review checklist will be implemented by FMS to assist with the identification of all compliance requirements for each award. FMS currently holds grant kickoff meetings with departments, and additional focus on contract compliance will be emphasized at that time. Departments will be required to provide FMS additional compliance documentation. FMS will review the documentation for reasonableness and load the records to the PeopleSoft Project Definition page as evidence of timely compliance. As an additional measure, system reminders will be emailed to departments and FMS providing notification of upcoming deadlines. FMS will continue to provide training for grant management personnel to reinforce key concepts of grant compliance. This action plan will be completed by September 30, 2023. Contact Person: Reginald Zeno, Chief Financial Officer, FMS 817-392-8517 Contact Person: Tony Rousseau, Assistant Finance Director, FMS 817-392-8338

Program: AL 21.026 ? COVID-19 Homeowner Assistance Fund ? Allowability & Eligibility Corrective Action Plan: Coaching has been provided to the appropriate review staff. Contact: Major General Bohac Anticipated Completion Date: Completed

Program: AL 21.023 ? COVID-19 Emergency Rental Assistance ? Allowability & Eligibility Corrective Action Plan: N/A Contact: Lee Will Anticipated Completion Date: N/A

Program: AL 17.225 ? Unemployment Insurance ? Admin ? Special Tests & Provisions Corrective Action Plan: The Agency is working with the vendor to better identify and report amounts in the Tax Systems. Contact: Rea Easton Anticipated Completion Date: June 30, 2023

Program: AL 12.401 ? National Guard Military Operations and Maintenance (O&M) Projects ? Cash Management & Reporting Corrective Action Plan: The USPFO Grants Officer Representative (GOR) will continue to work closely with the Cooperative Agreement Program Mangers (CAPMs) to track projected invoices so they are paid out in a timely fashion (per Federal Cash Management requirements) from the Cooperative Agreement advance funds (as required by the State). Also upon implementation of the recommendation to change the data in the SF270 (contained in the Exit Conference), the SF270 submission will track the availability of advance funds ? thereby preventing excessive advance funds requested ? and fully expending current available advance funds to the federal requirements. Contact: Matt Zeigler, Grants Officer Representative Anticipated Completion Date: Implementation will occur at the start of the new State Fiscal Year 01-Jul-2023.

Program: AL 93.558 ? Temporary Assistance to Needy Families; AL 10.561 ? State Administrative Matching Grants for the Supplemental Nutrition Assistance Program; AL 93.658 ? Foster Care Title IV-E ? Allowable Cost/Cost Principles Corrective Action Plan: DHHS will continue to train staff on the proper RMTS procedures, which includes correct method of validation. Contact: Patrick Werner Anticipated Completion Date: 06/30/2023