Corrective Action Plans

FINDING 2022-001 Contact Person Responsible for Corrective Action: Jim Evans Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: This finding was corrected beginning July 1, 2022. Concord Community Schools hired an additional staff member and that staff member reviews the information used to prepare the Monthly Sponsored Claims for reimbursement to verify that the claims are accurate, complete and prepared in accordance with the grant requirements. Once the review is complete, the Monthly Sponsored Claims are printed and signed by both the Food Service official who prepared the claims and the food service official who reviewed the claims for accuracy, completeness and compliance with grant requirements. Anticipated Completion Date: This finding has been corrected.

Corrective Action for Finding 2022-001: Internal Controls over Allowable Costs The Theatre agrees with the recommendation. This finding occurred due to a new Controller who did not adequately document expenditures per the grant requirements. This person has since been replaced by the Theatre. Going forward, procedures will be implemented to ensure all grant expenditures are reviewed for allowability. This will include a secondary review performed by the Director of Finance & Operations or designated Theatre personnel knowledgeable of the applicable grant requirements. The Director of Finance & Operations will be responsible for initiating and executing this corrective action plan effective immediately and with an expected completion date by August 31, 2023.

2022-001 Reporting: Significant Deficiency over Internal Controls over Contact person responsible for corrective action: Juan Hernandez, AVP for Finance Completion date: September 30, 2022 Summary of new and revised controls used to ensure timely posting of the special reports: Part 1: Starting with the quarter ended 9/30/2022 the AVP for Finance will send calendar reminders to Pre-Award, Post Award, Financial Aid, Finance, and other parties involved to set a reminder of submission deadlines for each quarterly report and set an internal deadline prior to such due date. Due dates are specified by OMB Control Number 1840-0849, the reporting deadline for quarterly reports is 10 days after each reporting period. Additionally, the AVP for Finance will now be the responsible party to coordinate and submit the report to the DOE and to initiate the upload to the university website with the help of all the aforementioned parties. Part 2: In addition to the calendar invitation in part 1 above, the AVP will be responsible for submitting the report to the DOE and emailing all parties involved confirming that the report was submitted to the DOE. This email will confirm that the report is final and will indicate to designated uploader (currently financial aid department) to make the information public by uploading it to the CGU CARES website. Once this is uploaded the uploader will send a follow up email to all parties involved to confirm that the upload to the website has occurred.

The District Department of Health (DC Health) concurs with the finding, causes and recommendations cited in the fiscal year 2022 single audit for the Immunization Cooperative Agreements (ICA) program. Corrective action plan objectives are to have the following completed in fiscal year 2023: (1) a regular schedule of payroll data runs and reports of budget-to-actual time migrated to a certification platform managed by the Office of Grants Management, (2) full utilization of a uniform navigable tool and one-stop document for supervisors to certify time and effort and to request next actions if actual costs do not align with personnel budgets, (3) to create an IT solution or mechanism to route and track submissions between supervisors, the Office of Grants Management and the Office of the Chief Financial Officer (OCFO), and (4) the SOP will also be updated to integrate any procedural changes resulting from full implementation. See Corrective Action Plan for chart/table

UDC OCFO agrees with the conditions and recommendations of this finding. No action is required since UDC has already implemented corrective action to maintain evidence of submission of quarterly reports to the UDC webmaster. UDC also developed a sign-off coversheet to document evidence of review by the preparer, the reviewer and approver of the quarterly and annual reports. See Corrective Action Plan for chart/table

The District of Columbia Public Schools (DCPS) agrees with the conditions and recommendations of this finding. The DCPS corrective action plan includes the following: ? DCPS will establish a link between the various systems to ensure purchasing and receiving records are attached to individual asset tags or other identifiable information in our asset management system. Effective March 23, 2023, TIPWeb has been updated reflect these changes. See Corrective Action Plan for chart/table

OCFO concurs with the finding. In the compilation and reconciliation of the SEFA, the PAYGO ARPA Local Revenue Replacement expenditures component was inadvertently included in the draft District FY 2022 SEFA presented to the external auditors. The District SEFA Compilation Worksheet will be updated to include guidance on treatment of PAYGO FY 2023 ARPA Local Revenue Replacement expenditures (if any) to ensure they are not included in the draft FY 2023 SEFAs presented to the external auditors. See Corrective Action Plan for chart/table

The Department of Human Services (DHS) concurs with the findings. In response to a similar finding for the fiscal year 2021 ERA single audit where original submission data was overridden by formatting updates, DHS began saving screen shots of reported data within Treasury?s reporting portal. This practice began in June 2022 and will continue for the duration of the ERA program, through ERA2 closeout reporting. This will ensure that even if Treasury reporting portal functionality changes in the future, there is clear supporting documentation of the information submitted. See Corrective Action Plan for chart/table

The Department of Human Services (DHS) agrees with the findings. DHS will reach out to the four (4) STAY DC payees to formally request the return of improper payments to the District of Columbia. This will be tracked to ensure the return is recorded against ERA within the District?s financial system. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in FY23. The new SOP implements stricter internal control procedures, regular audits, and streamlining the eligibility determination process. The District will reclass all identified errored payments off of the ERA fund to Local funding by the closeout of FY23, Sept. 30, 2023. DHS also completed a reconciliation of data reported to U.S. Treasury for ERA1 closeout reporting and ERA2 2023 Q2 reporting to ensure that no errored payments were included. See Corrective Action Plan for chart/table

Finding 2022-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Fund Pass-Through Agency: Not applicable Award Number/year: Not applicable / 2022 Criteria: Nonfederal 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. Review and approval of reports to be submitted under the program should be completed before submission by an individual separate from the preparer. Condition/Context: For the one report required to be submitted under the program in FY2022, the report was both prepared and reviewed by the same individual. The sample was not statistically valid. Cause: The City does not have an internal process in place to ensure all reports are reviewed by someone separate from the preparer prior to submission. Effect: Reports could be submitted that contain errors or reports may not be submitted within the allowed reporting periods. Questioned Costs: None noted. Recommendation: The City should consider enhancing its internal controls related to this program to include a review of reports by someone separate from the preparer prior to submission. Corrective Action Plan Corrective Action Planned: Finance Director will prepare the report. Deputy Treasurer/Clerk will review the report before Finance Director submits the report. Name(s) of Contact Person(s) Responsible for Corrective Action: Mark Stevens, Finance Director Anticipated Completion Date: April 2024 (at point of annual submission)

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Brook Cleaver Contact Phone Number: (765) 675-2147 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Superintendent and Treasurer will work to ensure that bids are sought and kept on file for projects exceeding the simplified acquisition threshold. Once a vendor is selected, Treasurer will search exclusions in the Sam.gov portal for vendors that may be suspended or debarred from participation in federal assistance programs and keep said documentation on file. Anticipated Completion Date: Immediately.

Department: Health and Human Services Title: Internal control over P-EBT Food Benefits needs improvement Questioned Costs: Known: $61,507,558 Likely: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding and does not believe that corrective action is warranted. During the course of the audit, the Department provided the Office of the State Auditor (OSA) with the complete population of recipients as well as the supporting information necessary for OSA to conduct testing to verify compliance with federal program requirements. The only remaining action that is required is for OSA to perform their testing. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104

Corrective Action Plan: The coronavirus pandemic and the Minnesota Governor?s resulting emergency closure of large, in person gatherings through May 28, 2021, impacted the theatre ability to produce live, in-person theatre events. The Theatre continued to operate but with minimum staffing levels to decrease expenses. Due to the lower staffing levels, segregated duties were not always possible. Several of the items tested were from this decreased staffing timeframe. The Theatre will re-evaluate internal controls to mitigate the risk of non-compliance. To assist in this process, the theatre will add a Chief Operating Officer position. This position will assist in evaluating controls and procedures. They will also contribute an additional level of oversight on expense.

The OCFO/OFT for DHS concurs with this finding. As a result of the findings, OCFO/OFT is committed to working with Fidelity National Information Services (FIS) to ensure: ? Strict procedures and practices are in place to ensure contract compliance. Quarterly management reviews of UPO practices have been conducted to ensure proper handling of DHS referral forms. OFT will ensure UPO up-holds policy and procedures that govern receiving proper signature on the referral forms; this should mitigate errors that appear in the current process. ? All Intake Procedures and Processes found in the EBT Manual are followed thoroughly by all employees. UPO will continue to enforce the progressive disciplinary process for errors or omissions identified during daily operations. ? The Division of Program Operations (DPO) along with the Office of Information Systems (OIS) are working to automate the Electronic Benefit Transfer (EBT) photo identification process. DPO will use the new EBT Portal to complete all photo identification referral online. This new process will be more streamlined and reduce any errors. See Corrective Action Plan for chart/table

The DHS and DHCF DCAS team agree with the findings noted in this report. DHS self-reported these findings as part of the Agencies ongoing effort to maintain integrity with all eligibility determinations. The root cause for each of the eleven (11) issues with the ADP system for SNAP varied. For bullet point #1 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. In March 2023, a request to run this report was made. The run took place in April 2023 and ultimately found that the report could not be derived. Ultimately the request/ticket below will be closed. For bullet point #2 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. DCAS system will be fixed no later than FY2024 Q3. For bullet point #3 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Implementation of DCAS Release Part 2 was completed on March 26, 2023. The District requested FNS close this finding. Implementation of DCAS Release Part 2 was completed on March 2023. The District is requesting that this finding be closed. For bullet point #4 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation: Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. The data needed from DCAS to determine the scope/magnitude has not yet been provided. However, DCAS considers this as a high priority ticket for Releases 4 and 5. See Corrective Action Plan for chart/table

DCPS agrees with the conditions and recommendations of this finding. The DCPS corrective action plan includes the following steps: While the meal program review process generally works well, it has become evident that there is a need to better capture completed reviews in addition to off-boarding staff from the FNS team. In this situation, a transition of staff and incomplete off boarding and incomplete uploading of the departing staff member?s laptop was found to be the root cause for FNS? inability to produce the 2 missing reviews. Moving forward, FNS Staff will be completing a verified upload of reviews to the DCPS-FNS SharePoint site as each cycle is completed. Validation that the upload from each Field Specialist has been completed will flow from the FNS Field Operations Specialist to the FNS Operations Manager. And a confirmation email will be sent from the FNS Operations Manager to the Specialist, Nutrition & Compliance who is accountable to OSSE. A copy of the communication will be maintained with the electronic file for ease of locating. See Corrective Action Plan for chart/table

Audit Finding: CFDA: 21.027 Grant No.: 207317 & 207957 Grant Period: Year ended September 30, 2022 Type of finding ? Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: The Compliance Specialist will download the state?s debarment report (http://www.mmd.admin.state.mn.us/debarredreport.asp) to the Finance department?s Sharepoint site. At the conclusion of each month, the Compliance Specialist will compare the list to Second Harvest?s existing vendors in its ERP system. Departments using any disbarred vendors will be notified. Any payments made to debarred vendors will be excluded from reimbursement calculations for any government funding. Anticipated Completion Date: As of December 6, 2022, the Director of Sourcing and Demand Planning and Controller have each reviewed the current list and found no matches between the state?s list and current Second Harvest vendors. Contact: Dan Fuhrman, Controller Second Harvest Heartland 7101 Winnetka Ave N Brooklyn Park, MN 55428 651-209-7901 651-484-1064 (fax)

CFDA: 21.027 Grant No.: 207957 Grant Period: Year ended September 30, 2022 Type of finding ? Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: The Purchasing Specialist tracks spending on a shared spreadsheet, which includes vendor, purchase order #, product type, product description, pounds ordered, quoted amount due, and expected receipt date. Once the product is received, the Purchasing Specialist notes the actual receipt date and amount due. At the conclusion of every month during the grant period, a separate member of the Sourcing Team will review all purchase orders and related items in the system for accuracy and to ensure the items purchased are in accordance with the requirements of the funding, including any applicable qualifiers. The team member will also verify the amount due matches the associated NetSuite bill/invoice. The team member will indicate the date of the review and the name of the member completing the review on the spreadsheet. Once the review is completed, the team member will take a screenshot of the applicable expenses for the current month and email it to the Controller. This is to state the information is ready for submission to the government for reimbursement. Anticipated Completion Date: The Director of Sourcing and Demand Planning reviewed all prior purchase orders for accuracy as well as began the monthly review process with the month of November.

Finding# 2022-001 Federal Agency Name: U.S. Department of Housing & Urban Development Program Name: Community Development Black Grant/COVID-19 Community Development Block Grant ALN# 14.218 Finding Summary: 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 the terms and conditions of the federal award. 2 CFR Part 170 establishes requirements for recipients' reporting of information on subawards as required by the Federal Funding Accountability and Transparency Act of 2006 (FFATA). During the testing of the CDBG program, it was noted the City does not have a process in place to identify that FFATA reporting was required and did not report information on the subawards as required by FFATA. Responsible Individuals: Crystal Campbell, Community Development Program Coordinator. Corrective Action Plan: The City of Meridian has implemented the following changes to its internal control procedures to address finding # 2022-001 as listed above. Effective January 1, 2023, we have updated our Grant Management Software (Neighborly) to provide a monthly report that displays all New Subrecipient Agreements executed with a value of $30,000 that fall under the Federal Funding Accountability and Transparency Act (FFATA). This monthly report will establish an effective control over the necessary reporting of subrecipient agreements executed over the value of $30,000. The monthly Neighborly report will be reviewed and approved by the Community Development Program Coordinator along with their supervisor on a monthly basis to make the City compliant for FFATA reporting requirements. The Community Development Program Coordinator will have also added to the internal quarterly review process to discuss any FFATA items being considered and reviewed. Anticipated Completion Date: Ongoing.

The Executive Director will implement measures to ensure that reports are submitted in a timely manner.

The Executive Director will implement measures to ensure that the most recent ICRA is utilized on drawdown requests.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Steve Snider, CFO Contact Phone Number: 260-920-1011 Views of Responsible Official: We concur with the finding. Although the wages paid during the project exceeded the prevailing wages referenced in the Davis-Bacon Act and certified payrolls were provided to support the wages paid, we understand the proper information was not available in a timely manner. Description of Corrective Action Plan: An addendum to the Emcor/Shambaugh contract will be issued with language regarding the wage rate requirements as referenced in the Davis-Bacon Act and certified weekly payrolls will be provided to the school. Anticipated Completion Date: We will put the addendum in place immediately and the certified payrolls will be provided when work resumes (approximately May 2023).

FINDING 2022-002 Contact Person Responsible for Corrective Action: Steve Snider, CFO & Gina Buhr, Director of Business Operations Contact Phone Number: 260-920-1011 Views of Responsible Official: We adamantly disagree with the finding. The ?annual? reports in question were nothing more than a mid-point check on spending with the federal relief grants in the form of a jotform, which in and of itself, does not provide any good way to have an additional sign off. We already had controls in place for all of the spending occurring within these grants, so the proper controls were in place upstream from the jotform. Description of Corrective Action Plan: Jotform requests from the state are now entered with the data, printed out prior to submission, reviewed by a second party (if the CFO completes, the Director of Business Operations reviews and vice versa), then once the review is complete, the data is reentered and submitted. Anticipated Completion Date: We are starting this process in February with the Teacher Benefit jotform.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Steve Snider, CFO Contact Phone Number: 260-920-1011 Views of Responsible Official: We disagree with the finding. The entire premise of the cooperative agreement and appointing a lead education agency is to have someone providing the services and managing the grants for those districts who participate. Description of Corrective Action Plan: DeKalb County Central United School District will work with the Northeast Indiana Special Education Cooperative to implement the procedures detailed below. The Northeast Indiana Special Education Cooperative (NEISEC) Treasurer will reach out to member schools during the writing process of the IDEA 611 and 619 grants in order for each member school to submit their plans for their allocation of proportionate share money. NEISEC will provide the allocation amounts to each cooperative school. These submissions will include a proportionate share budget and include proportionate share staff names and any necessary information for the budget categories. The NEISEC Treasurer will then compile the proportionate share information and include on the grant submission. The LEA Treasurer will be given a copy of the grant application and budget upon approval of the grant. Any NEISEC employee being paid out of proportionate share grant funds for salary and benefits will be paid from the LEA?s financial software. The LEA Treasurer will keep a spreadsheet of employee proportionate share expenses and this spreadsheet will be updated monthly based on time and effort logs that are submitted by all cooperative schools to the LEA and NEISEC. Any employee utilizing proportionate share funds that is not an employee of NEISEC, but rather a direct employee of a member school, will be paid directly by that member school. Time and effort logs will still be submitted to the LEA and NEISEC Treasurers for these employees in order to generate a direct reimbursement from the grant fund to the member school. For any expenses for a category outside of salary and benefits, a member school will need to submit an invoice and proof of purchase for equipment, supplies, etc. to NEISEC and the LEA in order to be directly reimbursed for those proportionate share expenses. If the request was not in the initial grant budget, the member school must submit all relevant information to NEISEC in order for a grant modification to be completed. Per IDOE the grant modification must be approved first prior to purchasing the items. Time and effort logs as well as invoice and proof of payment must be sent to the LEA Treasurer in order to completed the grant reimbursement requests. At the end of the grant period, any school with remaining proportionate share money will be required to complete a waiver. As of this date (2/10/2023) the LEA (DeKalb County Eastern CSD) and NEISEC are still in communication with SBOA and IDOE to review the proportionate share plan and ensure all necessary requirements will be satisfied. Anticipated Completion Date: Changes discussed above will be implemented for the remainder of the FY23 grant period starting 07/01/2023.

DPH agrees with the finding and recommendation. DPH will continue monitoring subawards upon execution and monthly to identify when a subrecipient surpasses the threshold triggering FFATA reporting. DPH will also retain screenshots or printouts when submitting FFATA reports to document the submission date.