Corrective Action Plans

Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system of authorization and approval for all expenses. This system was piloted from September 1, 2024 – December 31, 2024 and implemented as of January 1, 2025. • The hiring of new fiscal staff with expertise in nonprofit financial management and standards, completed by June 30, 2024. • Updates to our fiscal policies and procedures to ensure alignment with Uniform Guidance requirements completed on December 1, 2024.

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: At the March 27th, 2025 Board Meeting, the District addressed the issue of missing signatures on checks. As a result, the following actions were agreed upon: • The District Manager will comply with District Policy 3140 at all times. • When possible, Board Members will sign checks at regularly scheduled Board meetings. • If waiting for the next meeting is not feasible, the District will implement the following internal control process, documented in an internal Standard Operating Procedure (SOP): 1. The District Manager will initiate payment and draft the check. 2. The Bookkeeper will log the relevant information into the internal Check Control Log. 3. The District Manager will contact the Board to obtain the necessary signatures. 4. Once signed, the District Manager will notify the Bookkeeper of the signatories, who will update the Check Control Log with their names or initials. 5. The Bookkeeper will verify the check and signatories once the check has cleared but before it is uploaded to the QuickBooks General Ledger. Anticipated Completion Date: June 30, 2025

Contact Responsible for the Corrective Action: District Manager & Board Treasurer Corrective Action to be Taken: The District has implemented the recommended action, requiring that all internal billing worksheets be reconciled to the QuickBooks general ledger prior to final District Manager approval. However, to ensure proper documentation, the District will develop and implement a check-off spreadsheet to track when this reconciliation has been completed for each payment request. Additionally, an internal Standard Operating Procedure (SOP) for Billing Worksheet – General Ledger reconciliation will be created to formalize and document the process, ensuring it is retained. Anticipated Completion Date: June 30, 2025

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2025 regarding a reportable audit finding related to Inadequate Controls over Waiver and Support Coordination Service Providers. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over Waiver and Support Coordination Service Providers Recommendation: LDH should ensure all departmental policies for waiver and support coordination services are enforced, including documentation to support claims and evidence that deviations from the approved POC meet the needs of the recipient. LDH should consider additional provider training regarding documentation requirements. LDH Response: The LDH through the Office for Citizens with Developmental Disabilities (OCDD) concur in part with the finding and recommendation set forth by the LLA. LDH/OCDD does not concur with three errors LLA noted in the determination of inadequate controls over waiver and support coordination providers and have concerns with LLA’s overreliance on documentation in determining control adequacy. Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determines the state has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability, and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS the assurances have been met. By completing the HCBS waiver application, the state specifies how it has designed the waiver’s critical processes, structures, and operational features in order to meet these assurances. Despite highlighting CMS approved controls and assurances, as well as LDH policy allowances, LLA continues to overlook other control mechanisms in place and rely solely on reconciling documentation to determine control adequacy. 1. “For 121 claims for 9 recipients, the waiver services provider did not provide documentation substantiating the reason for departures from the approved POC.” There is no error because there was no departure from the plan of care. The nine (9) recipients referenced herein received the individual and family support (IFS) service(s) as outlined in the plan of care. The confusion here seems to stem from the structure of our IFS service. As approved in our 1915(c) waiver, IFS can be provided on a 1:1 basis or a shared basis (i.e. one direct support worker providing IFS to two waiver recipients). There is no difference in the service definition for 1:1 and shared IFS, nor a reduction in the scope or intensity of care. In other words, it is the same service. It appears LLA has based its determination of departures from the comprehensive plan of care (CPOC) on the typical weekly schedule portion of CPOC. The typical weekly schedule serves as a map to determine the amount of supports needed, but it does not prohibit a recipient from altering the amount and type of IFS hours utilized within a day, week or month, so long as the recipient does not exceed the budgeted hours for the quarter. Understanding the dynamic nature of individuals’ lives, LDH/OCDD’s expectation is that people operate within their allocated budget or budget hours for the quarter, not the typical weekly schedule. Health and safety is assured through OCDD’s Support Coordination Monitoring (Policy 604) process. The Support Coordination Monitoring Process evaluates if waiver participants receive the supports and services necessary to meet their needs (health and safety) and achieve their personal goals. Support Coordination Monitoring provides required evidence to the Centers for Medicare and Medicaid Services that the agencies are operating in accordance with applicable federal regulations/policies. For this monitoring process a composite sample that includes individuals served by all SC agencies are reviewed. The components of the monitoring process include an Agency Review, Record Review, Participant Interview, and Support Coordination Interviews. The process in place is included in our 1915 c waiver applications and has been approved by CMS. 2. “For 50 claims for 3 recipients, the waiver services provider billed the claim at the incorrect rate.” There was no error since the waiver provider billed the appropriate rate for the procedure code and modifier submitted on the claim. Furthermore, there are adequate controls in place by way of max allowed rate coding which prohibits a provider from billing above the maximum-allowed rate for the procedure code and applicable modifier. Based on a review of the available data, it appears LLA has based its determination of improper rate on an individual 1:1 IFS rate. For the instances where the LLA noted the improper rate was paid, the procedure code and modifier identified was for a shared IFS service, which was the service the provider delivered. The rate billed aligned with the shared IFS rate. 3. “For 4 claims for 1 recipient, the waiver services provider inappropriately billed for services that overlapped with non-waiver institutional services.” While the claim was paid, the example provided was not an error, as LDH’s established controls identified and addressed the overlap in billing. LDH allows the delivery of direct care services by an in-home provider prior to the time of admission and after the time of discharge. The claim identified with date of service April 25, 2024 was the date of admission and the claim, with date of service (DOS) April 27, 2024, was the date of discharge. The agency billed Gainwell for the DOS for April 26, 2024 and Gainwell reimbursed the agency for that DOS. However, LDH has mechanisms in where claims paid but should have been denied cause future units to be blocked once the system recognizes the participant was inpatient during the date of the claim. SRI notifies the provider of the block (on the LaSRS® Blocked Report) and of their need to reimburse Gainwell, if the claim has already been billed and paid. Once they have repaid the blocked units at Gainwell, they will have enough units available to bill for the claims at the end of the prior authorization (PA). This logic (or “block”) was implemented when the inpatient stay was billed and sent to our data contractor, SRI. SRI reduced the total amount released on this PA and the provider is currently being denied for later dates of service under this PA and will not be able to be reimbursed for the dates of service until they pay back the claims for April 26, 2024. LDH/OCDD concurs with LLA’s error finding of inadequate documentation on 383 claims for 13 recipients. Included in OCDD’s response to the last audit, OCDD developed a corrective action plan which consisted of the following elements: • Develop/Finalize a standardize note to be utilized by all personal care type providers. The standardized note is developed. Starting February 2025, providers are required to begin using the note or electronic alternative/equivalent. • Training/Implementation of standard progress note. Training is underway and scheduled to be completed by end of January 2025. • Develop/Implement a monitoring process to review provider records/notes. Planned Implementation of monitoring process is July 2025. LDH concurs with LLA’s recommendation regarding policy enforcement and additional support coordination (SC) training. Corrective Action Plan: LDH developed the action steps below to address the need for SC documentation training and provide additional oversight for policy enforcement. 1. OCDD will revise the SC policies/procedures and interpretive guidelines to address findings from monitoring, including SC documentation requirements by February 2025. 2. OCDD will circulate revised policies/procedures and interpretive guidelines to LGEs and SCAs to provide feedback/recommendations by March 2025. 3. Finalize the policies/procedures and interpretive guidelines by May 2025. 4. Provide statewide training regarding policies/procedures in June 2025. 5. Implement revised policies/procedures and interpretive guidelines in July 2025. 6. Measure effectiveness by comparing results of monitoring post-revised guidelines with monitoring that occurred prior to the changes in December 2025. Bernard Brown, Deputy Assistant Secretary, OCDD is responsible for the execution and implementation of this corrective action. You may contact Bernard Brown, OCDD Deputy Assistant Secretary, at (225) 342-8807, or via email at Bernard.Brown@la.gov with any questions about this matter.

Mr. Waguespack: I am in receipt of the letter dated January 24, 2025 from Angel Cavaretta, Audit Manager, related to the misappropriation of research and development cluster funds. Louisiana Tech concurs with the recommendation. The misappropriation of funds occurred as a result of a sophisticated cyber fraud scheme in which perpetrators submitted fraudulent email requests directing that funds be deposited via electronic funds transfer (EFT) into accounts purportedly affiliated with the out-of-state University. However, the accounts were later discovered to have no connection to the institution. These deceptive actions exploited the University's payment processing systems and evaded detection at the time. Upon information a d belief, the data breach originated with the out-of-state University, and it is also noted that the out-of-state University did not detect discrepancies in its invoicing processes, including non-payment or fraudulent communications, which may have contributed to the fraud's success. Upon discovering the fraud, the University promptly reported the incident to appropriate law enforcement authorities, the Legislative Auditor, and the federal grantor. The University immediately reviewed all suppliers with an EFT payment type and has temporarily suspended the approval of any supplier requests related to the EFT payment option. As stated in the finding, the University is evaluating internal and external opportunities to further enhance its internal controls and verification procedures to better safeguard against increasingly sophisticated cyber threats targeting payment remittance processes.

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) Child Welfare (CW) is in receipt of the audit findings identified as Control Weakness over SSBG Expenditures. DCFS concurs with the finding and is committed to minimizing errors and ensuring documentation practices support our efforts for accuracy and compliance. DCFS will develop and implement training to ensure that instruction provided regarding the maintenance of TIPS records and payments will achieve compliance to the extent possible. DCFS CW Training and Foster Care will create a short refresher video course on policies and procedures relating to payment protocols to be made available to child welfare staff. The anticipated completion date will be June 30, 2025. Additionally, DCFS CW has adopted the use of DocuSign for TIPS forms which allows for a more streamlined process for signatures and supporting documentation to be uploaded. A short video course providing instruction on completing and submitting TIPS forms for reimbursement using the DocuSign platform is available to child welfare statewide. Management will reiterate staff to refer to this training. Should any additional information be required, please contact Renee M. Spell at (337) 250-1690 or Renee.Spell.DCFS@LA.GOV.

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has received the finding titled "Unauthorized Employee Fuel Transactions." The finding states that the Department of Children and Family Services (DCFS), Bureau of Audit and Compliance Services, investigated and identified multiple instances of unauthorized fuel transactions made by a former DCFS employee, estimated at approximately $97,500 in fiscal year 2024. Of that total, $5,191 was charged to the Social Services Block Grant program and $32,555 was charged to the Foster Care program through the cost allocation process. DCFS concurs with the finding and has zero tolerance for unauthorized use of state or federal funds. The department's Fleet Manager has developed monitoring reports to review transactions on a monthly basis. The results of these reviews will be communicated with the Director of Administrative Services who will ensure compliance with the established policies and procedures governed by the Fleet Card Program. The department has also established adequate segregation of duties to the Fleet Coordinators in the field offices. Any DCFS employee engaged in such an unauthorized use of state and federal funds would be terminated. If you have any additional questions, please reach out to Director of Administrative Services. Tina Hebert, who oversees Fuel Purchasing Program. You can reach her at (225) 342-1875 or Tina.Hebert.DCFS@la.gov.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 3, 2025 regarding a reportable audit finding related to the Office of Public Health (OPH) – Inadequate Controls over and Noncompliance with Federal Financial Reporting. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over and Noncompliance with Federal Financial Reporting Recommendation: OPH should design and implement controls to ensure all information contained in the financial reports submitted to Federal agencies is accurate, current, and complete for the reporting period covered under the report. LDH Response: LDH Fiscal Management recognizes its responsibility to accurately report financial data, however, LDH Fiscal Management does not concur with the finding of Inadequate Controls over and Noncompliance with Federal Financial Reporting (FFR) due to immateriality of the questioned expenses. The expenses in question reported on the Federal Financial Report were eligible grant expenses for this award. LDH Fiscal understood the expenses in question to be related to the same award that was ending 6/30/24, but received a No Cost Extension through 12/31/2024. After consulting with the grantor on this matter, the grantor conveyed that reporting these eligible expenditures earlier than the No Cost Extension date was not a material concern and would not require a revised FFR for this period, as the main concern is that they were eligible expenses and would be included in the final FFR. Total expenses in question ($142,568) represent approximately .3% of the cumulative expenses reported on the Federal Financial Report ($42M) as of 06/30/2024; therefore, the stance of LDH is the amount in question is immaterial and does not misstate the Federal Financial Report. Corrective Action Plan: Procedures and internal training currently exist for fiscal team members on completing Federal Financial Reports. A corrective action plan to reiterate and reinforce the understanding of various reporting periods to include No Cost Extension and liquidation periods to the preparers and reviewers of the FFR’s to mitigate this occurrence was implemented immediately. Quintesah Syas, Accountant Manager 4/Comptroller within the LDH Fiscal Office for Office of Public Health Financial Reporting and Helen Harris, Deputy Undersecretary 2/LDH Fiscal Director are responsible for the execution and implementation of this corrective action and may be contacted with any questions about this matter. You may contact Quintesah Syas Accountant Manager 4/Comptroller, within the LDH Fiscal Office for Office of Public Health Financial Reporting at (225) 342-9333 or via email at Quintesah.Syas@la.gov, or Helen Harris), Deputy Undersecretary 2/LDH Fiscal Director at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

Dear Mr. Waguespack, Please find enclosed the Louisiana Workforce Commission's response to the above-mentioned finding. On behalf of Secretary Susana Schowen, we thank your staff for their guidance and technical assistance throughout this process. If you have any questions or need additional information, please do not hesitate to give me a call at (225) 342-3474 or email at swilliams@lwc.la.gov. Noncompliance and Inadequate Controls Related to Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA) The Louisiana Workforce Commission concurs with the audit finding Noncompliance and Inadequate Controls Related to Reporting Requirements for the Federal Funding Accountability and Transparency Act (FFATA). We have taken proactive steps to ensure that internal controls have been implemented to address issues of non-compliance. The Office of Workforce Development has revised policy OWD 1-9.1, Federal Funding Accountability and Transparency Act to align with Uniform Guidance 2 CFR 200.303 and 170, Appendix A (l)(a) requiring non-federal entities receiving federal award to establish and maintain internal controls, and requiring the reporting of subaward information in the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which obligation was made. The policy includes guidance and requirements on reporting timelines, process and procedure, internal reviews by appropriate management staff, and maintenance and storage (electronic file) of evidence of the review and approval of report information and submission. This information will be made available upon request. All relevant OWD staff have been provided training on how the FSRS operates, how data is entered in the system, how reports are generated, and all associated timelines of submission. The OWD Grants Manager and Compliance and Monitoring Administrator have been trained on the required review and approval process prior to report submission, including accurate and timely submission of all subawards. The Grants Manager is responsible for entering data into the FSRS no later than the end of the month following the month of obligation. A draft report will be submitted to the Compliance and Monitoring Administrator for review and approval. Once approved, the final report will be submitted in the FSRS. This process may be repeated each month as required based upon the issuance of each subaward. This revised process has been fully implemented effective July 3, 2024. OWD leadership will be provided monthly updates to include initial subawards, corrections, and modifications to ensure compliance is met and maintained.

Dear Mr. Waguespack: The Division of Administration is submitting the following as a response to the audit finding titled “Noncompliance with Reporting Requirements for the Federal Funding Accountability and Transparency Act”. The DOA agrees with the LLA that the subawards tested were not reported in the Federal Funding and Accountability and Transparency Act Subaward Reporting System (FSRS) within the required time frame. The Office of Community Development – Local Government Assistance and the Office of Community Development – Disaster Recovery have revised written procedures to increase the frequency of reporting and reviews, which should reduce or prevent future errors. The contact person responsible for the corrective action is Traci Watts, OCD Director or Ginger Moses, OCD Chief Operating Officer. If you have questions or require additional information, please feel free to contact me.

Dear Mr. Waguespack, Thank you for the opportunity to respond to your office’s findings related to federal research and development expenses. LSU Health Sciences Center in Shreveport (LSUHSC-S) has reviewed the issues identified by your staff. LSUHSC-S concurs with the recommendations to address the findings and provides the following response and corrective action plan. Recommendation: Management should ensure they have adequate controls over time and effort certifications, purchases, and reimbursement requests. In addition, management should ensure adequate segregation of duties covering approvals of all transaction types. Response and Corrective Action Plan: Effective FY25, LSUHSC-S has implemented an electronic Time & Effort certification system through PeopleSoft in conjunction with New Orleans. Training in the new system was provided by the New Orleans IT Department to all departmental Business Managers. Technical support questions are addressed by OSP Post Award and New Orleans IT Department. LSUHSC-S Administrative Directive 4.4 will be revised to include the new electronic process. The Office of Research Administration will hold Post-Award Monitoring meetings with all principal investigators and designated departmental staff on a quarterly basis. These meetings will begin in March 2025. During these meetings, Grant Managers from OSP Post Award will review grant ledgers to ensure that all grant accounts are reconciled monthly. Departmental Business Managers will sign off on the completed monthly reconciliations. Personnel expenditures will be included in this monthly review. Discrepancies will be reviewed with the PI and business manager for accuracy and possible corrective action plan. Prior to submission, OSP Pre-Award will provide the RPPR to the PI and Business Manager for review and certification, to ensure time and effort allocations match the current budget and PER report. OSP Pre-Award will aid Business Managers as needed. A new PER electronic system was implemented and the AD for Cost Transfer is being revised and approved. The revised AD will require greater detail in the justification for changes in source funding for salaries. Justification must meet the requirements in the revised AD. A new Standard Administrative Procedure will be implemented in March 2025 that requires all salary changes on grant accounts to be made no later than 90-days after the effective date. All requests that are greater than 90 days will be evaluated through a rigorous review process and may or may not be approved. LSUHSC-S Research Administration will ensure accurate information is available and provided to auditors upon request in a timely manner. LSUHSC-S will explore the implementation of additional PS module vendor transaction utility, such as adding more approvers, to ensure adequate segregation of duties for approval. The removal of the ability for self-approval of requisitions within the PeopleSoft requisition workflow will prevent a requestor and an approver from being the same person. A monthly report will be auto-generated and emailed (ad-hoc ability as well) to the Director of Purchasing and the Executive Director of Financial Operations. The report will list detailed requisition information to include the requestor names and approver names of requisitions created for that period for review to ensure the approval process is properly working. Name of Contact(s) Responsible for Action Plan Ramey Benfield, Chief Financial Officer, Vice Chancellor for Research Administration Jen Katzman, Vice Chancellor, Administration and Budget (with Departmental Business Managers) Tracy Calvert, Associate Director, Office for Sponsored Programs Post Award William Haacker, Assistant Director, Office for Sponsored Programs Post Award Steven McAlister, Associate Director of General Accounting Anticipated Completion Date: Continuous

Dear Mr. Waguespack: The Department of Children and Family Services (DCFS) has received the finding titled “Control Weakness and Noncompliance Related to Cost Allocation Process" and appreciates the opportunity to provide this response to your office's finding. Finding: The Department of Children and Family Services did not have adequate controls in place to ensure the correct allocation of expenditures in accordance with the Cost Allocation Plan, which assigns costs to federal programs. Recommendation: DCFS should strengthen internal controls over the cost allocation review process. DCFS Response: DCFS concurs with the LLA's finding and recommendation. Corrective Action Plan: DCFS's Division of Management and Finance has implemented a corrective action plan aimed at addressing the identified issue and strengthening internal controls. 1. Internal Procedure Revisions: The Division of Management & Finance has trained relevant stakeholders on proper cost allocation procedures, emphasizing compliance with federal regulations and accurate reporting. Additionally, internal procedures have been revised to strengthen the review process, ensuring expenditures are correctly allocated in accordance with the Cost Allocation Plan. 2. Strengthening Internal Controls & Ongoing Monitoring: To prevent recurrence, the Cost Allocation team has implemented a more rigorous review process for cost allocation supporting documentation. This includes, but is not limited to, generating a LaGov report during the three-day fiscal month close to proactively identify any expenditures incorrectly allocated to a closed grant. This step will ensure a real-time review process, allowing errors to be detected and corrected promptly. DCFS acknowledges the importance of accurate cost allocation to ensure compliance with federal regulations and the proper distribution of expenditures across programs. Strengthening our internal controls and reviewing processes remains a top priority to prevent misallocations. Should you require additional information, please contact Christopher Bahm at Christopher.Bahm.DCFS@la.gov or (225) 219-0536.

Finding 2024‐005 Student Financial Assistance Cluster ALN: 84.268 Finding: The College did not submit the required monthly reconciliation for the direct loan program Corrective Action Plan: To address the issue of not submitting the required monthly reconciliation for the Direct Loan Program, the Financial Aid office has implemented a process to ensure Direct Loan reconciliation is completed monthly. An outlook calendar reminder entry will serve as a reminder to begin the reconciliation process on the 15th of each month. The Senior Financial Aid Counselor requests a YTD SAS report from COD, which contains loan data from the central processor, the report is delivered to our electronic mailbox within 24 hours. The Senior Financial Aid Counselor runs a second report from the SIS System to generate YTD loan disbursement information. The files are reformatted and compared by the Senior Financial Aid Counselor. Any discrepancies are reviewed and resolved in the appropriate system (COD or SIS), dependent on the discrepancy. The Senior Counselor notifies the Senior Manager of Financial Aid that the comparison and updates are complete. The Senior Manager of Financial Aid then reviews delta from the compared data and verifies that corrections are made in the correct system. The Senior Manager ensures that resolved amount is within the COD delta found on the summary page in COD and a screenshot is maintained in the reconciliation file. Senior Manager marks “Sr Manager Reviewed” column on the loan reconciliation spreadsheet with a date of review as evidence. The completed reconciliation is maintained in the Financial Aid Shared Directory. Person Responsible: Scott Moore, Senior Manager, Financial Aid, Baylor College of Medicine Expected Completion: April 2024

Finding 2024-004 Reporting ALN: 21.027 Finding: The College did not submit monthly reports for the CSLFRF or TCMHCC grants by the 15th of each month. Corrective Action Plan: BCM agrees that these reports were not submitted by the 15th deadline. Going forward, BCM will require the department to attest that the programmatic reports were submitted when the monthly financial reports are submitted on the TCMHCC grant. Person Responsible: Chryll Batiste, Director, Research Administration, Baylor College of Medicine Expected Completion: April 2025

2024-003 Indirect Costs ALN: Research and Development Cluster (R&D), 21.027 Finding: The College did not retain documentation and evidence of review of the indirect cost amounts being charged to the R&D and CSLFRF programs. Management performed a monthly control that included reviewing a sample of indirect costs charged to grants on a sample basis. The College had a new ERP implementation that went into effect on January 1, 2024. Management did not perform the monthly control subsequent to the ERP implementation for the last 6 months of year. Corrective Action Plan: With the implementation of the new ERP system, BCM went from an on-premises solution to a software-as-a-service solution. Since we no longer have access to modify the code that calculates the F&A expense on awards, management concluded that previous random testing control was no longer necessary. Management also believes that there are numerous compensating reporting controls that would alert us if the F&A calculations were not accurate. Notably, management’s compensating controls and the testing the audit firm conducted identified no instances where the F&A calculations were inaccurate. However, to satisfy this audit finding we will be resuming the manual control procedure used with the legacy system. Person Responsible: Chryll Batiste, Director, Research Administration, Baylor College of Medicine Expected Completion: April 2025

Finding 2024-002 Procurement ALN: 93.855 Finding: The College did not have effective internal controls and procedures in place to ensure the College maintained records for procurements sufficient to detail the history of procurement, including the rationale for the method of procurement and other required elements. Corrective Action Plan: BCM management agrees that a sole source documentation form was not completed for this procurement. We do believe that this would have been easily justified as a sole source procurement as this vendor had unique capabilities required by the grant. The master service agreement for this procurement was effective September 1, 2019, and the related PO for this scope of work was issued on June 15, 2023. Since this time period, BCM has implemented a new procure to pay system with improved internal controls and approval routings. With this new system, we believe we have already put in place the appropriate corrective actions necessary to prevent this from happening going forward. Person Responsible: Rob Falivene, Vice President, Supply Chain Services, Baylor College of Medicine Expected Completion: March 2025

FINDING 2024-006 Finding Subject: COVID-19 Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The comptroller will reach out to the IDOE regarding the dates required for submission. The comptroller, with the curriculum director, will populate the spreadsheet. The comptroller will get a signature from the assistant superintendent or superintendent before submittal. Anticipated Completion Date: March 31, 2025

FINDING 2024-005 Finding Subject: COVID-19 Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The curriculum director and comptroller will make sure funds are entered correctly into the accounting software to ensure accurate tracking of expenditures. The comptroller will complete the financial report based on IDOE’s instructions. The curriculum director will review it for accuracy and initial. The assistant superintendent will review it for accuracy and initial. The comptroller will submit the jot form. Anticipated Completion Date: March 31, 2025

FINDING 2024-004 Finding Subject: Special Education Cluster – Level of Effort Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The human resource specialist has been trained regarding the importance of assigning the correct account codes to new employees. The comptroller and then the assistant superintendent or superintendent will review new employee payroll account assignments and sign off on their employment paperwork to ensure employees are coded correctly in our system. Anticipated Completion Date: March 31, 2025

FINDING 2024-003 Finding Subject: Special Education Cluster - Earmarking Contact Person Responsible for Corrective Action: Shelly Leifer Contact Phone Number and Email Address: 260.306.3359 shelly_leifer@mcs.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: 1. A proportionate Share Working Spreadsheet was developed and is distributed annually to service providers working with non-pub students. 2. Service providers document the following information for each corporation: Student name, Date of service, Time of Service, Number of hours, Type of Service, and any other required information. 3. Documentation is reviewed monthly. 4. Reimbursement for non-pub services is requested when reimbursement amounts reach $1,000.00 or annually, whichever comes first. Anticipated Completion Date: March 1, 2024

FINDING 2024-005 (Auditor Assigned Reference Number) Finding Subject: Special Education Cluster (IDEA)- Period of Performance Contact Person Responsible for Corrective Action: Julie Remschneider Contact Phone Number and Email Address: julie.r@nn.k12.in.us, 219-285-2228 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will ensure the Special Education Co-op will have controls in place to make sure payments are made within the period of performance. Anticipated Completion Date: September 30, 2025

FINDING 2024-004 Finding Subject: Child Nutrition Cluster- Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Julie Remschneider Contact Phone Number and Email Address: julie.r@nn.k12.in.us, 219-285-2228 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The business official or superintendent will review and sign off and date the procurement and suspension and debarment documents. We will follow the internal control procedures beginning on p. 41 of the internal controls manual. Anticipated Completion Date: September 30, 2025

FINDING 2024-003 Finding Subject: Child Nutrition Cluster- Eligibility Contact Person Responsible for Corrective Action: Julie Remschneider Contact Phone Number and Email Address: julie.r@nn.k12.in.us, 219-285-2228 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The business official or superintendent will review and sign off and date the eligibility reports. Anticipated Completion Date: September 30, 2025

Action taken in response to finding: • The Department has revised its internal policy and procedures to include timelines and a tracking mechanism to ensure the timely submission of fiscal reports and documents. Name(s) of the contact person(s) responsible for corrective action: • Anthony Walker, Associate Director of the Management Services Division • Anissa Curtis, Budget Analyst III for Aging and Disabilities Services Division Planned completion date for corrective action plan: • Items previously cited for submission have been updated and at this time the Department is in compliance with all fiscal reports. • Revisions to the internal Policy and Procedures have been corrected and disseminated to appropriate staff.

Action Taken: The District will improve internal controls over Federal Grants to make sure that they are in compliance with all compliance requirements, including the review of certified payroll on construction projects completed with Federal funding to make sure that prevailing wages are paid.