Corrective Action Plans

Views of Responsible Officials and Planned Corrective Actions: Agree with recommendation. Prior to executing a contract, employees with responsibility for engaging contractors and consultants funded by a Federal award will be required to check SAM.gov. This step will be included in the procurement policy.

Views of Responsible Officials and Planned Corrective Actions: Agree with recommendation. A draft procurement policy has been prepared. It will be modified to ensure compliance with procurement of property or services required under a Federal award. Employees with procurement responsibilities will be required to follow the policy.

Finding Number: 2023-006 Finding Title: Eligibility Name of Contact Person Responsible for Corrective Action: Patti Hart – Financial Assistance Supervisor II in conjunction with Kevin DeVriendt – Auditor-Treasurer Corrective Action Planned: This topic will be a standing agenda item on the Public Health and Human Services Income Maintenance unit meeting agendas, being reviewed at least monthly to ensure compliance. Supervisor Hart will review five Medical Assistance (MA) applications or renewals per month, to ensure MAXIS has been updated with the correct asset and income eligibility information. Anticipated Completion Date: May 15, 2025

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new grants policy. The City Manager shall review and approve it for implementation by September 2025. Planned Implementation Date: September 2025 Responsible Person(s): City Manager

View of Responsible Official Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s bookkeeper forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any payments. Once reviewed, the CEO will contact the bookkeeper with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organization accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements and make purchases. Going forward, the Organization’s Director of Communications will retain the Board Chair’s check stamp. The Director of Communication will only be allowed to use the Board Chair’s check stamp once the Board Chair and CEO approved payment.

Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.

Management agrees with the auditors' finding and will take action to implement controlling procedures over federal programs. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Accounting Specialist, Alex Sukalski, Chief Financial Officer

FINDING 2023-004 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Mindy McGee Contact Phone Number and Email Address: 812-265-8300, mmcgee@madison-in.gov Views of Responsible Officials: We concur with the finding regarding errors in Coronavirus Fund reporting. Description of Corrective Action Plan: Historically, the city has not had a centralized position who would be responsible for grant compliance and reporting. Individual department heads were responsible for comp0lying with each awarded grant for their own area of responsibility. In spring of 2025, a new Project & Grant Manager position was created and filled by a qualified individual. The responsibilities of the position include data collection and analysis, project management, grant coordination, information management and compliance monitoring and reporting. Anticipated Completion Date: The new position referenced above has been filled and is in operation as of April 8th 2025.

FINDING 2023-003 Finding Subject: COVID-19 – State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Bob G. Courtney, Mayor Contact Phone Number and Email Address: 812-265-8300/mayor@madison-in.gov Views of Responsible Officials: We concur with the finding regarding the lack of policies or procedures in place related to the SLRF suspension and debarment requirements. Description of Corrective Action Plan: Historically, the city has not had a centralized position who would be responsible for grant and compliance management which created an inferior process of internal controls. A new Project & Grant Manager position was created in the Mayor’s office in April 2025. When contracts for goods or services equal or exceed the required amount, verification will be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person, or adding a clause or condition to the transaction with that person. Proper education on the process is already underway. Anticipated Completion Date: The new position referenced above has been filled and is in operation as of April 8th 2025.

Auditor's Recommendation: The auditor recommends the Organization enhance the design of its control activities and procedures over the reporting of consumer eligibility dates to ensure that date of eligibility agree between the ILS and DRS systems. Management’s Response: The LIFE Inc. staff have received training on new measures to ensure that the eligibility dates in the databases are consistent. When new Consumers request assistance through the Purchased Services Program, their intake appointments are scheduled simultaneously with those for the Base Grant Services. This coordination helps guarantee that the dates in both databases match. Due date of completion: May 31, 2025 Responsible Official: Program Director, Lidia Taylor

Auditor's Recommendation: The Auditor recommends the Organization implement controls for documenting and retaining information to indicate the Organization follows the requirements over 2 CFR section 200.430(i), and that all time charged to the grant are reviewed for approval. Management’s Response: In fiscal year 2024, LIFE Inc. implemented the following: • Reviewed, updated and established policies/procedures that aligned with the compliance of 2 CFR, 200.430(i). • Implemented a newly customized timekeeping system that enabled accurate recording of time spent on grant-related activities and that ensured capabilities for supervisory review and approval. • Conducted training sessions for all staff on updated policies regarding timekeeping procedures, the new online timekeeping portal and adherence to federal regulations. • Scheduled internal audits and reviews at least once a fiscal quarter to ensure that the new timekeeping system was being used correctly and that all time charged to grants was appropriate and compliant with LIFE Inc.’s policies/procedures and federal regulations. Due date of completion: August 31, 2024 Responsible Officer: Executive Director, Michelle Crain

Auditor's Recommendation: The auditor recommends the Organization enhance the design of its control activities and procedures over the allocation percentage forms used throughout the year to ensure the staff know how to apply percentages and are using the correct approved allocation form for the period in the year. Management’s Response: A process was implemented in fiscal year 2024 to address this issued and included the following: • The allocation form was updated and is now clearly labeled with the period and type of expense for which it applies. • The Executive Director communicated the revision of all forms to staff involved in the allocation process, followed by a training session to ensure understanding and proper application of the form. • A monthly review of the process, whereby allocation forms were audited for current updates and application consistency. Due date of completion: August 31, 2024 Responsible Official: Executive Director, Michelle Crain

Chairman of the Board of County Commissioners: Oklahoma County will comply with federal laws and regulations and grant agreements by creating award agreements that are designed and implemented to ensure Subrecipient Monitoring is performed. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Myles Davidson, BOCC Chairman

Finding #SA2023-001 Cash Management and Accuracy of Federal Financial Reports Assistance Listing Number: 20.507 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants Name of Federal Agency: Department of Transportation Federal Award Identification Number: CA-2020-212-00 and CA-2022-083-00 • Name(s) of the contact person: Shay Narayan, Director of Finance • Corrective Action Plan: There was significant turn-over in the Finance Department during the periods where accounting and spending of COVID-19 related grants occurred. There was a lack of monitoring reimbursement claim activities and coordination with the Transit Division on its activities. With the Finance Department being fully staffed with competent talent, these issues should not occur in the future. • Anticipated Completion Date: 08/31/2025

2023-009- Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: American Rescue Plan Act / Coronavirus State Fiscal Recovery Fund (ARPA) Assistance Listing Number: 23.027 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ARPA expenditures, multiple transactions were identified as 2022 fiscal year expenditures that were included in the 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

2023-008 – Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Emergency Rental Assistance Program (ERAP) Assistance Listing Number: 23.023 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ERAP expenditures, six transactions were identified as prior fiscal-year expenditures that were included in the unadjusted 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

Finding Number: 2023-007 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Charles Schrader, Auditor / Treasurer Corrective Action Planned: Faribault County will implement procedures to ensure documentation is maintained verifying that vendors are not debarred, suspended, or otherwise excluded from conducting business with the County. This verification will be completed and documented prior to entering into any covered transaction. Anticipated Completion Date: December 31, 2025

Finding Number: 2023-006 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Charles Schrader, Auditor / Treasurer Corrective Action Planned: Faribault County will implement procedures to ensure federal program reports are completed accurately. This includes consulting reporting instructions provided by grantor agencies and seeking clarification from grantors when needed. Anticipated Completion Date: December 31, 2025

Finding Number: 2023-002 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Matthew Walberg and Tarah Yaggie Corrective Action Planned: We now have access to sam.gov and we will access the website and search for the vendor to ensure that they are not listed on the suspension list. We will then store the printout in the F-DRIVE and will also keep a paper copy. Anticipated Completion Date: 1/1/2026

2023-011 Excess Food Service Fund Balance (Material Weakness) Management’s Response: We completed and Excess Balance Use of Funds report and worked with the State to understand exactly the parameters of this/ The funds were spent down and we are working hard to make sure to stay under the three months of expenses as worded in CFR Title 7, 210.14(b). Again management is trying to take on a bigger role as this monitoring was not considered prior to COVID. Fund Balances at year end averaged no more than $10,000. Name of Contact Person and Completion Date: Toni Butterfield Anticipated Completion Date - Immediately

Finding Number: 2023-006 Finding Title: Reporting – DHS Social Service Fund (DHS-2556) Program: 93.658 Foster Care – Title IV-E Name of Contact Person Responsible for Corrective Action: Janelle White – Controller for Ramsey County’s Health & Wellness Service Team Enrique Rivera – Fiscal Services Manager for Ramsey County’s Health & Wellness Service Team Corrective Action Planned: Starting in the third quarter of 2024, Ramsey County instituted an additional verification step in the review process to support the determination of accurate cost pool categorization of reimbursable costs for the Random Moment Time Study Reports cost reports. The additional step will be to confirm that on the Summary Tab of the Quarterly Payroll file, the cost codes lines are in sequential order and that the corresponding expense totals match the cost code. The Senior Accountant will do the first review of this step, and the Fiscal Manager will complete the second review. The error on the 2nd quarter 2023 report was remedied and resubmitted in the 2nd quarter of 2024. Anticipated Completion Date: July of 2024 when the 2nd quarter DHS-2556 and DHS 2550 are due to be complete and finalized.

Finding Number: 2023-004 Finding Title: Eligibility Program: 21.023 COVID-19 – Emergency Rental Assistance Program Name of Contact Person Responsible for Corrective Action: Daniel Rahkola, Division Director Finance Corrective Action Planned: Staff will be retrained on the procedures to ensure compliance with the needed standards. Anticipated Completion Date: June 30, 2025

Finding Number: 2023-005 Finding Title: Reporting – PR29 – CDBG Cash on Hand Quarterly and Federal Funding and Accountability and Transparency Act Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Max Holdhusen, Deputy Director of Community and Economic Development Corrective Action Planned: 1) Ramsey County will implement internal procedures to complete PR29 quarterly reports as required by HUD and ensure the correct accounting basis and accounts are being utilized. 2) Ramsey County will implement procedures to complete reports on FSRS required by FFATA. 3) Ramsey County will develop/update our agency’s written grants administration policies and procedures to align with current practices and applicable rules. 4) Ramsey County will conduct regular trainings of policies and procedures for staff involved with CDBG grants administration. Anticipated Completion Date: July 15, 2025

2023-004 Internal Control Over Eligibility and Compliance Over Eligibility - U.S. Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS, Assistance Listing Number 14.241, Passed Through the City of Las Vegas, Nevada. Criteria: As defined in 2 CFR 200.303, auditee is required to maintain a system of internal control over compliance designed to provide reasonable assurance that federal award transactions executed are in compliance with the terms and conditions of the federal award. For services to be provided under the Housing Opportunities for Persons with AIDS, individuals requesting services must meet criteria under the grant which includes providing identification and validating proof of HIV/AIDS diagnosis, income, rent or mortgage payment, and need for assistance. A full validation of these criteria is required to be performed for any individual receiving assistance. Condition: Of 21 files selected for individuals who received assistance under the grant, one selection included two copies of the same support for the client’s need for assistance that contained differing amounts for that client’s earnings during the same period which may be indictive of fraud in the application process. No documentation was included in the client file addressing the inconsistency and related risk of fraud for the earnings and the client was determined to be eligible for assistance when the existence of duplicative information that was not addressed or resolved would make it not possible to determine eligibility for this client. Cause: AFAN had designed controls such that each client file would be reviewed by the lead case manager for proper support of eligibility requirements. However, this internal control system did not detect the duplicative eligibility support that may have been indicative of fraud in the application process, nor did the internal control system identify the individual as being ineligible before providing assistance to the individual. Context: Management failed to consistently and effectively perform an internal control to address the risk of ineligible individuals receiving financial assistance. Effect: Failure to properly perform controls over the review of the client files could result in providing assistance to individuals who are not eligible. The allowance of individuals to receive or continue receiving services without ensuring they meet the eligibility criteria is a violation of the terms of the federal grant agreement. Repeat Finding: No Recommendation: We recommend management design and implement a system of internal controls whereby a review of client files to ensure eligibility is properly supported is performed before any grant funds are disbursed and that management ensures proper documentation of this review is maintained to support the performance of the control. Views of Responsible Officials and Planned Corrective Actions: Management intends to put in place additional training for case managers to identify eligibility of clients and ensure proper backup is submitted. Supervisors will ensure all backup is included in the case file before being submitted.

2023-003 Internal Controls System Over Allowable Costs. – U.S. Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS, Assistance Listing Number 14.241, Passed Through the City of Las Vegas, Nevada. Criteria: As defined in 2 CFR 200.303, auditee is required to maintain a system of internal control over compliance designed to provide reasonable assurance that federal award transactions executed are in compliance with the terms and conditions of the federal award. Funds utilized under the Housing Opportunities for Persons with AIDS program are required to be expended on costs consistent with those outlined in 2 CRF 200 Subpart E – Cost Principles, and within the core service categories outlined in the grant agreement. Condition: Of the fourteen request for reimbursement (RFR) forms prepared and submitted to the grantor in order to receive reimbursement for expenditures during the year, seven were not reviewed and signed by the Executive Director. AFAN has designed a control such that a review of each RFR is performed to ensure expenditures are for allowable costs and allowable activities allowed for under the grant. However, this control was not performed consistently. Cause: The internal control system over the assessment of allowable costs was not operating effectively. A review of requests for reimbursement was either not performed or documentation was not maintained to support the appropriateness of expenses allocated to the grant. Context: Management failed to consistently perform an internal control to address the risk of improper expenses being reimbursed by the Organization’s grant. Effect: Not performing a review over the documents and allocations supporting requests for reimbursement for the grant increases the risk that inappropriate costs could be submitted for reimbursement which could be a violation of the terms of the federal grant agreement. Repeat Finding: No Recommendation: We recommend management design and implement a system of internal controls whereby a review of costs and the related supporting schedules being submitted for reimbursement are reviewed on a consistent basis and management ensures proper documentation of this review is maintained to support the performance of the control. Views of Responsible Officials and Planned Corrective Actions: Management will implement a control whereby the Executive Director will review and sign all requests for reimbursement prepared by the Finance Manager for submission. The Executive Director will ensure all backup is included and that all direct costs are approved and allowable prior to submission. Payroll related reimbursements will be reviewed to ensure the individuals included and allocation amongst grants are appropriate and the allocations agree to the final payroll records.