Corrective Action Plans

Assistance Listings number and program name: 84.374 Teacher and School Leader Incentive GrantsDepartment: Maricopa County School SuperintendentContact Person(s): Matt Morales, Deputy Superintendent of Schools, Maricopa County School Superintendent?s Office.Anticipate completion date: June 30, 2023Concur: The Maricopa County School Superintendent?s Office (Superintendent's Office) acknowledges the human error that was made with the May 2022 drawdown. Once the error was identified, the Assistant Superintendent for Economic Management, along with the grant project leader and the Human Capital Management Administrator, contacted the program officer at the US Department of Education and notified them of this error. The overdraw was resolved as there were additional program costs prior to the grant?s closeout in September 2022, and all program expenditures and reimbursements were reconciled prior to closeout. The Superintendent?s Office has implemented updated procedures including the addition of one more person to the reimbursement request approval process who will ensure that program expenditures are reconciled based on the fund balance report from the financial system for the correct time frame.

Federal Funds Received Were Not Disbursed or Refunded Within Required TimeframeState Agency: Utah State UniversityFederal Program: Student Financial Assistance ClusterUtah State University will change its process for requesting federal funds in advance. The Controller?s Office will down less than the full amount of the estimated financial aid disbursement amounts to be issued to students, as calculated by the University?s Financial Aid Office at the first of each semester.The Controller's Office personnel will then review federal financial aid disbursements within three days of receiving the advance draw in order to return any undisbursed funds to the Department of Education within the required timeframe. Federal financial aid funds will then be drawn down on an on-going basis as additional federal financial aid funds are disbursed to students during the semester.Contact Person: Jennifer Jenkins, Manager of Sponsored Programs Accounting, 435-797-1077Completion date: October 31, 2022

ULMS Corrective Action Plan for FY 21-22 Audit FindingsULMS faced significant challenges with the departure of its longtime CFO two months post fiscal year 2021. In addition, the third-party management company who had been responsible for the Partnership accounting, ceased the relationship abruptly without opportunity to smoothly transition the responsibility in-house to ULMS. Our external auditor does not prepare a Management Letter typically used to communicate with the Board of Directors and Governance issues that may not elevate to a finding. As such, significant findings are reflected in Section III ? Federal Award Findings and Questioned Costs.FY 2021 was the organization?s first single audit reporting requirement. ULMS engaged a third-party CPA to review past audit and current documents needed to commence the FY 2022 audit. However, due to an emergency there was limited independent review of documents prior to being submitted to the auditor due to time constraints. ULMS continues to strengthen its accounting team and has hired a new Controller in July 2023. The new Controller is a licensed CPA with over 30 years accounting experience and over 10 years? experience as an independent auditor for a range of organizations including non-profits. The Controller will collaborate with the CFO to ensure there is accuracy in reporting, especially for major federal programs. Finding #: 2022-003Contact Person: Mansour Camara? During the FY 2021 audit, the auditor recommended that ULMS formalize written federal payment procedures in compliance with required standards. ULMS developed procedures for advance federal payment which was sent to the auditor for feedback. There was no feedback proposing ULMS update its advance federal payment procedure until the issuance of this finding. The finding states a lack of written policy that complies with the federal payment standard per CFR 200.305. However, the recommendation instructs ULMS to formalize written procedures. Such procedures were in place during FY 2022.Actions to be taken: Notwithstanding the inconsistency between the finding and the recommendation provided by the auditor, ULMS prepared written procedures consistent with CFR 200.305 and recorded transactions consistent with that procedure for FY 2022. ULMS will update its accounting policy and procedures manual to create a written policy in addition to the procedures that have already been in place consistent with CFR 200.305.

ULMS Corrective Action Plan for FY 21-22 Audit FindingsULMS faced significant challenges with the departure of its longtime CFO two months post fiscal year 2021. In addition, the third-party management company who had been responsible for the Partnership accounting, ceased the relationship abruptly without opportunity to smoothly transition the responsibility in-house to ULMS. Our external auditor does not prepare a Management Letter typically used to communicate with the Board of Directors and Governance issues that may not elevate to a finding. As such, significant findings are reflected in Section III ? Federal Award Findings and Questioned Costs.FY 2021 was the organization?s first single audit reporting requirement. ULMS engaged a third-party CPA to review past audit and current documents needed to commence the FY 2022 audit. However, due to an emergency there was limited independent review of documents prior to being submitted to the auditor due to time constraints. ULMS continues to strengthen its accounting team and has hired a new Controller in July 2023. The new Controller is a licensed CPA with over 30 years accounting experience and over 10 years? experience as an independent auditor for a range of organizations including non-profits. The Controller will collaborate with the CFO to ensure there is accuracy in reporting, especially for major federal programs. Finding #: 2022-002Contact Person: Mansour Camara? Management has determined that the finding as written is misleading. The Schedule of Expenditures of Federal Awards (SEFA) prepared by ULMS initially contained errors. However, all errors were corrected by the time the draft financial statements were presented. There was no financial impact on the organization and the most significant issue on the SEFA schedule was a result of miscommunication with ULMS? funding source including the lack of clear identification of the funding source within the contract.Actions to be taken: ULMS migrated to a new and more sophisticated accounting system. This new system has more reporting and tracking capabilities which will enhance grant tracking and review of activities. These additional tools will aid management in overseeing future endeavors. In addition, ULMS will proactively contact the CFO or contract signer of the funding entity and confirm the source of funding for all grants over $100,000. ULMS will participate in more nonprofit conferences on a regional and national level.

Federal Agency Name: Department of State ? Bureau of Population, Refugees, and MigrationProgram Name: Oversees Refugee Assistance Programs for AfricaCFDA #19.517Federal Agency Name: Agency for International DevelopmentDepartment of StateProgram Name: USAID Foreign Assistance for Programs OverseasCFDA #98.001Finding Summary: CVT does not have an internal control designed to ensure advance payments are placed in an interest-bearing account.Responsible Individuals: James Behnke, CFO and Mary Kinder, ControllerCorrective Action Plan: Management will complete an extensive review over cash management policies to make sure requirements under the CFR section are met.Anticipated Completion Date: June 2023

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: The Organization is implementing a grant tracking system in addition to its job costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement. Corrective Action Plan: (1) Records will be kept in a newly developed spend down report for each grant/contract and reviewed with Division Directors and DFO monthly. All transactions are now being logged in QuickBooks with respective grant codes and departments, will not be processed without. (2) Monthly and quarterly invoicing according to each grant / contract agreement will be enforced by the GDCM and DFO in compliance with 2 CFR section 200.305(b). (3) The Organization has enrolled with the Treasury’s Invoice Processing Platform (IPP) to ensure all future Invoicing and payments can be easily tracked to the program/grant. Person Responsible: Matt Poss, Director of Finance Operations Timeline: All expenses and disbursements being coded to proper Grant/Type in QuickBooks Online – January 2023 Treasury Invoice Processing Platform (IPP) Onboarded – April 18th, 2023 Invoicing Timeline Created per collaboration with GDCM and DFO – May 18th, 2023 Revenue Reconciliation and clearing out of uncollectible or overbooked revenue – June 30th, 2023

During 2022, there was a change in accounting staff which led to difficulty in tracking and preparing the SEFA. Once management became aware of the issues, changes have been made to internal processes to allow for proper SEFA tracking moving forward.

2022-006 a. Name of Contact Person Responsible for Corrective Action: Jeff Burks, General Manager, and Cynthia Fowler, Office Manager & Comptroller Phone Number: (256) 356-8622 b. Corrective Action Planned: The Water Works and Gas Board of the City of Red Bay will ensure payments under reimbursable grants are made prior to reimbursement requests. c. Anticipated Completion Date: Immediately

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-007: Cash Management – Material Weakness Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2022-007: We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. Previously draw down documentation was uploaded to a shared folder, in which the CEO and Fiscal Manager had access. In 2023, we implemented additional procedures to document review of drawdowns and supporting documentation. Additionally, documentation includes attaining the CEO signature on draw down documentation before the draw down is made. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

Significant Deficiency in Internal Control over Compliance and Compliance Recommendation: CLA recommends that The Organization move away from using a cumulative profit and loss report and instead run monthly general ledger details by program as support for their monthly reimbursement requests. This will enhance clarity of costs attributable to each monthly period and reduces the chance that costs will be missed when requesting for reimbursement. Any reconciling transactions can be clearly tracked an Excel file of the general ledger detail by program. In addition, CLA recommends that The Organization emphasize to program management staff the importance of filing reimbursement requests each month and in a timely manner to reduce administrative and financial burden. There is no disagreement with the audit finding. Action taken in response to finding: The organization has modified our approach to making monthly reimbursement requests by including monthly general ledger details by program to ensure we have appropriate support and to increase clarity of costs attributable by month. Since fall/winter 2023, we have increased training to financial and program management staff around the importance of filing reimbursement request in a timely manner and we intend to increase the size of the financial support staff to further help minimize timely delays in reimbursement requests. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 4/1/2024

Finding: 2022-006: Significant Deficiency in Internal Controls over Compliance – Cash Management Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Controller reviews and corrects billings received which includes backup by AR, then CFO reviews prior to submission to payment management system. Proposed Completion Date: 6/30/23

March 27, 2024 2022-003: Significant Deficiency in Internal Control / Immaterial Noncompliance – Cash Management (repeat comment) Condition: 1) The Consortium requested funds in advance of when the related disbursements were made, 2) the basis for the advances (requests) were not supported by appropriate documentation, and 3) authorization for requesting funds in advance not obtained. Corrective Action: We agree with the finding. The Consortium has carefully reviewed our policies and procedures and have made the necessary changes to ensure that cash draws are based on expenditures already incurred and they are supported by transactions recorded in the books and records of the Consortium. We believe the updated procedures will result in the reduction over time and ultimately the complete elimination of this issue. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: December 2024 Respectfully, Shamar Herron

The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Grantee Response: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to establish procedures that incorporate controls to review expenditures for payment prior to submitting request for reimbursement, and that the outstanding checks (and other reconciling items) be resolved in a reasonable period of time. Such evidence of control activities including review will be documented and maintained.

Finding 2022-006 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023

Finding 2022-001 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023

2022-005 - Year Ended December 31, 2022 Department of Health and Human Services CFDA #93.829 Section 223 Demonstration Programs to Improve Community Health Services (CCBHC) Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance Finding Summa,y: - Rimrock Foundation does not have formally documented written internal control procedures over compliance with federal award programs to meet the requirements regarding compliance with federal regulations for procurement, suspension and debarment. Responsible Individuals Jeffrey Keller, CEO and Shirley Ehlang, Lead Financial Accountant Corrective Action Plan: Rimrock Foundation will adopt written internal control procedures over compliance with federal award programs regarding compliance with federal regulations for procurement, suspension and debarment. Anticipated Completion Date: Ongoing

Finding 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that funds are disbursed for incurred expenditures prior to reimbursement requests. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

The Treasurer, Town Manager and Select Board has taken the following actions to address finding 2022-007: The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. This policy was approved and implemented by the Select Board on January 23, 2024.

Recommendation:We recommend management and the board of directors should review reporting frequently to make sure that they are complying with the requirements. Management Response: We agree with the recommendation and the record retention policy that was adopted on November 14, 2022 should prevent this from happening in the future.

2022-005 Significant Deficiency in Controls over Compliance: Administrative Requirements of Uniform Guidance-Administrative Policies The schools have documented their administrative policies effective 3/1/2023.

2022-003 Cash Management Management?s Response and Planned Corrective Action: Management will monitor reimbursement requests to insure that payments have been made to vendors prior to submitting the reimbursement request. Name and Title of Contact Person: Timothy Matte, Executive Director

Finding 2022-003: Noncompliance with Cash Management Condition: Cash draws from WIOA Cluster and Coronavirus Relief Fund grants exceeded the amount needed to cover allowable costs. Recommendation: Management needs to work with the State of Indiana Department of Workforce Development to refund the overdrawn funds or apply the funds to allowable costs in the upcoming fiscal year. Management?s Corrective Actions: Staffing changes have occurred, and the fiscal management duties have been outsourced to a third party which has experience with Workforce Boards and related grants. These issues are being addressed with IN DWD.

Federal Program Name: ? Block Grants for Community Mental Health Services ? ALN 93.243 ? Substance Abuse and Mental Health Services Projects of Regional and National Significance ? ALN 93.829 ? Section 223 Demonstration Programs to Improve Community Mental Health Services ? ALN 93.958 Recommendation: Our auditors recommended the Organization revise their Financial and Control Policy to encompass the requirements defined within ? 2 CFR 200.305. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the audit finding. While the policy has been updated previously, it was not updated such that it complied with the requirements of 2 CFR 200.305. The Controller and CFO have updated the policy so that it fully complies with all of the requirements defined within 2 CFR 200.305. Name(s) of the contact person(s) responsible for corrective action: CFO and Controller. Planned completion date for corrective action plan: Will implement in fiscal year 2023.

FINDING 2022-014 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The approved grant budgets for all federal grants will be input into the financial management system and with all expenditures reported monthly from the Treasurer to the Director overseeing the federal grant for review and final approval. The monthly reports will then be used by the Director to generate a reimbursement request for actual expenditures. The reimbursement request must then be reviewed and signed by the Treasurer or the CFO prior to submission to the State by the Director. Anticipated Completion Date: April 2023