Corrective Action Plans

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from the employee’s total hours when calculating the amount of match for the federal program. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could claim as match disallowed costs under the federal award and would not be able to detect and correct noncompliance in a timely manner. The employee’s Medicaid hours were not properly included within a revenues report due to the employee’s provider number not being included within the report parameters. Responsible Individuals: CEO (Dan Ries) Corrective Action Plan: CEO will double check and confirm that all revenue reports run have data for the correct staff to ensure that the accurate information is being used to calculate match hours. Anticipated Completion Date: September 2024.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to a Means of Financing Reallocation. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Noncompliance with Medicaid Federal Matching and Reporting Requirements Related to a Means of Financing Reallocation Recommendation: LDH management should strengthen the system of internal controls over preparation and review of the quarterly CMS-64 reports to ensure expenditures are accurately reported and that the required amount of state and/or local funds are available and used to match the state’s allowable expenditures. LDH Response: LDH Management concurs that the reallocation of the Medicaid expenditures that include federal and state shares should have been excluded from the June 30, 2024 CMS64 report. LDH Management recognizes its responsibility to accurately report financial data, but also acknowledges that staffing shortages and inadequate/insufficient training resulted in less-than-ideal reporting conditions creating limited knowledge and experience with the data and reporting requirements and time for thorough reviews Corrective Action Plan: LDH Fiscal Management has already taken steps to aggressively work towards improving staffing knowledge and skills by way of securing the services of a vendor who offers CMS64 support and training for federal reporting requirements. In addition, LDH Fiscal is working with the vendor to develop a comprehensive training/development plan for staff responsible for CMS64 reporting and establish collaboration with Human Resources to address staffing efforts. The corrective action plan completion date to address this compliance was effective immediately upon notification of the error, recognizing that this will be an ongoing corrective action plan of monitoring as LDH Fiscal works to create a culture of continuous improvement. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

Dear Mr. Waguespack: The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated January 27, 2025 regarding a reportable audit finding related to Inadequate Controls over and Noncompliance with Matching and Reporting Requirements Related to the Cost Share Process. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over and Noncompliance with Matching and Reporting Requirements Related to the Cost Share Process Recommendation: LDH management should ensure the cost share tables are appropriately updated for all periods during the fiscal year. In addition, LDH should strengthen controls over preparation and review of the quarterly CMS-64 federal expenditure reports to ensure that the appropriate federal match is applied to qualifying expenditures and the required amount of state and/or local funds are available and used to match the state’s allowable expenditures. LDH Response: LDH management concurs that the cost share tables were not updated for all periods during the fiscal year in LaGov. Although the rates in LaGov did not impact accurate federal reporting in MBES, we recognize that for comparison and accuracy, the rates should have been verified in both instances. Our expenditure reporting to CMS via MBES is entered based on total expenditures as MBES calculates the FMAP automatically. However, we are implementing additional controls in our SOPs that will ensure the FMAP information in LaGov remains current. Corrective Action Plan: The tables have been updated in the LaGov system as of January 2025 and we are currently adding a task to quarterly checklist to ensure the rates are aligned between LaGov and MBES. In addition, we are exploring the possibilities to update queries and reports, where possible, to further strengthen reporting accuracy by automatically tying to the FMAP information in LaGov so queries and reports can automatically calculate the appropriate federal and state match which will also avoid any potential discrepancy that may arise from manual intervention/calculations. This corrective action plan to address the feasibility of updating queries and reports is ongoing, but an anticipated assessment date is May 30, 2025. Clinton Summer, Accountant Manager 4/Comptroller for Medicaid Financial Reporting and Helen Harris, Deputy Undersecretary 2/Fiscal Director, are responsible for the execution and implementation of this corrective action. You may contact Clinton Summers, Accountant Manager 4 at (225) 342-5701 or via email at Clinton.Summers@la.gov or Helen Harris, LDH Fiscal Director, at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

CORRECTIVE ACTION PLAN State Fiscal Year Ended June 30, 2024 Fish and Wildlife Cluster (Assistance Listing #15.605, #15.611, #15.626) State Agency: NH Fish and Game Department Audit Contact: Kathy LaBonte Title: Business Division Chief Telephone: 603 271-2274 E-mail address: kathy.a.labonte@wildlife.nh.gov Audit Report Reference: 2024-008 - Matching Anticipated Completion Date: June 30, 2025 Corrective Action Planned: To have revised procedures in place to include additional documentation to ensure accuracy from the subrecipient. We concur with the finding; A. In-kind match documentation earned requires additional documentation to support subrecipient match contribution. Revised procedures will be implemented to include additional documentation from the subrecipient to ensure accuracy. B. Internal review of volunteer in-kind match calculations are in place, however, in one instance, prior year rates were used resulting in under reported in-kind match earned. The Department does review and track match received from the subrecipient. We do not agree there are questioned costs of $201,250.

The Crenulated will request a quarterly in-kind contribution report from DOE and will ensure the in-kind contributions are recorded in the financial statements. The Crenulated plans to hire an in-house Controller with expertise in accounting for grants, and review its existing contract with current third-party accounting provider.

FEDERAL AWARD FINDING Finding: 2024-003 Significant Deficiency in Internal Controls over Compliance and Compliance – Setup and Monitoring of Reporting and Match Name of Contact Person: Angie Flick, Director of Finance Corrective Action: The accountants will be going through additional training on setting up grants in the system and how to reconcile them. CBJ will also be completing a grant reconciliation process quarterly instead of annually. This will act both as a control as well as an opportunity to make timely corrections in the case of error. Proposed Completion Date: September 30, 2025

Matching, Level of Effort and Earmark Significant Deficiency in Internal Control over Compliance, Instance of Noncompliance We concur. Corrective Action Plan: The City was not provided with payroll registers or pay stub copies for the in‐kind local match contribution from Solano County and the Travis Community Consortium. However, the City did maintain hourly tracking for the two agencies when they attended meetings and used a lower pay rate, as outlined in the approved grant budget, when reporting back to the agencies. The required 10% in‐kind match was exceeded by $9,224.28, with a portion of the $30,000 mentioned above included in the excess match. Additionally, the grant had a pay rate cap of $87 for one of the County employees, so using the actual pay rate to calculate the in‐kind match was not permitted. The City will collaborate with the other agencies to obtain better documentation for the shared local match. Responsible Individual(s): Liz Aptekar, Assistant to the City Manager Anticipated Completion Date: To be completed by 6/30/2025

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted item is not already written into another grant ● Presenting a list of budgeted items and their corresponding fund codes at a grants meeting prior to submitting the budget ● Notifying the Business Manager when the budgets have been approved and that those budgeted items can now be allocated to the corresponding grant under their specific fund code ● Checking the expenditure report to make sure it accurately reflects what was written in the grant before submitting information to the state ● Reporting any errors in coding to the Business Manager to ensure an accurate representation of expenditures is reported before submitting to the state 3. Anticipated completion date: Implementation of the corrective action plan began March 15, 2025.

We concur with the condition. 1. Name of the contact person responsible for corrective action: Grants Manager 2. Corrective action planned: Grants Manager will be tasked with the following: ● Researching and understanding what items are allowable within each federal grant ● Ensuring each budgeted item is not already written into another grant ● Presenting a list of budgeted items and their corresponding fund codes at a grants meeting prior to submitting the budget ● Notifying the Business Manager when the budgets have been approved and that those budgeted items can now be allocated to the corresponding grant under their specific fund code ● Checking the expenditure report to make sure it accurately reflects what was written in the grant before submitting information to the state ● Reporting any errors in coding to the Business Manager to ensure an accurate representation of expenditures is reported before submitting to the state 3. Anticipated completion date: Implementation of the corrective action plan began March 15, 2025.

RMIPA will update its processes to better track obligations alongside expenses for more accurate financial reporting and compliance. This includes obtaining additional Microix modules to enhance internal tracking and compliance.

The Government concurs with the auditor’s findings and recommendations. VIDE acknowledges need to enhance monitoring and internal controls. VIDE will establish a team for quarterly reviews of documentation, report issues, and recommend corrective actions. The IDEA State Office will set procedures for verifying accuracy of data reported by LEAs. Comprehensive staff training will ensure understanding of new policies and procedures.

While the ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Director of Audit and Compliance has been onboarded. Once the audit team is developed, support and compliance monitoring will be provided to ensure compliance.

PAX implemented a dedicated cost center in the books and records specifically for tracking cost shared expenses midyear during FY23 rather than the previous practice of recognition of cost share at year end closing. Full implementation of contemporaneous tracking of cost share was implemented in FY24. Additionally, PAX now reconciles against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures.

Views of Responsible Officials: ICFJ will implement procedures and control processes to track cost share requirements and the progress towards the requirements. Support for the cost share claimed should also be available upon request.

Finding Number 2023-005 Subject Heading (Financial) or AL no. and program name (Federal) ALN: 21.027 Federal Program name: Coronavirus State And Local Fiscal Recovery Funds (CSLFRF) Planned Corrective Action Management Response: OMES-GMO concurs with the finding that CSLFRF program funds were applied to GEER and ERA expenses. OMES-GMO specifically notes that while the applied expenditures are indeed allowable under federal programs, the application of CSLFRF to these programs was in error ostensibly due to administrative challenges experienced throughout this tumultuous period. During the COVID-19 pandemic, states across the country faced numerous operational and compliance challenges, including frequently changing federal guidance and firsttime handling of federal funds. In response to the growing complexity of managing multiple federal funding programs, OMES established the Grants Management Office (OMESGMO). However, in its initial phase, the OMES-GMO experienced consistent instability with a high frequency of employee turnover, understaffing, limited resources, restricted internal controls, and practiced leadership. These factors contributed to classification errors and delays with internal review. Since then, OMES-GMO has taken steps to stabilize operations by maintaining consistent leadership, hiring additional staff, and the uniform application of organizational processes. These improvements have strengthened internal controls and allowed for the identification of previously misapplied expenditures. Prior to the finding, OMES-GMO reviewed and flagged these expenditures and is actively working to correct the issue. To resolve the misclassification, OMES has requested state appropriations to properly adjust and reallocate these expenses to their appropriate funding sources. Anticipated Completion Date Controls have been put into place and will continue through the end of the Federal Period of Performance and closeout. Responsible Contact Person Parker Wise

Corrective Action Plan: ALN 10.760: The Program will work with the Finance Department to thoroughly review the grant award documentation for any cost-sharing contribution requirements. If identified, this requirement will be marked on the intake form and tracked by the Finance Department. ALN 93.575 and 93.596: The Program satisfied these matching requirements in fiscal year 2024. In future awards, the Program will ensure that the match requirements are met in the appropriate period of performance. Person(s) Responsible: Randez Bailey, SRST OMR/MRI Director,Jackie Brownotter, Child Care Assistance Program Director Estimated Completion Date: September 30, 2025, March 31, 2024

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Establish an indirect cost policy to standardize the evaluation and approval for subrecipient. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will endeavor to make sure the FEMA files are updated and complete after FEMA reimbursement.

This matter was investigated by both the AOS, the Allen County Auditor’s Office, and by board members of the RPC. GLCAP was met with and records from both RPC and GLCAP were scrutinized and matched. As a result, the duplicate payment made in the amount of $4,386 was returned by GLCAP to RPC and was deposited on 10/03/2024 into the Allen County Community Development Fund.

2023-004 Name of Contact Person: Matthew Roy Corrective Action: In 2024, a new template was created for grant expense submissions which identifies Cost Share coding from the time that a payment request is made. The grants team is responsible for completing this file and identifying how much of any expense incurred should be considered cost share. This approach allows for supporting documentation to be available for all cost share items and eliminates the need for adjusting journal entries to break out cost share. Proposed Completion Date: Management considers this finding resolved as of August 2024.

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-006 Matching Program: Continuum of Care Program (ALN 14.267) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While we were able to test a manual compensating control over matching, we were not able to review and test the automated application controls and related ITGCs within the State’s MAXIS system. The State was not able to provide information regarding the design and implementation of MAXIS system controls, nor were we able to test those controls directly. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2024

Responsible: Thomas Hoover, Chief Financial Officer Corrective Actions: Updated Finance policies: Specify that documentation of review and approval of costs charged to federal grants be maintained and that costs are recorded in the appropriate grant funding period. Completion Date: July 10, 2024. Explanation: Policies have been in place over the coding of costs allocated to federal grants in compliance with CFR 200 and were enhanced in 2023 in response to an OJJDP/OCFO recommendation. Review and approval of costs after being approved by an authorized signer takes place in multiple steps and concludes with preparation of reimbursements and financial grant reports (FFR). In order to further demonstrate compliance as recommended, Management updated Finance policies to capture the documentation and approval of cost allocation methods and coding of costs to federal grants and maintenance of such documentation of Supervisory review and approval. Policies already in place specified that supporting and source documentation be maintained for at least 3 years, in compliance with federal grant requirements. In addition, the updated policy specifies that grant costs be recorded in the appropriate grant funding (fiscal) period. Four transactions sampled were partially or fully recorded in the incorrect funding (fiscal) period, though they were within the grant period.

FINDING 2023-003 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – Body Camera – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: The City entered into a grant agreement on 03/03/2023 for the purchase of body cameras. The invoice for the body cameras was dated 10/28/2022, prior to approval from the state. The purchase was outside the period of performance. Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 Ext. 2006 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: In order for the City to insure that internal controls are in place to prevent noncompliance with federal awards, the City Controller’s office will review and discuss with department personnel, all federal grant applications to ensure compliance with allowable costs and period of performance. Anticipated Completion Date: 08/26/2024

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, the Accounting Manager, Grants Manager, and Grants Supervisor attended the 2023 Southern Grants Forum in Nashville, TN. This investment in training assisted these key employees in understanding and implementing procedures to effectively match Federal Grant awards. We have updated our Policy and Procedures Manual to reflect a new policy of matching Federal Grant awards with non‐federal funding. The Grants Supervisor reviews all invoices submitted by the Grants Manager to ensure compliance with this new policy. Responsible Parties: Kimberly Yoo, CFO Whitney Gillis, Director of RD Mary Guzman, Accounting Supervisor Date Corrected: 7/1/2023

Finding 2023-024 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626 - Inappropriate Telecommunication Expenditures Management Views DNR agrees with the finding. Planned Corrective Action DNR sent an email communication on May 7, 2024, to the Department Budget Control Team as a reminder to use the monthly DTMB telecom billing detail to verify all employees coded to fish and wildlife activities are valid. The monitoring of these charges will continue to occur as part of the interim quarterly assessments. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Houle, DNR