Corrective Action Plans

County department personnel changes have been implemented, which address this deficiency. Additional training from the Auditor’s Office and state grantors has occurred for newer staff in certain departments with large amounts of federal and state awards.

August 15, 2025 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL (Repeat) Views of Responsible Officials and Planned Corrective Actions: We concur with this finding - Management is in the process of assessing the organizational structure, capacity to provide adequate financial reporting. With Board review and approval of the Agency’s financial funding sources, the Agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and Uniform Guidance regulations. The new automated financial systems, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 2024. Concerning preparation of external reports required by various funding sources (i.e., SF-425, DHS’s reports for LIHEAP, LIHWAP, etc.), the Agency will ensure adequate training is performed to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action. Comment #2024-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START, LIHEAP, LIHWAP, CSBG, ASTHO, CACFP, and SLFRF FAL # 93.600, 93.568, 93.499, 93.569, 93.185, 10.558, 21.027 (Questioned Costs - Undetermined) Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Management and staff are in the process of assessing and updating the policies and procedures over the accounting and reporting of federal and state grants and contracts. In connection with training staff on the new and updated accounting system, we are providing ongoing training on the requirements of the Uniform Guidance and the specific requirements for each individual grant award as outlined in each applicable Compliance Supplement issued by Office of Management and Budget (OMB). We are currently reconciling all cash accounts and completing and amending, where necessary, all SF-425 reports and other external reports required by each funding source (state and federal). We anticipate completing this corrective action by December 31, 2025. See also the response to Comment #2024-001. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action.

Finding 2024-002 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS) Assistance Listing: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Pass-Through Grantor: Not applicable Award Number: U3REP220676 Award Period: 9/30/2024-9/29/2025 Summary of Finding: For one of the two Federal Financial Reports (FFRs) submitted in FY 2024, incorrect project/grant period dates and federal share of expenditures amount was reported in the FFR. Two FFR reports were submitted in FY 2024. The FFR instructions required reporting the cumulative Federal share of expenditures amount ($2,253,211) from the date of inception of the award (9/30/2022) through the end date of the reporting period specified. However, Corewell reported only the current period expenditures ($933,054) for the current grant year and consequently, this error also resulted in incorrect amounts reported for the Unliquidated balance of Federal funds. The total federal expenditures for HPP for FY 2024 were $1,292,999. Corrective Action Plan: Leadership acknowledges the need for more robust deliverable tracking and review of Federal Financial Reports (FFRs) prior to submission. A written protocol and tracking matrix will be developed to record and track all federally funded projects that report through the Payment Management System (PMS) to ensure the correct period of performance report is created and a second level of review performed on a timely basis in accordance with sponsor requirements prior to submission. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller David Ross, Director, Research Finance and Analysis Timing of corrective action: September 1, 2025, and going forward

Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.

The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mitigate the reporting lapse since the oversight. To prevent recurrence, the Town has implemented the following corrective actions: 1. Formal Reporting Calendar: A centralized ARPA reporting calendar has been created. This calendar will include internal deadlines at least 14 days in advance of federally mandated submission dates. 2. Assigned Reporting Officer: A designated ARPA Reporting Officer has been appointed, responsible for coordinating all necessary documentation and submissions related to ARPA funding. 3. Pre-Submission Review Process: A new protocol has been established requiring internal review and sign-off from both the Comptroller and the Town Supervisor’s designee no less than one week prior to each deadline. 4. Ongoing Training and Coordination: The Town will continue to work closely with its auditors and legal counsel to remain current on federal guidance, ensure continued compliance with Uniform Guidance standards, and maintain internal staff awareness of applicable obligations under ARPA. We believe these measures will ensure timely and accurate reporting for all future quarters and strengthen our internal compliance infrastructure.

The grant administrator shall include notifications within their Outlook calendar two weeks prior to the due date for each progress report deadline. This will ensure progress reportes are completed and submitted on time.

Management will ensure Federal expenditures are obligated during proper period and reported appropriately.

We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took some time before we got the access to all the projects on PMS. We are already tracking both financial and narrative reports from the signing stage of projects, and most of the reports are prepared on time. Going forward, we will further strengthen our backup plans for submission of reports, both online and through email. We will develop a backup plan and strengthen delegation plans for each region during the times when the primary contact is not available

Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes to ensure that reports are filed in accordance with the grant requirements. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

Management acknowledges the need for compliance with reporting requirements for COVID-19 State and Local Fiscal Recovery Funds. We will follow the auditors’ recommendation to review our policies and procedures to ensure that internal controls are properly designed, implemented and maintained to ensure accurate and timely financial close and reporting.

Recommendation: We recommend that the District develop and implement formal policies and procedures to ensure that federal reports are reviewed for accuracy, completeness, and timeliness prior to submission. Management should assign responsibility for report preparation and review, implement checklists or reconciliation processes, and provide training to staff involved in federal reporting. Corrective Action: 1. Assign separate personnel for report drafting and supervisory review to ensure segregation of duties. 2. Create and require use of a Quarterly Report Review Checklist to confirm accuracy, completeness, and timeliness before submission. Person Responsible for Corrective Action: William Clayton, Finance Manager. Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

Recommendation: We recommend that the District strengthen its internal control system by implementing a formal tracking mechanism for federal reporting deadlines, assigning responsibility for report preparation and submission, and establishing a review process to ensure timely compliance with all grant reporting requirements. Corrective Action: 1. Designate a primary report preparer and assign a secondary reviewer to verify report accuracy, completeness, and timeliness prior to submission. 2. Implement a report review checklist to be completed and signed by both preparer and the reviewer, filed with each submission. Person Responsible for Corrective Action: William Clayton, Finance Manager Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

Views of Responsible Official(s) and Planned Corrective Action: Management concurs with the finding. The report found lacking was reviewed by the Executive Director, and the error was based on a difference between cash and accrual accounting. Management will review federal financial reports with contracted accountants and retrieve source documents before submitting. Management will also review scope of contracted accounting services to ensure it includes review of all NEH reports.

The District acknowledges the continuing issue of receiving material vendor invoices many months after performance of contracted work. One set of late invoices entered into QuickBooks accounts payable with retroactive dates was not recognized as grant revenue earned. As recommended by the auditors, the District will begin tracking grant expenditures on an accrual basis beginning with the period ending July 31, 2025. In addition to the monthly recognition of cash accounts by the Finance Coordinator, all balance sheet accounts with material balances will be reconciled each month by the Treasurer with review by the Executive Director beginning with the period ending July 31, 2025. We anticipate both audit findings will be fully resolved by these actions. Responsible party: Patrick Moreland Date: Ongoing

FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The town is contracted with Baker Tilly Financial Advisors and the Clerk Treasurer will provide all pertinent information to Baker Tilly in order for them to prepare the Statement of Budget, Income, and Equity- Form 442-2; and the Balance Sheet - Form 442-3) that is required by the USDA for the Sewer Bonds. Once the reports are completed by Baker Tilly, the Clerk Treasurer will review the reports and then submit them to the USDA. This will be done annually. Anticipated Completion Date: Effective immediately

Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Reporting Finding Summary: No review and approval processes are in place over quarterly progress reports. Corrective Action Plan: Management has implemented procedures and control processes to incorporate an independent review and approval over quarterly reporting and retain documentation to support the review was performed. Responsible Individuals: Teena Conrad, SSVF Program Manager, Lysa Allison, Executive Director and Sara VanVlack, Business Manager Anticipated Completion Date: June 2025

Finding Number: 2024-001 : Significant Deficiency and Noncompliance - Reporting Planned Corrective Action: As recommended, Management will implement controls and processes to ensure all required reports are submitted timely. Anticipated Completion Date : June 30, 2025 Responsible Contact Person: Randy Bartels, City Auditor

Audit Recommendation – We recommend that management and relevant staff participate in comprehensive training on federal grant compliance – emphasizing FFATA obligations and financial reporting deadlines – to ensure a clear understanding requirements. Management should then formalize and document procedures for FFATA reporting, including a calendar driven workflow with designated preparers and approvers, mandatory sign-off checklists, and automated reminders. Finally, the Organization should implement a centralized reporting tracking system that monitors all federal award deadlines and captures evidence of timely preparation, review, and submission for both financial and performance reports.   Management Response – We concur with the recommendation and in process of making changes the both the work flow and processes stated. Specifically, we have contracted with two outside consulting firms for both grant compliance and internal audit services from Certified Public Accountant licensed professionals. Finally, both independent consultants will report the compliance status to the CEO on a periodic basis. 

The Conservancy District has implmenented controls and processes to ensure that the required reports are prepared and submitted timely.

Management acknowledges the lapse in consistently meeting the grant requirement to submit financial reports within the specified 30-day period. To address this issue, the Organization has initiated a series of procedural improvements to ensure timely and accurate reporting moving forward. As a first step, the Organization has taken the crucial step of meeting with the grant manager to establish clear communication and alignment on reporting expectations. This direct dialogue has helped clarify requirements, strengthen mutual understanding, and lay the groundwork for a more seamless reporting process. To support ongoing compliance, the Organization has implemented a shared calendar for both program and fiscal management teams, providing a unified view of reporting deadlines and improving coordination and accountability across departments. Additionally, the Organization’s fiscal team has implemented a separate, dedicated calendar focused on financial reporting deadlines. This targeted approach allows the team to proactively track and meet reporting timelines with promptness and consistency.

Corrective Action Plan for Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs: Reporting – Finding 2024-002 We are in receipt of the Findings Required to be Reported by the Uniform Guidance, specifically finding 2024-002 regarding failure to complete and submit the required annual Federal Financial Reports (SF-425) for the two awards identified below for the year ended December 31, 2024. • Department of Transportation, Award Number 3-05-0047-031-2023, Award Year 2023 • Department of Transportation, Award Number 3-05-0047-032-2024, Award Year 2024 View of Responsible Officials and Planned Corrective Actions Management agrees with the finding. The City experienced turnover during the fiscal year leaving less time for preparation and review of required reporting. As a result, internal controls and review processes were not in place or were not followed to ensure all required reporting was completed accurately and timely. Overall, we will increase compensating controls by introducing additional management oversight and review for the processes in this area. We will develop a process for reviewing and tracking the submission of FFR reporting to the Federal Aviation Administration (FAA) to ensure that reporting is in compliance with FAA and CFR rules and regulations. Ember Strange, Chief Financial Officer, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director