Corrective Action Plans

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organization which will include the monthly financial statements, general ledger detail, a listing of all journal entries made, significant accounts reconciliations, aged payables and receivables, and any significant adjustments in the previous period. Report will also include an update to the Schedule of Federal Awards and other significant grant reporting done in conjunction with the development team. President will review and approve the packet monthly. Expected Completion Date: 3/31/2025

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 Reporting and Matching Federal Compliance Requirements for the Medicaid and Children’s Health Insurance Programs. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over Reporting and Matching Federal Compliance Requirements for the Medicaid and Children’s Health Insurance Programs Recommendation: LDH management should strengthen controls over preparation and review of the quarterly federal expenditure reports and quarterly adjustments to ensure federal expenditures are accurately reported. In addition, LDH management should incorporate a reconciliation of federal expenditures in the financial statements to federal expenditures reported to CMS. LDH Response: LDH Management concurs that controls over preparation and review of the quarterly federal report were insufficient and should be strengthened. LDH Management recognizes its responsibility to accurately report financial data, while also acknowledging 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 adequate time for thorough reviews for this reporting year. Corrective Action Plan: LDH Fiscal Management in collaboration with our contracted consultants are working towards updating standard operating procedures to include the review process as well as training for the preparer and reviewers of the work. Also, a development of a reconciliation to capture all reporting in MBES in comparison to LaGov is being created. The corrective action plan completion date to address this is anticipated for completion during the April 2025 federal reporting period. 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 February 3, 2025 regarding a reportable audit finding related to the Office of Public Health (OPH) – Inadequate Controls over and Noncompliance with Federal Financial Reporting. LDH appreciates the opportunity to provide this response to your office’s findings. Finding: Inadequate Controls over and Noncompliance with Federal Financial Reporting Recommendation: OPH should design and implement controls to ensure all information contained in the financial reports submitted to Federal agencies is accurate, current, and complete for the reporting period covered under the report. LDH Response: LDH Fiscal Management recognizes its responsibility to accurately report financial data, however, LDH Fiscal Management does not concur with the finding of Inadequate Controls over and Noncompliance with Federal Financial Reporting (FFR) due to immateriality of the questioned expenses. The expenses in question reported on the Federal Financial Report were eligible grant expenses for this award. LDH Fiscal understood the expenses in question to be related to the same award that was ending 6/30/24, but received a No Cost Extension through 12/31/2024. After consulting with the grantor on this matter, the grantor conveyed that reporting these eligible expenditures earlier than the No Cost Extension date was not a material concern and would not require a revised FFR for this period, as the main concern is that they were eligible expenses and would be included in the final FFR. Total expenses in question ($142,568) represent approximately .3% of the cumulative expenses reported on the Federal Financial Report ($42M) as of 06/30/2024; therefore, the stance of LDH is the amount in question is immaterial and does not misstate the Federal Financial Report. Corrective Action Plan: Procedures and internal training currently exist for fiscal team members on completing Federal Financial Reports. A corrective action plan to reiterate and reinforce the understanding of various reporting periods to include No Cost Extension and liquidation periods to the preparers and reviewers of the FFR’s to mitigate this occurrence was implemented immediately. Quintesah Syas, Accountant Manager 4/Comptroller within the LDH Fiscal Office for Office of Public Health Financial Reporting and Helen Harris, Deputy Undersecretary 2/LDH Fiscal Director are responsible for the execution and implementation of this corrective action and may be contacted with any questions about this matter. You may contact Quintesah Syas Accountant Manager 4/Comptroller, within the LDH Fiscal Office for Office of Public Health Financial Reporting at (225) 342-9333 or via email at Quintesah.Syas@la.gov, or Helen Harris), Deputy Undersecretary 2/LDH Fiscal Director at (225) 342-9568 or via email at Helen.Harris@la.gov with any questions about this matter.

FINDING 2024-004 – COVID-19 – Education Stabilization Fund – Reporting Context: The School Corporation was required to submit one Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II amount reported for the reports covering the FY23 time period ($4,934,473) did not agree to the underlying expenditure records ($4,801,053) for the period of July 1, 2022 through June 30, 2023. Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: 765-747-5222 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next ESSER reports due in FY25

Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER I amount reported on the Year 3 report ($266,367) did not agree to the underlying expenditure record ($96,019) for the period of July 1, 2021 through June 30, 2022. Additionally, the ESSER II and ESSER III amount reported on the Year 2 report ($1,433,207, and $643,771, respectively) did not agree to the underlying expenditure records ($1,400,698, and $630,465 respectively) for the period of July 1, 2021 through June 30, 2022. We also noted that the ESSER II and ESSER III amounts reported on the Year 3 report ($4,291 and $1,522,378, respectively) did not agree to the underlying expenditure records ($4,590 and $1,774,722, respectively) for the period of July 1, 2022 through June 30, 2023. Additionally, the School Corporation was not able to provide any support for the 288 full-time equivalent (FTE) positions on September 30, 2022, reported on the Year 2 CrossAct report or the 338 full-time equivalent (FTE) positions on September 30, 2023, reported on the Year 3 CrossAct report. Crowe also noted that the School Corporation reported 0 full-time equivalent (FTE) positions paid by ESSER on September 2023, but there were ESSER positions reported in the ESSER applications. Corrective Action Plan: The School Corporation will implement a system of internal controls and an effective review process to ensure amounts reported on annual data reports agrees to the underlying transaction detail or other supporting documentation. Person responsible for implementation and projected implementation date: The Business Manager will be responsible for overseeing the implementation of the corrective action plan, which will go into effect with the next annual data report submission.

COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF VEGA BAJA Corrective Action Plan For the Fiscal Year Ended June 30, 2024 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2023 – June 30, 2024 Fiscal Year: 2023-2024 Principal Executive: Hon. Marcos Cruz Molina, Mayor Contact Person: Mr. Edgardo Pérez, Department of Management, Administration and Budget Director Phone: (787)855-2500 Original Finding Number: 2024-003 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: In the quarterly reports (QPR), accumulated expenses are reported up to the closing date of each quarter. These expenses are assigned to the quarter in which the contractor invoices the completed work. However, in some cases, the payment is made in the quarter following the one in which the invoice was issued. This discrepancy may cause the expenses not to be accurately reflected in the quarter they were reported during the audit process. This situation will be addressed prospectively, and expenses will be assigned to the quarter in which the payment is made. Implementation Date: Fiscal Year 2025-2026. Responsible Person: José A. Torres Otero Program Accountant

The Municipality will establish additional procedures to maintain the schedule of the required reports in order to avoid this situation.

The City internally identify improvement opportunities in managing grants. As a part of the City’s grant oversight improvement efforts, the City began implementing various processes and internal controls surrounding grant monitoring, which improves the SEFA drafting process and mitigates risks of future inaccuracies. These efforts began in early 2024 and include the following: • Creation of a grant policy that provides City staff with guidance, information, and expectations surrounding grants. • Creation of a master grants database that lists the general ledger fund, applicable project ledger references, status, grant type, start/end dates, granting agency, pass-through agency, grant name, assistance listing numbers, grant amounts, and the grant manager for each grant. This database is now used to verify the completeness and accuracy of the SEFA (beginning FY24). • Formal quarterly monitoring. Each quarter, the City will formally review the grants database with department contacts and grant managers to verify the completeness and accuracy of the database. The City is formalizing this process and plans to include department signoffs evidencing the review process. If any items are missing, the missing component will be identified and added to the database on a timely basis. The City will also utilize this quarterly process to review the grants policy to ensure grant managers are aware of the requirements related to their grants. • The City is in the process of formalizing the SEFA drafting process utilized during the FY24 SEFA preparation, which includes additional mitigating procedures such as reviewing all next FY federal receipts to ensure none of them relate to the SEFA year federal expenditures. Personnel Responsible for Implementation: Marvin Lopez Position of Responsible Personnel: Deputy Administrative Services Director (Fiscal Services) Expected Date of Implementation: June 30, 2025

Planned Corrective Action: DNR has developed a master tracking spreadsheet to track all of the grants and the financial reporting requirements for each grant. This spreadsheet is maintained and reviewed by the Management and Grant Accounting Section Chief to ensure all federal financial reports are submitted by the due dates. This corrective action was implemented in October 2024, prior to receiving the interim audit memo. Anticipated Completion Date: 10/31/24 Person responsible for corrective action: Name, Title: Gabriel Nankee, Management and Grant Accounting Section Chief Division or Unit (if applicable): Internal Services, Bureau of Finance Email address: Gabriel.Nankee@Wisconsin.gov

Description of Corrective Action Plan: Shoals Community School Corporation will implement a secondary review of all reports submitted in the future regarding any federal funding. Kindra Hovis, Superintendent will share the reports with Kendra Wright, Treasurer and Kendra Wright, Treasurer, will share with Kindra Hovis, Superintendent all future federal awards’ expenditures and revenue reports to ensure accurate reviews and submissions. Responsible Party and Timeline for Completion: Kendra Wright, Treasurer and Kindra Hovis, Superintendent-this will be implemented monthly to review any federal funding moving forward.

Audit Finding: Pursuant to 2 CFR 200.327 and CFR 200.328 Report Requirements, Army West Point Athletic Association Inc. (“AWPAA”) did not submit its interim performance reports within 30 days after the completion of each reporting period. Root Cause Analysis: During FY2024, AWPAA did not submit its quarterly interim performance reports in accordance with the CA requirements. Instead, AWPAA submitted the FY2024 quarterly reports concurrently in October 2024. This was an oversight by the AWPAA & Government Program Management Teams. Corrective Action Plan: To review the interim performance reporting requirements as outline in Section 10B of the Cooperative Agreement and coordinate the timely monitoring and submission of these quarterly reports by the AWPAA Program Management Team. Estimated Completion Date: October 30, 2024 and note: Interim Performance Report for the period ended September 30, 2024 was submitted October 28, 2024 (due by October 30, 2024). Interim Performance Report for the period ended December 31, 2024 was submitted January 29, 2025 (due by January 30, 2025).

FINDING 2024-004 Information on the federal program: Subject: COVID-19 – Education Stabilization Fund – Reporting Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the following exceptions in data reporting submissions:  ESSER I Year 4, ESSER II Year 3, and ESSER III Year 3 expenditures for the period of July 1, 2021 through June 30, 2022 ($0, $360,404, and $12,974, respectively) did not agree to underlying expenditure records ($60,937, $477,914, and $0, respectively).  ESSER II Year 4 and ESSER III Year 4 expenditures for the period of July 1, 2022 through June 30, 2023 ($57,667 and $363,486, respectively) did not agree to underlying expenditure records ($361 and $400,473, respectively). Description of Corrective Action Plan: Management will implement control processes surrounding federal data reporting to ensure that expenditures reported to granting agencies are in agreement with underlying records maintained by the School. Responsible Party and Timeline for Completion: Gretchen Berger, Corp Treasurer - 6-1-2025

Finding 2024-002 Name of Responsible Individual: Tamara Hill, AVP Research Operations and Finance Corrective Action: We concur. We will review our processes and ensure timely and accurate completion of reporting. We will complete the corrective action no later than June 30, 2025. Anticipated Completion Date: June 30, 2025

Contact Person Responsible for Corrective Action: Dalton C. Tunis Contact Phone Number: 574-896-2155 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: An internal controls procedure will be put into place that ensures annual data reports are both reviewed and signed off on before submitting. The procedure will be that the Business Manager prepares the report and then reviews the report with the Superintendent. Once the Superintendent approves of the report he or she will sign of on the report and the report can be submitted. Documentation will be recorded to ensure the School Corporation stays in compliance with the requirements related to grant agreements and reporting requirements. Anticipated Completion Date: June 30, 2025

Management concurs. The City will strengthen its policies and procedures related to federal award reporting to comply with reporting requirements.

Management concurs. The City will ensure responsible personnel will have a clear understanding of the reporting guidance. The City will implement policies and procedures to monitor and review all reports prepared and submitted by the Grants Department or its designee.

Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER I and ESSER II amounts reported for the reports covering the FY22 time period ($0 and $459,915 respectively) did not agree to the underlying expenditure records ($27,092 and $455,658 respectively) for the period of July 1, 2021 through June 30, 2022. Additionally, we noted that the ESSER II, and ESSER III amounts reported for the reports covering the FY23 time period ($459,616 and $22,273 respectively) did not agree to the underlying expenditure records ($107,610 and $1,274,716 respectively) for the period of July 1, 2022 through June 30, 2023. We also noted there was no documented, secondary review of the information in the annual data reports by someone other than the preparer. Additionally, the School Corporation was unable to provide the supporting reports containing the FTEs reported as of 9/30/22 and 9/30/23. Contact Person Responsible for Corrective Action: Jennifer Graves Contact Phone Number: 812-659-1424 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Federal reporting will be completed by the due date assigned and approved by the Superintendent prior to submission. After submission, the reports will be maintained. Anticipated Completion Date: Immediate

FINDING 2024-003 Finding Subject: COVID-19 - Education Stabilization Fund – Reporting Contact Person Responsible for Corrective Action: Carolyn Wallace Contact Phone Number and Email Address: 812-738-2168, extension 102 and WallaceC@shcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The following internal controls will be implemented related to the required reporting of information:  Supporting details of reported information will be retained within the grant files for audit purposes.  Documentation of the collaboration between personnel submitting the report will be retained for audit purposes.  Documentation from the Indiana Department of Education to assure that the submitted data was correctly uploaded will be requested and retained for audit purposes. Anticipated Completion Date: June 30, 2025

2024-002 – Untimely Reporting of Student Disbursements Auditor Description of Condition and Effect. One student out of forty tested received disbursements that were not reported to the federal government within the required timeframe. As a result of this condition, the College did not fully comply with the requirements to report disbursements within 15 days of disbursing funds. Auditor Recommendation. We recommend that the College implement policies and procedures, including designating an individual to oversee this reporting requirement, to ensure information is submitted to the Common Origination and Disbursement in a timely manner. Corrective Action. During the upload of records to COD, if a file is rejected, the Financial Aid Federal and State Coordinator will work to clear the reject and upload the record again. The process will continue until the record is uploaded successfully. File uploads are occurring weekly. Responsible Person. Lexie Seidel and Emmalee Gilaspie, Financial Aid Federal and State Aid Coordinators. Anticipated Completion Date. Spring 2025.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Jeff Gambill, Superintendent; Jennifer Barcus, Corporation Treasurer; Jeri Morin, Data Coordinator Contact Phone Number: 812-665-3550 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Superintendent will prepare all annual data reports and have a documented formal review from the Corporation Treasurer and the Data Coordinator, prior to submission, to validate the accuracy and completeness of the data submitted. Anticipated Completion Date: Immediate review will begin of all annual data reports.

FINDING 2024-006 Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Federal Agency: Department of Education Federal Program: COVID‐19 ‐ Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013, S425U210013 Pass‐Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Chad Yencer, Superintendent Contact Phone Number: 765-348-7550 Views of Responsible Official: We concur with this finding Description of Corrective Action Plan: Internal Control 1. For state reporting related to ESSER grants, the Grants/Data Specialist will compile all required information and maintain thorough supporting documentation. The Corporation Treasurer will then review the compiled financial data for the reporting period, verifying its accuracy before presenting it to the Superintendent. Finally, the Superintendent will review the information and supporting documentation, confirming its accuracy prior to submission to the Indiana Department of Education (IDOE). All workpapers and calculations will be recorded and kept for verification Anticipated Completion Date: August 2025

Finding 2024-002: Compliance requirement: Reporting-Coronavirus State and Local Fiscal Recovery Reportable Condition: See Condition 2024-002 Recommendation The Municipality should maintain the schedule of the due dates or the reuired rports of each federal program to comply with the required submissions to the federal awarding agencies. Also, they had to submi the quaterly report to comply with the requiremnts. Action Taken Due to the shift from annual to quaterly reporting, the Municipality initially missed a quaterly report deadline because of unfamiliarity with the new schedule. however, since then , we have consistently met all the subsequent quaterly deadlines. we will continue to carefully monitor and verifiy all reporting deadlines to guarantee accurate and timely submissions moving foward.

Corrective action plan: TxDOT Aviation has modified the procedures for the SF-425 report preparation to require the subrecipient share of the expenditures to be properly reported when the match is from a local source. A Checklist will be created to include this amount when the document is reviewed by the Grant & Admin Section Director. TxDOT AVN will explore the consideration of including the local share in its accounting system which would allow identification of the local amount. Implementation dates: February 15, 2025 Responsible persons: Michelle Burcham, AVN Grant & Admin Section Director, Allison Martin, Grant Manager Lead

Corrective action plan: Federal Reporting will seek direction from the awarding agency if corrections are found to be needed after a report is submitted. If directed to, Federal Reporting will submit a revised report. If directed to wait until the next cumulative report to make the correction, Federal Reporting will save this documentation from the awarding agency. Implementation dates: February 12, 2025 (Implemented) Responsible persons: Alan Flynn, Manager, Federal Reporting

Future reporting of ESSR information will be noted wherever possible either in written notation or email format to document who worked on and reviewed reporting information and submissions. We will attempt to take screenshots of any forms that are not available for printing