Corrective Action Plans

Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." In addition, 2 CFR 200.329(c)(1) states that “the non-federal entity must submit performance reports at the interval required by the Federal awarding agency or pass-through entity to best inform improvements in program outcomes and productivity”. Per the award agreement for contract W912DW-20-2-0003, "Recipient shall submit to the Agreement Administrator (see paragraph 1.2.1) progress reports on a quarterly basis utilizing the form included in Attachment B of this agreement. Reports are due no later than 30 days following the end of each reporting period. A final performance progress report shall be submitted within 90 days after the expiration date of the award." Condition: During testing it was noted that 3 of the 6 financial reports tested did not include documentary evidence of Executive Director review and approval. In addition, 2 of the 2 performance reports tested were filed after the filing deadline. Questioned costs: None. Context: A sample of 6 was made from a population of 17 financial reports, and a sample of 2 was made from a population of 4 performance reports. Of the 6 financial reports sampled, 3 did not have documentary evidence of Executive Director review and approval. Of the 2 performance reports sampled, both were filed after the submission deadline date. Cause: Late filing is due to a lack of adherence to the due dates as defined within the contract terms. The Organization does not have adequate controls in place to document the Executive Director's review and approval of the Federal Financial Reports (SF-425). Effect: Not filing reports on a timely basis can present risks, such as outdated and unreliable information or the inability to detect potential fraud or irregularities. In addition, delayed reports can impede regulatory authorities' ability to monitor compliance, detect patterns or trends, and assess risks in a timely manner. Without adequate documentary evidence around the review of financial reports, there is an increased risk of errors and fraud in the reporting process, which could result in inaccurate financial reporting and misappropriation of funds. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-004. Recommendation: CLA recommends for the Organization to place emphasis on stronger controls around the timely filing of required reports, such as retaining a monthly checklist of required reconciliations and reports. CLA also recommends implementing a procedure that documents the Executive Director's review and approval of the Federal Financial Reports (SF-425s), whether that be via an email chain or retaining a copy that also includes the Executive Director's signature on the report. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and strengthened our internal controls and training to all staff around the timely filing of required reports. This has included creating a calendar of required reconciliations and reports for all agreements. Further, we have updated our procedure for review, approval, and documentation of Federal Financial Reports. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree with the data submitted in the Reports, therefore we could not determine their accuracy. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improve record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs / Cost Principles, Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Any transfers that happen, will be reviewed, and will have better documentation of what claims made the transfer happen and make sure supporting documentation is attached to the claim to prove the use of the transferred funds. Anticipated Completion Date: Immediately

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full – range of controls relating to reporting, including federal program reporting. MARR will take such steps as necessary to ensure that reports are timely and accurately prepared, reviewed, and approved prior to filing. All controls, including review and approval will be documented in such documentation to be maintained.

Finding 2023‐004 Condition Both of the two reports selected for testing contained a contractor that was incorrectly reported as a subaward. Our sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Effective with the 2024 third quarter reporting, the contractor incorrectly reported as a subaward with Treasury was corrected. Name(s) of Contact Person(s) Responsible for Corrective Action: Jillian Stacey, Housing Program Specialist, made the correction. Anticipated Completion Date: July 2024

FINDING 2023-006 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – US 12 Stormwater Drainage Improvement Project – Reporting Summary of Finding: The Michigan City Sanitary District did not design or implement a system of internal controls that would have prevented the omission of required progress reports, and lack of oversight process. Contact Person Responsible for Corrective Action: Mary Lynn Wall 219-873-1404 Ext 2006 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: The Sanitary District will review the federal grant requirements in order to ensure required reports are submitted in a timely manner. Reports will also be reviewed and documented by another employee prior to submission. Anticipated Completion Date: 08/26/2024

FINDING 2023-004 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – Body Camera - Reporting Summary of Finding: The City did not design or implement a system of internal controls that would have prevented the omission of required progress reports, and lack of oversight process. 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: The City department responsible for federal grant reporting will review the grant requirements in order to ensure required reports are submitted in a timely manner. Reports will also be reviewed and documented by another employee prior to submission. Anticipated Completion Date: 08/26/2024

FINDING 2023-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Kosciusko County Sheriff's Office applied for the Indiana Local Body Camera Grant (ILBC). The sheriff’s office was awarded this grant on January 1, 2023, with a grant cost amount of up to $31,920. This grant is a reimbursable grant through the Indiana Department of Homeland Security. The period of performance was from January 1, 2023, to December 31, 2023. The Kosciusko County Sheriff's Office ordered body-worn cameras and equipment on April 26, 2023. The invoice for the cameras and the camera equipment was paid on July 14, 2023. The Kosciusko County Sheriff's Office then submitted a Reimbursement Claim Form on September 11, 2023. The Reimbursement Claim Form shows the Sheriff's Office incorrectly requested the full $31,920. They received $31,920 from the Indiana Department of Homeland Security on September 27, 2023. However, the county had only spent $9,581 of the grant money towards the body camera purchase. Therefore, there is a remaining balance in the fund of $22,339 as of December 31, 2023. Due to the period of performance, the county should have reimbursed the Indiana Department of Homeland Security $22,339. On May 9, 2023, the Sheriff's Office grant administrator submitted a Program Report for the ILBC grant. This report was filed without an implemented internal control or evidence of a review. The report was completed and submitted by the Sheriff's Office grant administrator. The report incorrectly indicated that all expenditures had been completed. As of the date of the submission, the county had not purchased the bodyworn cameras and all federal funds had not been expended. Contact Person Responsible for Corrective Action: Alyssa Schmucker Contact Phone Number and Email Address: 574-372-2325 aschmucker@kosciusko.in.gov View of Responsible Officials: We concur with the findings identified. Description of Corrective Action Plan: The Kosciusko Sheriff’s Office, grant coordinator will contact IDHS for instruction on how to return the $22,339.00 and prepare a claim to be processed by the Kosciusko County Auditor’s office. The grant balances are submitted each month by departments these are checked and confirmed by the Auditor’s Office this one was overlooked in the review process. The person who applied for the grant no longer works for the county. It is believed the new person handling the grants was not aware that this grant even existed. The Grant Administrator(s) will have someone sign off on the grant report submissions and forward all reports to the Auditor’s Office. Anticipated Completion Date: It is anticipated that this will be completed as soon as the information to return the funds is received from the state and the claim is submitted to the Auditor for payment. This claim will be paid as soon as it is received. On or before 12/31/2024.

Timely Performance Reporting for Pacific Fisheries Data Program, 11.437; and Bipartisan Budget Act of 2018 (Disaster Relief Program), 11.022 Recommendation: CLA recommends for the Commission to implement stronger internal monitoring to ensure reports are completed by program managers and submitted to the Grants Manager timely to ensure ample time for internal review and upload to the Federal Agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will set an internal deadline at least one week prior to the external report due date. The Grant & Contract Specialist will coordinate with the Finance Officer to submit report timely in the event the Grant & Contract Specialist is absent. Name(s) of the contact person(s) responsible for corrective action: Michael Arredondo and Ngu Castro. Planned completion date for corrective action plan: October 15, 2023

CONDITION: The District did not properly record its federal program expenditures for the ESSER and ARP ESER federal grant programs using the various funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations and well as Section 2 CFR 200.302(a) of the Uniform Guidance. CRITERIA: The financial management system of the District must provide for 1) identification in it’s accounts, of all Federal awards received and expended and the Federal programs under which they were received, and 2) accurate, current and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements set forth in sections 200.328 and 200.329 of the Uniform Guidance. 74CORRECTIVE ACTION PLAN: The School District concurs with the above noted finding. The School District has employed a new Business Manager whose responsibilities include the oversight of the financial management system and the posting of all transactions into that system. Procedures will be put into place during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for ensuring federal program expenditures are properly coded within the District’s financial management system so as allow for proper reporting related to those expenditures.

Finding 2023-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Anita Fuller, Finance Director Corrective Action Plan: Proposed Completion Date: Immediately

Audit Finding Reference: 2023-002 – Improve Oversight of Reporting of Federal Funds The March 2023 Annual Performance report showed an expense of $239,098 in FY2023 which was not actually expended until FY2024. The Town agrees with the finding. Planned Corrective Action: When the FY2023 report was filed, the expense in the wrong period was discovered. Efforts were made to try and correct this error prior to filing the FY2023 Report, but the system would not allow any corrections. The Town makes every effort to include the source documents that support the reports submitted, which is the way this was discovered prior to submitting the FY2023 report. The Town will continue this procedure to include the source documents (Trial Balances) which support the projects and amounts filed within the report. This will ensure that the General Ledger and the reports filed are in balance. The only corrective measure for this error will occur when the FY2024 Single Audit is prepared which shows the expense expended in FY2024.

The Auditor’s office with work with the Department of Job and Family Services and provide training on the importance of grant reporting and tracking. We will also explain and show how using the ERP system can aid in the tracking of expenses and help to ensure better accounting for grants. The Auditor’s office will implement an additional level of control for this department’s grant award, reporting, and reimbursements to be reviewed by our office for accuracy. Use online state and federal agency websites to verify grant awards amounts and disbursements.

Microloan Program – Assistance Listing No. 59.046 Recommendation: We recommend management develop procedures to ensure the required reporting is completed within the timeline allowed by the granting agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ADC will hire a new loan officer who will also be an SBA Microloan Program Manager then develop and implement procedures to ensure the required reporting is completed within the timeline allowed by the granting agency. Name(s) of the contact person(s) responsible for corrective action: Felicia Ravelomanatsoa (CFO) Planned completion date for corrective action plan: December 31, 2024

As a result of the 2023 Single Audit, the Department of Housing (DOH) received an audit finding related to a missing quarterly report that was not filed for the Emergency Rental Assistance (ERA) Program. Currently, Treasury reporting for ERA is conducted primarily by the Director of Policy, and the Treasury reporting system is not integrated into other DOH grant systems to provide a wider view to DOH contracts and finance staff as to the status of report submissions. As a corrective action, DOH will establish an internal process requiring that quarterly reports, including a time stamp of submission, be saved and circulated to DOH contracts staff by the 15th of the month following the end of each quarter. Acting Director of Policy Stern at Department of Housing will be responsible for ensuring that this corrective action plan is implemented by January 1, 2025.

All Final Expenditure Reports will include the appropriate expenditure amounts associated with the grant year.

Company-wide reports are submitted monthly to the Board of Directors for approval. Reports that are submitted are separated by grant, so that the Board of Directors can see the activity in each grant for each month during the fiscal year. The reports submitted to the funders by Marlon Mitchell are taken from the financial reports that are approved by the Board of Directors. In addition, Marlon does not enter the financial information, nor does he prepare the monthly reports submitted to the Board. He serves as a fourth set of eyes on the information before the reports are submitted to the funders. Khayriyah Mitchell enters all of the revenue and expenditures into the accounting system, Shanelle Herman reconciles the bank and credit card accounts and runs the reports for the Board of Directors, the Board reviews and approves the financial statements, and Marlon Mitchell uses the approved financial information to create the reports to the grant funding agencies.

Corrective Action Plan: The San Diego County Air Pollution Control District (District) agrees that a report for the Homeland Security Bio Watch Program was submitted more than 30 days after the reporting period ended as required by OMB. As corrective action to ensure reports related to Federal awards are submitted timely the District has added additional resources to the grants team to ensure timely report submission. Additionally, the District is currently establishing a written procedure for the grant reporting process and once finalized, will communicate to the appropriate staff of required federal reporting standards and deadlines. Anticipated Implementation Date: June 2025

The Council disputes this finding and did have a system in place to document program participant enrollment and received services participant's file records and sign-in sheets. Due to the number of various kinds of services an individual received in a month, services and activities sign-in sheets had to be used to prevent duplication of counting for program reports Regarding reports, the organization does use its email system involving multiple employees to prepare, review, approve, and submit reports which involves the Executive Director or Grants Manager submitting final reports. A new form was created to include a final sign-off by the Executive Director to indicate approval of reports. However, this was not accepted as sufficient by the auditor. Per new grant reporting regulations, at the recommendation of the auditor, staff will establish a shared Adobe document system to allow for the collection of staff signatures and approvals at all levels before each report is submitted. These signatures and approval document will be attached to submitted reports for review. Expected completion date: July 2024

Recommendation: Internal controls over reporting should be designed, implemented, and documented to ensure compliance with 2 CFR section 200.302(b)(2), including who is responsible, what they are reviewing for, when reviews are to take place, and how documentation of the controls will be maintained. The general ledger should be set up to properly capture and track expenses as well as budgets prepared and approved with the actual costs expected to be incurred. Reports should be reconciled to the general ledger. Budgets should be complete and include all line items and not just include all expenses under supplies. Ac􀆟on Taken: This is a project Finance team is currently working on. The new Compliance Director will manage the grant writing process. During the grant and award process, Compliance, the Program with award, and Finance will establish an appropriate budget which, in turn, will be reflected in general ledger and monitored by the team. The contact persons responsible for this corrective action plan are Alan Branch, Sr VP of Compliance and Workforce Development, the new Compliance Director, Wendi Speed, CFO, and the entire Finance Team. The anticipated completion date is June 30, 2025.

Timely Performance Reporting for Pacific Fisheries Data Program, 11.437; and Bipartisan Budget Act of 2018 (Disaster Relief Program), 11.022 Recommendation: CLA recommends for the Commission to implement stronger internal monitoring to ensure reports are completed by program managers and submitted to the Grants Manager timely to ensure ample time for internal review and upload to the Federal Agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will set an internal deadline at least one week prior to the external report due date. The Grant & Contract Specialist will coordinate with the Finance Officer to submit report timely in the event the Grant & Contract Specialist is absent. Name(s) of the contact person(s) responsible for corrective action: Michael Arredondo and Ngu Castro. Planned completion date for corrective action plan: October 15, 2023

Federal Agency Name: U.S. Treasury Department; Assistance Listing Number: 21.027; Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds; Material Weakness in Internal Control Over Compliance – Compliance Requirement – Reporting Finding Summary: The City’s submitted quarterly reports as required, but the reports contained errors including incorrect amounts and reporting information on the incorrect line items. Corrective Action Planned: The City concurs with the auditors’ findings. The City is working to coordinate and maintain supporting documentation used to prepare and review quarterly reports prior to submission to ensure the accuracy of the reports submitted. Responsible Individual(s): Mark Hagedorn, Finance Manager/Treasurer; Brooks Slyter, Assistant Finance Manager; Lisa Farris, Grant Administrator Anticipated Completion Date: October 2024