Corrective Action Plans

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

Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access to updated health assessments. We have been directed by the funding agency never to exclude these youth from participation for an inability to obtain a health assessment. BGCP has already taken steps to address these issues. The funding agency, PHMC has begun sending monthly compliance reports. Over the last three months, we have collected 42% of missing health assessments organization wide. Additionally, on our recent FY24 Admin review from PHMC, which included a full compliance report, all of our sites received overall scores of above 95%. We will continue to monitor compliance and follow-up with youth and families to complete needed items.

The migration to a new general ledger financial reporting system is an isolated incident and given the improved reporting capabilities the change in product provided a positive impact. UWGC experienced turnover for the program manager position that created a learning curve that was addressed but resulted in audit completion delay. UWGC has an experienced manager currently overseeing the program who will follow policies and procedures as prescribed and on a timely basis to allow for prompt reporting submission.

UWGC experienced a staffing turnover during the 2024 fiscal year of the manager responsible for the reporting on the SEFA. The manager tracked financial reports on a cash basis causing a timing difference with not recognizing accounts payable. The finance team accounted for expenses in the appropriate period, therefore the Finance team will crosscheck reports for timing difference prior to submission to governing agency.

2023-003 – Reporting – Significant Deficiency in Internal Controls over Compliance Federal Agency Name: Department of Education Federal Assistance Listing Number: 84.425E, 84.425F Federal Program Name: Higher Education Emergency Relief Funds (HEERF) Student Aid Portion, Higher Education Emergency Relief Funds (HEERF) Institutional Portion Finding Summary: A sample of 4 special reports from the population of 4 special reports was selected. For the three quarterly reports selected, the College could not provide support that the reports were published timely. In addition, the College could not provide consistent institutional records for the data included in the three quarterly reports or annual reports. Three of the four quarterly reports were corrected based on the audit procedures performed, the College did not properly identify these as “corrected” upon posting to the College website. Responsible Individuals: Dr. Lorelle Davies, Chief Financial Officer 105 Courtney Judah, Executive Director of Institutional Effectiveness Corrective Action Plan: The college will continue to apply a detailed reporting process for timely collection and reporting of grants. Reporting to include the following:  Accurate and regular collection of data needed to report outcomes and service populations.  Cross verify data with Institutional Effectiveness and Institutional Research.  Post in accordance with grant requirements including documentation to record posting and submission dates. Anticipated Completion Date: Completed April 30, 2024

The College omitted lost revenue and reported incorrect expenses on quarterly grant reports (9/22 and 3/23 reports). The College will revise procedures to ensure amounts reported on quarterly reports are correct.

The YWCA will ensure that all federal award reports are filed in a timely manner. The YWCA is in the process of posting a new position, Director of Grants and Compliance. The individual in this new role will be responsible for tracking report due dates and working with the individuals responsible for the content of these reports to ensure the information is accurate and on time. In situations where the Director of Grants and Compliance is responsible for gathering the data for required reporting, the data will be reviewed by either the CFO or CEO prior to submission of the report.

Corrective Action Plan: Due to staff turnover of key personnel in the Housing Division, the Finance Department has partnered with the Community Development Department to ensure that CDBG reporting is timely and accurate. In March 2024, a new consultant was contracted to assist the Housing Division staff with training and oversight for entering data to HUD's Integrated Disbursement and Information System (IDIS) which includes the Cash on Hand reports. Responsible Individual: Kimberly Cole-Muck, Director of Community Development Anticipated Completion Date: September 2024

Management response to finding 2023-001: Accuracy of expenditures on the Schedule of Expenditures of Federal Awards and submission of special reports for the Head Start Program Cluster Name: Head Start Federal Awarding Agency: Department of Health and Human Services Award Name: Head Start and Early Head Start, COVID (P.L. 116-260) Award Number: 09CH010228-05-05, 09CH011831-02-03, 09HE000328-01-00 Award Years: 2019-2021, 2021-2022, 2021-2023 Assistance Listing Title: Head Start Assistance Listing Number: 93.600 Pass-through entities: Not applicable As described in finding 2023-001, the University inadvertently charged and drew down budgeted capital expenditures from Head Start awards before actual expenditures were incurred by the University. Additionally, the University charged expenditures to a Head Start award after liquidation extensions had expired. The adjustments required to correct these errors were identified in the subsequent fiscal year, resulting in expenditures on the fiscal year 2023 Schedule of Expenditures of Federal Awards (SEFA) being overstated. The University will take the necessary corrective actions as described below to ensure the accuracy of expenditures reported on the SEFA. Finally, as described in finding 2023-001, the University did not identify and track reports required to be submitted for Head Start awards. The corrective actions described below will ensure all award specific reporting requirements are met. Although the University has limited federal awards that are utilized to fund capital expenditures, the Office of Sponsored Projects Accounting and Facility Planning and Management will perform a full review of the current Head Start capital construction accounting policies and practices to ensure they comply with the Uniform Guidance and the terms and conditions of federal awards before June 30, 2024. Reinforcement of the University’s policies and practices will ensure proper grant accounting, and thus, will prevent SEFA reporting adjustments from having to be made. Faculty leadership responsible for overseeing the Head Start program at the University will fill current vacant financial management positions within the Head Start program as soon as possible (with a three month target), undergo a full review of program requirements with all staff, and modify and develop new internal controls related to this finding. Specifically, before July 2024, Head Start fiscal personnel along with faculty leadership will develop a reporting schedule specific to Head Start awards, provide training and resources to staff involved with reporting, implement internal controls related to the reconciliation and validation of reported data prior to report submission, and strengthen internal controls related to the allocability of expenditures to awards (particularly in situations where liquidation extensions or expenditure carry forwards have been granted). Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu

Finding No. 2023-006: Reporting (Material Weakness - Internal Control Over Compliance) Federal Award: 21.023 - COVID‐19 – Emergency Rental Assistance Program (ERA) Audit Recommendation: We recommend the City be more diligent in following its policies and procedures for submitting quarterly information to the Department of Treasury. We also recommend the City implement retention procedures to track the reports and supporting information submitted to the Department of Treasury. Administration’s Comments: The City will follow policies and procedures for submitting quarterly information to the Department of Treasury and also implement retention procedures to track the reports and supporting information submitted to the Department of Treasury. Office of Economic Revitalization (OER) will provide Fiscal with a copy of the reports. Anticipated Completion Date: May 1, 2024 Contact Person(s): Denise Obrero, Mayor’s Office, Planner VII Rowena Santamaria, Department of Budget and Fiscal Services, Fiscal Officer II

Dear Mr. Waguespack, The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor dated January 4, 2024, regarding a reportable audit finding related to controls over reporting and other Federal compliance requirements for the Medicaid and CHIP programs at the LDH. The LDH appreciates the opportunity to provide this response to your office's findings. Finding: Inadequate Controls over Reporting and Other 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 to ensure Federal expenditures are accurately reported and should ensure all quarterly checklist reviews are completed. LDH Response: LDH partially concurs with the finding and recommendation. LDH disagrees that the quarterly checklist is intended to demonstrate compliance with the federal reporting requirements. The quarterly checklist is used to document and track the receipt of source documents from other departments so the fiscal staff can develop work papers for the federal expenditure reports. The checklists do not track the accuracy of the work papers. Additionally, the quarterly reconciliations purpose is to reconcile expenditures in the state's accounting system (LaGov) to the Medicaid and Children's Health Insurance Program Budget and Expenditure System (MBES/CBES). During this audit period, LDH was in the process of reviewing the reconciliation procedures to transition from previous methods of reconciliation utilizing the old accounting system (ISIS) to LaGov. Although the duplication was identified through this Single State audit, LDH maintains it would have identified the duplicative entries during the annual grant award reconciliation process which would have been within the federal reporting timelines Corrective Action Plan: LDH will continue to build on the improvements already implemented to prevent Medicaid expenditure misstatements from recurring. As discussed with the Single State auditors, measures to increase operational accuracy were being worked on during the audit or are in the process of being developed. LDH management has already taken steps to implement a corrective action plan to strengthen the internal controls that will enhance the State Agency's preparation and review of the quarterly federal expenditure reports which includes a more thorough review of procedures to collect and review data from program offices and incorporate more cross training amongst the fiscal staff responsible for federal reporting. The anticipated completion date of this corrective action plan is April 30, 2024. You may contact Helen Harris, LDH Fiscal Director, by telephone at 225-342-9568 or by e-mail at helen.harris@la.gov with any questions about this matter.

FINDING 2023-005 Finding Subject: COVID‐19 Education Stabilization Fund ‐ Reporting Summary of Finding: Reports were not supported by underlying accounting records. Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: (812)254-5536 calford@wcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Washington Community Schools like all other school corps across the state, got the requests for these reports with very little to no instruction of how to complete them. We weren’t told they would be part of the audit and therefore didn’t retain reports used to complete some of the reports. Going forward we will ensure reports proving numbers reported are available to SBOA. Anticipated Completion Date: 06/30/2024

I was instructed by our U.S. Department of Education representative to not post additional reports to our website until all prior reports have been corrected.

The university endeavors to follow all applicable reporting regulations and guidance mandated for federally funded grant and contract programs. The HEERF awards were fully expended as of June 30, 2022 for the Student Portion and as of September 30th, 2022 for the Institutional Portion. Should similar programs become available in the future, management will develop, in advance of expending funds, documented policies and procedures to administer the program and will maintain documentation demonstrating compliance with program requirements and related institutional policy and procedure. Specifically for the HEERF program that has ended, the university will amend relevant Quarterly report(s) and submit an Annual Report for 2022, as required and in consultation with the Department of Education on reporting timelines and processes for amended reports. Reviews will be completed and documentation retained as described below. For future programs, the Office of Sponsored Projects will monitor available published information from the funding agency(ies) to ensure the university offices responsible for any element of the reporting process are aware of applicable deadlines and requirements. The Office of Sponsored Projects and the Office of Financial Aid will prepare required reports for institutional and student grant-related activity, respectively. These reports will be reviewed by the Office of Financial Aid (for any student portion) and the Office of Institutional Research and the Business Office (for all portions, including any institutional funds). These offices will collaborate to implement a review procedure to ensure the reports are accurate, complete, submitted timely, and if required, posted publicly to the university’s website. Additionally, files will be maintained in a shared location so that documentation is available in the event of turnover, so that support availability (including detail support) withstands any changes in the employment of the employees responsible for preparing, reviewing, and/or posting the reports. Persons Responsible: Assistant VP for the Office of Sponsored Projects; Director of Financial Aid; Controller and Associate Vice President. Targeted Correction Date: September 30th, 2024. Fiscal Year in which Finding Initially Occurred: 2021 (Finding Number 2021-003).

Finding 2023-010 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and one ESSER III report, for a total of five reports. A single employee prepared and submitted each annual data report without a review or oversight process in place to prevent, or detect and correct, errors. All five reports were selected for testing, two of which were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Another individual will start to review the information entered into the required ESSER reports prior to submission and supporting documentation will be retained. Anticipated Completion Date: April 1, 2024

FINDING 2023-006 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: During the audit period the School Corporation submitted three final expenditure reports. The final expenditure reports were completed and submitted by the Treasurer without an oversight or review process in place to prevent, or detect and correct, errors. In addition, the final expenditure report for the Title I School Improvement for program year 2021, due December 30, 2021, was submitted March 7, 2024. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 39 Description of Corrective Action Plan: The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Another individual will start reviewing the final expenditure reports prior to submission to IDOE. Anticipated Completion Date: April 1, 2024

We agree that in previous years, there were deficiencies in compliance with reporting requirements related to the receipt and disbursement of federal funds. There has been turnover in Business Office staff, but now that staffing has stabilized, the following procedures will be implemented regarding the management of federal funds:  The Senior Accountant will be responsible for the receipt and disbursement of federal funds, and for monitoring reporting requirements  The Associate Vice President for Finance and Controller will oversee the process and ensure that spending guidelines are followed and that all deadlines for reporting are met

Department: Health and Human Services Title: Internal control over ELC program reporting needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: Financial Reporting: Quarterly financial reporting will be emailed to the reviewer by Maine CDC. Financial Reporting: Reviewer corresponds corrections/findings via email to Maine CDC. Financial Reporting: Maine CDC inputs financial reporting into CAMP. Performance Reporting: Quarterly meetings with each team to update progress will be recorded. Performance Reporting: All milestones that have progress in the last quarter will have a note describing how we determined the progress level entered into CAMP. Performance Reporting: A note about who reviewed the progress report and who submitted it will be entered into the Monitoring Notes section in CAMP. Completion Date: June 10, 2024 (first item), June 18, 2024 (second item), June 20, 2024 (third item) and June 30, 2024 (last three items) Agency Contact: Sara Robinson, Infectious Disease Program Manager, DHHS, 207-287-4610

FINDING 2023-002 Finding Subject: COVID 19 – Education Stabilization Fund - Reporting Summary of Finding: Material Weakness, Other Matters. Contact Person Responsible for Corrective Action: Steve Nauman, Treasurer Contact Phone Number and Email Address: Phone: 812-522-3340 Email: naumans@scsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The SCSC management team will design and implement a proper system of internal control, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place prior to filing required reports. Anticipated Completion Date: The projected date of completion is February 29, 2024.

FINDING 2023-008 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were complied, prepared and submitted by one employee without an oversight or review process in place to prevent, or detect and correct, errors. In addition, the six reports submitted during the audit period contained errors. The errors were as follows:  The ESSER I, Year 2 and ESSER II, Year 1 reports did not contain expenditures for the reporting period, however according to the School Corporation's records there were expenditures for ESSER I and ESSER II during this period.  The ESSER I, Year 3, ESSER II, Year 2, ESSER III, Year 1, and ESSER III, Year 2 reports were not supported by the School Corporation's records, was not accurate and complete, and was not mathematically accurate. Recommendation: We recommended that management of the School Corporation establish a proper system of internal controls and develop policies and procedures to ensure supporting documentation is used and retained for all required reports submitted on behalf of the Education Stabilization Fund program funds. Contact Person Responsible for Corrective Action: Dr. Tim Garland Contact Phone Number and Email Address: 574-626-2525 / garlandt@lewiscass.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: During the audit period, internal control opportunities were in place but not followed. Lewis Cass Schools has an internal control process that is in place but was not followed by the treasurer who in the position during the audit period. The treasurer who did not follow the internal control process is no longer employed by Lewis Cass Schools. To address and ensure Education Stabilization Funds are properly reported by the treasurer the treasurer will print out the form that was completed by the treasurer and must be signed by the superintendent or department head for review before submittal and filed for record keeping. Anticipated Completion Date: 3/11/2024