Corrective Action Plans

The District agrees with this finding and will implement the following:  Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling.  Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of the population used to calculate and select samples.  Internal Review Process o Establish manual review process to confirm all required documentation and applications are retained and accurately represent the population.

Finding #2024-002 – Lack of Subrecipient Monitoring Description of Finding: The Town passed through approximately $1,650,000 in federal funds to a local electric Co-op for broadband infrastructure installation. The Town did not perform subrecipient monitoring specific to this award by identifying applicable requirements for the award after the disbursement of these funds. Statement of Concurrence of Nonconcurrence: The Town concurs that applicable requirements for the award were not identified for the subrecipient, however the Town did monitor activities of the subrecipient. The Town monitored activities to ensure funds were used for allowable activities. Contact Person: Courtney Delaney, Town Administrator Planned Corrective Action: Establish and implement a formal subrecipient monitoring process for all federal funds passed through to other entities. Seek guidance from the awarding agency if responsibilities are unclear. Anticipated Completion Date: The Town has been in regular communication with the awarding agency and established clarity as to applicable terms and conditions as of this date. The Town is working to establish and implement a formal monitoring process and anticipates completion no later than December 31, 2025.

Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount transposed with the amount of another federal program. This resulted in an over-request of a material amount on the Ryan White Program. Duplicate Invoice Reimbursement: An invoice was requested and received for reimbursement on a prior drawdown and was subsequently included again in a draw after year-end, resulting in a duplicate reimbursement. Incomplete Expenditure Tracking: The entity did not have a complete system for tracking all expenditures eligible for reimbursement. The drawdown process was limited to cash disbursement and payroll transactions and excluded expenditures incurred and recorded by journal entries. This resulted in the entity having unreimbursed expenditures that could have offset the over-requests noted above. Corrective Action Plan: To correct the deficiency, we are implementing a plan focused on establishing a review and approval process for all drawdown requests and revising our policies to ensure that all eligible incurred expenditures are properly captured and reconciled, thereby assuring strict compliance with federal cash management regulations and preventing federal funds from exceeding our immediate needs. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.

2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.

FINDING 2024-001 Finding Subject: 20.205 Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Commissioner Ron Jarman, Auditor Tammy Justice Contact Phone Number and Email Address: 765.745.0013, rjarman@rushcounty.in.gov; 765.932.2077, auditor@rushcounty.in.gov Views of Responsible Officials: Rush County concurs with the finding. Description of Corrective Action Plan: The Commissioners will create a Procurement, Suspension & Debarment Policy with all necessary requirements. Anticipated Completion Date: September 2025

The District will aggregate and reconcile all application documentation and scan all supporting documentation and place in a secured central location electronically and/or physically.

The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. Condition #1 - All FFRs and corresponding programmatic and financial reports will be reviewed by the Accountant, the Accounting Officer, the Agency Fiscal Officer, the Budget staff, and the Grants Program Manager prior to submission to the Federal government. OCFO will utilize a grants matrix that will reflect the respective grants due dates to ensure timely filing of FFRs. The matrix will be reviewed to ensure compliance monthly with each Accountant during the monthly analysis and review process. Condition #2 -DBH will save the SOR tracking sheet that is used to calculate the earmarked amounts for administrative and data costs for the Federal programmatic reports. This will be retained in a central location. Condition #3 - Prior to the submission of the SEFA, the grant expenditures will be reviewed with the Accounting Officer, the AFO, and the Grants program manager for a detailed review of the SEFA to confirm expenditures are correctly categorized by fund and grant, reconciles to the financial system and reflects the amount expended for sub-recipients. Contact: FFR (SF-425) and SEFA: Barbara S. Roberson, Accounting Officer, Human Support Services Cluster PPR Reporting: Sharon Hunt, State Opioid Treatment Authority, DBH Estimated Completion Date: September 2025 See Corrective Action Plan for chart/table

The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are issued promptly after the drawdown is made.

The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written internal procedures to ensure that payments are issued promptly after the drawdown is made.

The PRDOH is working with the Finance Department to establish and strengthen our internal controls to ensure all payments comply with the guidelines established by the Federal Government. On the other hand, the PRDOH is working and verifying our own written procedures to ensure that payments are issued promptly after the drawdown is made.

Contact Person Responsible for Corrective Action: Dr. Tammy Rowshandel, Chief Accountability Officer Contact Phone Number: 812-462-4224 Views of Responsible Official: The School Corporation's management will establish an effective system of internal control to ensure compliance and comply with the grant agreement and the Special Tests and Provisions - Annual Report Card, High School Graduation Rate compliance requirement. Description of Corrective Action Plan: A system will be put in place that ensures compliance with the Special Tests and Provisions-Annual Report Card, High School Graduation Rate requirements. Records will be retained for audit so that appropriate documentation is available to substantiate all future reporting. Building registrars will enter state exit codes for students and upload documentation to substantiate the exit codes that are chosen. Once the documents are uploaded, the registrars will place the word “AUDIT” in the withdrawal comments. This indicates the exit is now audit ready. Schools will conduct regular internal cohort audits. Comparisons of IDOE cohort data and withdrawal information in Skyward will be done. The registrar, assistant principal, and data counselor in each building will work together to check the original uploads of documentation done by the registrar and keep record of this work. One final internal audit will take place at the school level by head counselors and assistant principals to indicate all graduates are correctly identified and all exits have proper documentation on file. The CFO and superintendent will digitally sign off on these records during IDOE July certification. Anticipated Completion Date: March 1, 2025

Finding #2024-001 – Inability to Produce Supporting Report to Confirms the Accuracy of the Verification Report Sample Contact for corrective action: Dr. Gregg Klinginsmith, Superintendent District’s response: Concur Anticipated completion date: December 31, 2024 Corrective Action: The District agrees with this finding and will implement the following: • Data Integrity Verification: o Implement a data review process to ensure data completeness and accuracy prior to sampling. • Staff Training: o Conduct training sessions for staff involved to ensure the accuracy of reports produced by the software used to select samples. o Obtain training from the software provider to understand how the software pulls reports, ensuring sample accuracy. • Internal Review Process o Establish periodic reviews to confirm all required documentation is retained and accurately represents the population.

Finding Number 2023-074 Subject Heading (Financial) or AL no. and program name (Federal) 93.575 – CCDF Cluster Planned Corrective Action Child Care Services has continually inspected child care programs for compliance with health and safety requirements according to the Oklahoma Child Care Facilities Licensing Act and Oklahoma Administrative Code. Our inspection monitoring checklist that was used for a significant part of the time this was audited contained health inspection as a work step, but the checklist did not require the worker to specifically mark it as performed. The checklist did specifically state that the worker performed all steps and only exceptions would be further documented. The Oklahoma State Auditor and Inspectors took the position that our process did not provide enough assurance for them to validate that health inspections were performed, and they wanted a specific tick mark on the inspection. We do not agree on this point as one additional tick mark on a form does not provide any more assurance than the employee’s signature stating that all of the steps were performed. We did however agree to change the form to resolve this issue with the auditors. As previously stated in our 2022 audit findings, Child Care Services is aware this would be a repeat due to the audit timeframe including monitoring inspections that were prior to our form update. On January 30th, 2023; Child Care Services implemented the “Go-Live” phase of updating the monitoring checklists and summaries to include visual verification that all health and safety requirements are observed during inspections. Licensing specialists indicate on each health and safety item; compliance, noncompliance, or not reviewed while completing inspections. Quality review audits are also being conducted annually with each supervisory group in Child Care Services to address errors or inconsistencies when monitoring child care programs. Child Care Services professional development unit has included a new training module regarding documentation requirements. Anticipated Completion Date January 30, 2023 Responsible Contact Person Dione Smith

Finding: 2023-003 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Labor Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Finding Summary: Iowa Workforce Development did not formally communicate subrecipient monitoring requirements to the County. Consequently, the County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Responsible Individuals: Dana Aschenbrenner, Finance Director Corrective Action Plan: This finding is due in part to the fiscal agent agreement with Iowa Workforce Development which does not state that subrecipient monitoring has to be done. Recently, Iowa Workforce Development received a finding from the Department of Labor stating that the fiscal agent agreements improperly place the liability of disallowed costs off on the fiscal agent. This was incorrect, the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement and no longer continue to be the fiscal agent as of June 30, 2023. Anticipated Completion Date: Ongoing

Management concurs with the finding and recommendation. Management will work to ensure proper policies and procedures are established and followed to ensure future reporting under the appropriate guidance by June 30, 2025.

The Department of Behavioral Health (DBH) agrees with the findings. The 425 reports will be reviewed by both the Accounting Supervisor and the Accounting Officer prior to entering in the Payment and Management System (PMS) and will appropriately be signed by either one of the two. Documentation from PMS will provide a history of the approval flow. Accountants will not have the authority to certify the reports in PMS. The HSSC Comptroller, the Accounting Manager, the AFO and the Budget Staff will perform a detailed review and walk through of the SEFA to confirm the expenditures are correctly categorized by fund and grant, and appropriately identify expenditures for subrecipients, if applicable. Additionally, DBH is working with OCP (Office of Contracting and Procurement), to attach to DC Health’s contract to implement a grants management system that is on the Salesforce platform. The system will automate workflow and enable “alerts” to notify users when reports are due. If the notification is not acted on, the system will automatically escalate the alert to senior management. In the interim, DBH is working through the Districts Grants Management Advisory Board to identify DIFS reports (e.g., DIFS report for FFATA, Subrecipient Grant Report R071). To note, all programmatic data that was used for the PPR was available to the auditors. The supporting documentation for the chart that included spending for administrative and data costs had not been saved, which was the source of the finding. Contact - FAPIIS and FFATA: Renee Evans Jackman, Director of Grants Management, FFR (SF-425) and SEFA: Barbara Roberson, HSSC Accounting Officer, PPR: Sharon Hunt, State Opioid Treatment Authority Estimated Completion Date - Grants Management System is due to be implemented on January 1, 2025. See Corrective Action Plan for chart/table

During the 2022-23 fiscal year, Ha:San had employee turnover in several key management positions and, unfortunately, the 2023 management team was not aware of all charter school finance compliance requirements which resulted in the findings noted in the single audit report. Ha:San has hired a new management team for the 2023-24 fiscal year who are knowledgeable of charter school finance and compliance requirements and are predicting no repeat findings in the 2023-24 audit. Ha:San and subsidiary will obtain contracts and employment agreements with all staff. Further, a records retention policy will be enforced. Finally, timecards with sufficient detail of federal project participation will have documented approval by the appropriate level of management throughout the year.

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

We will review processes uon termination to ensure all necessary documentation is maintained.

Views of Responsible Officials and Corrective Action: Us Helping Us acknowledges the audit finding based on fiscal year 2022, and not subsequent years, regarding missing supporting documentation for certain cash receipts. The organization understands the importance of maintaining complete and accurate records to ensure financial transparency, accountability, and compliance with applicable regulations. Us Helping Us has developed the proper systems to ensure proper filing and maintenance of documentation supporting various expenditures.Of note, Us Helping Us has developed a process to track income receipts from various sources, including donors, and will be able to verify any donor mandated restrictions, and that contributions conform to said donors/payees. The organization uses a cloud-based accounting system and donor software that allows for attaching documentation directly to transactions. Us Helping Us has made progress in implementing systems for documentation, and as with expenses, documentation will be maintained electronically on the organization’s server, in the financial software used and filed in the Fiscal Manager’s office. All relevant staff will be trained on proper documentation procedures and the importance of retaining records for audit and compliance purposes. Further, financial policies will be updated to include a checklist of required documentation for all cash receipts, procedures for handling and documenting missing receipts an retention schedule aligned with IRS and GAAP requirements (minimum of three years after filing Form 990). Us Helping Us is committed to maintaining accurate and complete financial records. The Executive Director and the Deputy Executive Director for Finance and Administration are responsible for any developing, implementing, and maintaining the Plan, which is currently in place and any enhancements will be effective immediately.

Views of Responsible Officials and Corrective Action: Us Helping Us acknowledges the audit finding regarding missing supporting documentation for certain expenses, takes this matter seriously and is committed to ensuring full compliance with applicable accounting standards and Federal regulations. Noting that the findings are based on the 2022 fiscal year, since then the organization has developed the proper systems to ensure proper filing and maintenance of documentation supporting various expenditures. The organization has adopted several cloud-based accounting systems, specifically Quickbooks, Bill.com, and Google Drive, with integrated document management to ensure all expense records are stored and easily retrievable, in addition to maintaining physical files for applicable (non-online, virtual) expenses. In this regard, copies of contracts are maintained electronically on the organization’s server, in the financial software used and filed in the Fiscal Manager’s office.In addition, Us Helping Us maintains the appropriate internal controls to ensure that the appropriate documentation for general expenditures is maintained. Emphasis has been placed on strengthening current internal controls by requiring dual review of all expense submissions and enforcing a checklist for required documentation. All relevant staff undergo training on non-profit accounting standards, documentation protocols, and compliance requirements. Us Helping Us’ financial policies will include: Clear guidelines on acceptable documentation for expenses; Procedures for handling lost or missing records; and a retention schedule aligned with Federal requirements (e.g., Title 2 CFR § 200.333). Us Helping us is committed to maintaining transparency and accountability in all financial operations. The Executive Director and the Deputy Executive Director for Finance and Administration are responsible for developing, implementing, and maintaining the Plan, which has been implemented.

2022 – 005: Reporting (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory. Without these reports, we were unable to perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly so this should take care of this issue. Management has worked on procedures and training to assure financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory are completed.

2022 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide sufficient documentation to support compliance with federal procurement and suspension and debarment requirements for purchases made under the Title V program. The general ledger did not allow for sufficient identification of transactions related to the Title V program as all expenditures were recorded through journal entries without supporting transaction-level detail. Due to this limitation, we were unable to select procurement transactions for testing or verify whether vendors had been screened for suspension and debarment before contracts were awarded. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software uused,and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. The following are updated procedures that are now in place. All purchases must come with a purchase order request and be signed by the supervisor prior to purchase. All purchases over $1000 must be CEO approved too. All purchases over $5000 must have 3 bids and be Board approved. All purchase orders must be completed completely in all fields to know what grant/funding source is covering the cost for draw downs. Anyone who uses the SDUIH credit cards must sign a credit card statement

2022 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly.