Corrective Action Plans

2023 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-004 and 2022-004) 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 used, 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 $1,000 must be CEO approved too. All purchases over $5,000 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. Vendor suspension and debarment status will be verified and documented prior to awarding federally funded contracts.

2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) 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. Management is strengthening documentation and recordkeeping procedures to ensure compliance with federal record retention requirements, including improved tracking of Title V expenditures and retention of transaction-level support.

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.

Recommendations: Management should enhance its internal control procedures to ensure all disbursements and payroll transactions charged to the federal program are supported by complete and properly approved documentation consistent with 2 CFR Part 200 and the operating contract. This includes retaining invoices, approvals, check copies, personnel files, and pay-rate authorizations. Management should assign clear responsibility for recordkeeping, implement periodic reviews for completeness, and provide staff training on documentation and retention expectations. Views of responsible officials and planned corrective actions: Management agrees with the findings and will ensure that all original supporting documents are maintained at the organization’s office in a secure location for a minimum of three years after an independent audit, and that every transaction is properly authorized and documented before expending monetary resources. Anticipated Completion Date: May 1, 2024

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.

Views of Responsible Officials and Planned Corrective Actions: Management agrees that improvement is necessary with respect to reconciliation and documentation of credit card expenses. Management is in the process of updated their process surrounding credit cards.

Epidemiology and Laboratory Capacity for Infectious Diseases Cash Management Significant Deficiency in Internal Control over Compliance For the audited period and until August 2023, the procedure of the program and the Department of Health was "advanced" and was as follows: 1. The Epidemiology program worked with the validation of the voucher and recovered the director's signature for the punch of the "certificate". Once the validation and signature were in place, the cash request was processed. Once the cash request was remitted or the credit notice was registered, the receipt was delivered to the Tax Intervention area. 2. The Fiscal Intervention area works on the approval of the payment on the vouchers. Vouchers were worked on a first-come, first-served basis. This intervention process can take a week or more. The program had no control over the timing of payment approvals. This created a weakness when it came to cash management compliance. The program did confirm that the money was available at the time the payment was approved but had no control over the date the payment was approved. However, due to the nature of our funds and the volume of invoices, the Treasury Department asked us to change the modality for terms of cash requests from "advanced" to reimbursement. This began to be implemented as of September 2023. This method of reimbursement makes it easier for the program to have better control over cash management. With this method, the program requests the funds on the days that the Treasury Department makes the payment rolls. Once the petition is created on the same day of the print run and approved by the Program Director, it is submitted to the Office of Federal Affairs to prepare the request for funds to the federal government. The Office of Federal Affairs has the flexibility and agility to process such a request within two days. This helps us to meet the requirements of cash management.

2022-005 Significant Deficiency in Controls over Compliance: Administrative Requirements of Uniform Guidance-Administrative Policies The schools have documented their administrative policies effective 3/1/2023.

FINDING 2022-007 Contact Person Responsible for Corrective Action: Kristin Nass Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In addition to on-going training and support of the Director of Grants/Programs who oversees Title I, a comprehensive checklist which includes required documentation and actions (including the verified data from non-pub school) is being developed and will be implemented in the spring of 2023. Checklist completion and reviewed data will be signed off by the CFO. Anticipated Completion Date: May 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 67 Description of Corrective Action Plan: Additional training related to grant budgets entered into and monitored within the financial software will occur, as will the new practice of having the program directors initiating monthly reimbursement requests informed by the accurate reports from the software (ledger), with documented review by the Treasurer or CFO. Additional training over the reporting requirements is taking place with the Treasurer, CFO and Directors overseeing federal funds provide accurate reporting. Anticipated Completion Date: June 2023

FINDING 2022-005 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: May 2023

FINDING 2022-011 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Additional training related to grant budgets entered into and monitored within the financial software will occur, as will the new practice of having the program directors initiating monthly reimbursement requests informed by the accurate reports from the software (ledger), with documented review by the Treasurer or CFO. Additional training over the reporting requirements is taking place with the Treasurer, CFO and Directors overseeing federal funds provide accurate reporting. Anticipated Completion Date: June 2023

FINDING 2022-010 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: June 2023

Program: AL 21.026 ? COVID-19 Homeowner Assistance Fund ? Subrecipient Monitoring Corrective Action Plan: N/A Contact: Major General Daryl Bohac Anticipated Completion Date: N/A

FINDING 2022-003 Contact Person Responsible for Corrective Action: Teresa Stuckey, Director of Elementary Education and Title I Contact Phone Number: 812-462-4228 Views of Responsible Official: The School Corporation will implement effective processes to ensure that the Special Tests and Provisions ? Annual Report Card, High School Graduation Rate data is solicited and maintained for audit purposes. Description of Corrective Action Plan: The School Corporation will work to develop a more defined process that ensures compliance with procedures that were established, but have not always followed, to ensure that the Special Tests and Provisions ? Annual Report Card, High School Graduation Rate compliance requirement is met. Specific employees will be placed in charge of obtaining documentation from students leaving the district and others will be asked to review and approve the documentation. If documentation is not successfully garnered from parents, schools will maintain records indicating the school?s efforts to solicit the correct documentation from parents. Anticipated Completion Date: Immediately.