Corrective Action Plans

FINDING 2023-004 Finding Subject: COVID 19 - Education Stabilization Fund - Reporting Summary of Finding: The School Corporation failed, due to the lack of internal controls, to ensure that the ESSER annual data reports were complete and accurate prior to submission and that the reports had sufficient oversight to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Carla Gambill Contact Phone Number and Email Address: 812-847-6020 ext. 1004 cgambill@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Director of School Finance will prepare the annual data reports to be reported to the IDOE by using records that accumulate or summarize the data. Prior to the submission of the reports, the Superintendent, or his or her designee, will review the records and annual data report. The Director of School Finance and the Superintendent, or his or her designee, will initial and date a hard copy of the report to ensure accuracy and completeness. Anticipated Completion Date: This Corrective Action Plan will be put in effect April 2024 or when the next annual data reports are prepared.

FINDING 2023-003 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. The October 1st Real Time Report of Pupil Enrollment (PE) was used by the Indiana Department of Education to pull data into the Title I application. These numbers were then used to calculate Percent Poverty which was used to rank schools for Title I eligibility. One person was primarily responsible for compiling and uploading student data, including poverty status for Real Time reports. There was no additional review or verification being done to ensure that the numbers being pre-populated on the grant applications were correct. There was no internal control in place, such as an oversight, review or approval process to ensure eligibility was properly determined. The Indiana Department of Education (IDOE) used the October 1 Real Time reports for fiscal years 2020- 2021 and 2021-2022, as provided by the School Corporation, to determine Title I Eligibility for the 2021- 2022 and 2022-2023 grant programs, respectively. There was no October 1 Real Time report presented for audit for fiscal year 2021-2022, which would have been used to pull in enrollment and poverty information for the 2022-2023 grant. Therefore, we were unable to verify if the amounts reported in the grant application were correct. Additionally, we were unable to verify if the correct socioeconomic status was properly reported for any of the students. Contact Person Responsible for Corrective Action: Nancy Schroeder Contact Phone Number and Email Address: 765-932-3901 schroedern@rushville.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: Eligibility – The Technology Director, Brevin Runnebohm will supply the Title I director with the official October 1 count each school year. This will be retained for audit and will be used by the Grant Coordinator, Nancy Schroeder, to determine the enrollment numbers in the Title I application have INDIANA STATE BOARD OF ACCOUNTS 45 been prepopulated correctly. The Grant Coordinator will sign off that she has reviewed this information and find it accurate. Anticipated Completion Date: 10/2024

FINDING 2023-005 Finding Subject:􀀃Title􀀃I􀀃Grants􀀃to􀀃Local􀀃Educational􀀃Agencies􀀃–􀀃Reporting􀀃 Summary of Finding: An􀀃effective􀀃internal􀀃control􀀃system􀀃was􀀃not􀀃in􀀃place􀀃at􀀃the􀀃School􀀃Corporation􀀃to􀀃ensure􀀃compliance􀀃with􀀃 requirements􀀃related􀀃to􀀃the􀀃grant􀀃agreement􀀃and􀀃the􀀃Reporting􀀃requirement.􀀃The􀀃School􀀃Corporation􀀃did􀀃not􀀃have􀀃 effective􀀃internal􀀃controls􀀃to􀀃ensure􀀃that􀀃reimbursement􀀃requests􀀃or􀀃final􀀃expenditure􀀃reports􀀃were􀀃properly􀀃 supported􀀃with􀀃documentation.􀀃 Contact Person Responsible for Corrective Action: Lela Simmons Contact Phone Number and Email Address: (219) 391- 4100, lesimmons@ecps.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls and policies will be put in place to ensure all Title cash request will have three approvals before submitting the request to the State. The Federal clerk will prepare the request, the federal director we do second approval. The CFO will do final approval after review all documentation associated with the cash request. All will sign document. All title state reporting and back up documentation will be reviewed by the CFO and signed. Anticipated Completion Date:􀀃We􀀃anticipate􀀃having􀀃the􀀃above􀀃corrective􀀃action􀀃plan􀀃in􀀃place􀀃by􀀃September 30, 2024.

FINDING 2023-005 Information on the federal program: Subject: Special Education Cluster (IDEA) - Reporting Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 19611-022-PN01, 20611-022-PN01, 21611-022-PN01, 22611-022-PN01, 22611-022-ARP, 23611-022-PN01, 20619-022-PN01, 21619-022-PN01, 22619-022-PN01, 22619-022-ARP, 23619-022-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness, Qualified Opinion Condition: The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the reporting requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that requests for reimbursement were submitted accurately and agreed to supporting documentation. There was a documented oversight, review, and approval process in place; however, the Cooperative did not adequately ensure that proper procedures were followed. Context: The School Corporation is a member of the Greene-Sullivan Special Education Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members.  As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Reporting compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the reporting requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that requests for reimbursement were submitted accurately and agreed to supporting documentation. There was a documented oversight, review, and approval process in place; however, the Cooperative did not adequately ensure that proper procedures were followed. For fiscal year 2022, 51 Reimbursement Reports were tested. 14 Reimbursement Reports could not be traced to unit ledgers for expenditures, and 21 Reports did not have appropriate supporting documentation. For fiscal year 2023, 23 Reimbursement Reports were tested. Three Reimbursements Report did not agree to supporting documentation, and key line items could not be verified. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action: 1 – Greene Sullivan Special Education Cooperative will implement a procedure that includes the requirement of proper documentation for all reimbursement requests, such as the detailed history report for each request submitted. The Director will then review each request prior to submission. Responsible party and timeline for completion: Chris Stitzle, Superintendent – April 1, 2024

Corrective action plan: In December 2021, HHSC implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Medicaid provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in Medicaid. Of the Medicaid providers requested during the fiscal year 2023 Statewide Single Audit, 47 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to Medicaid long-term care (LTC) providers whose enrollment and/or revalidation have not yet been processed through PEMS. The LTC enrollment and revalidation process mirrors the sampled acute care providers which were found to be 100 percent compliant during this review, further supporting that the process is working. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the PHE, the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all LTC providers is January 2027. HHSC continues efforts to enroll LTC providers through PEMS and expects to eliminate errors related to these documents once all LTC providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, LTC provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

Corrective action plan: In December 2021, the Texas Health and Human Services Commission (HHSC) implemented the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment Management System (PEMS), an automated system that is the single tool for provider enrollment, re-enrollment, revalidation, and maintenance requests (maintaining and updating provider enrollment record information). Children’s Health Insurance Program (CHIP) provider enrollment, revalidation, and re-enrollment documentation, including risk-based screenings, are tracked in PEMS. Additionally, the relevant federal databases are checked at least monthly for all providers currently enrolled in CHIP. Of the CHIP providers requested during the fiscal year 2023 Statewide Single Audit, 59 of 60 samples had been enrolled or revalidated through PEMS and the auditor received all requested documentation. The listed exceptions only apply to one CHIP provider. The provider enrolled with CHIP before the implementation of PEMS. HHSC operated under the public health emergency (PHE) between March 30, 2020, and May 11, 2023. In response to the public health emergency (PHE), the Centers for Medicare and Medicaid Services waived exclusion check requirements for provider reenrollments and revalidations. HHSC is in the process of revalidating providers through PEMS; however, as a result of the PHE end date and provider revalidation requirements, the projected completion date for the required revalidation of all CHIP providers is January 2027. HHSC continues efforts to enroll CHIP providers through PEMS and expects to eliminate errors related to these documents once all CHIP providers have revalidated. Implementation dates: December 2021, PEMS implementation January 2027, provider enrollment and revalidation completed Responsible persons: Jordan Nichols, Deputy Associate Commissioner, Medicaid and CHIP Services Operations Management

Corrective action plan: The HHSC Federal Funds Office will work with HHSC Accounting, Department of Family and Protective Services (DFPS), and Texas Workforce Commission (TWC) to strengthen oversight of the Social Services Block Grant (SSBG) post-expenditure report. As part of this oversight, HHSC will compile procedure documents, methodologies, data sources, and work documents from DFPS and TWC. The HHSC Federal Funds Office already has this documentation for HHSC. Implementation date: August 31, 2024 Responsible person: Racheal Kane, Director, Federal Funds

Corrective action plan: The Provider Finance Department (PFD) will take proactive measures to establish and enforce guidelines that guarantee documentation is retained for a minimum of three years from the date of submission of the final expenditure report for each grant. This approach aligns with our dedication to transparency, accountability, and responsible grant management. We will ensure that all the documentation is saved within our documentation repository for a minimum of three years from the date of submission. Implementation date: June 1, 2024 Responsible person: Stacy Kerns – Director, Business Operations and Support Services

FINDING 2023-007 Information on the federal program: Subject: Special Education Cluster (IDEA) - Reporting Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers: 19611-022-PN01, 20611-022-PN01, 21611-022-PN01, 22611-022-PN01, 22611-022-ARP, 23611-022-PN01, 20619-022-PN01, 21619-022-PN01, 22619-022-PN01, 22619-022-ARP, 23619-022-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness, Qualified Opinion Condition: The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the reporting requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that requests for reimbursement were submitted accurately and agreed to supporting documentation. There was a documented oversight, review, and approval process in place; however, the Cooperative did not adequately ensure that proper procedures were followed. Context: The School Corporation is a member of the Greene-Sullivan Special Education Cooperative (Cooperative). During fiscal year 2021-2022, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Reporting compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the reporting requirements. The Cooperative had not designed or implemented adequate policies or procedures to determine that requests for reimbursement were submitted accurately and agreed to supporting documentation. There was a documented oversight, review, and approval process in place; however, the Cooperative did not adequately ensure that proper procedures were followed. For fiscal year 2022, 51 Reimbursement Reports were tested. 14 Reimbursement Reports could not be traced to unit ledgers for expenditures, and 21 Reports did not have appropriate supporting documentation. For fiscal year 2023, 23 Reimbursement Reports were tested. Three Reimbursements Report did not agree to supporting documentation, and key line items could not be verified. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will take the following corrective action: 1 – Greene Sullivan Special Education Cooperative will implement a procedure that includes the requirement of proper documentation for all reimbursement requests, such as the detailed history report for each request submitted. The Director will then review each request prior to submission. Responsible party and timeline for completion: Mark A Baker, Superintendent Effective April 2024

FINDING 2023-006 Finding Subject: COVID-19 Education Stabilization Fund – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have effective internal controls over the ESSER funds and there was noncompliance in regards to the ESSER funds. Employee pay did not equal what transferred and supporting documentation for substitute pay and payment of sick days when school was closed. Contact Person Responsible for Corrective Action: Jamesi Lemon and Melanie Summers Contact Phone Number and Email Address: (260) 499-2400; jlemon@lakelandlakers.net/msummers@lakelandlakers.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 30 A spreadsheet has been created to track the substitutes and the classes they are covering. Pay scales are also now included in the employee handbooks, so pay can be calculated correctly and tracked. Any transfers of payroll expenses are now completed monthly to ensure the correct amounts are being charged to the ESSER funds. Anticipated Completion Date: Immediately

Checklists used during file review will be maintained in each client file. Checklists are available on Lane County's website under provider tools. When program ends, staff will store files in bankers boxes labeled by program, fiscal year and destruction date based on program requirements.

FINDING 2023-003 Finding Subject: COVID-19 - Education Stabilization Fund – Special Tests and Provisions – Wage Rate Requirements Summary of Finding: Weekly payroll reports were not reviewed by the unit for compliance with Davis-Bacon Act Contact Person Responsible for Corrective Action: Todd Nobbe Contact Phone Number: 812-934-2194 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will request and review weekly wage reports for all Davis-Bacon Act projects. Documents will be review and signed off by the Director of Operation and kept for audit. Completion Date: Immediately 2/26/2024

FINDING 2023-005 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. 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 the Assistant Superintendent and reviewed by the Treasurer prior to submission. However, this review process was not effective and did not detect and allow correction of errors prior to submission. All six of the submitted reports were selected for testing. Four of the reports were not supported by the unit's records. The financial information provided did not agree to the data submitted in the reports; therefore, we could not determine the accuracy of the reports. The lack of controls was systematic throughout the audit period. The noncompliance was isolated to the four reports identified above. The auditors recommended that management of the School Corporation establish a proper system of internal controls and develop policies and procedures to ensure reports are supported by the ledgers or reports used to complete the report Contact Person Responsible for Corrective Action: Rolland Abraham Contact Phone Number and Email Address: 765-584-1401, rabraham@randolphcentral.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation is required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted includes, but is not limited to, current period expenditures, prior period expenditures, and expenditures per activity. The annual data reports will be complied/prepared by the Treasurer and the Assistant Superintendent to ensure the reports are supported by the corporation’s financial data. The JotForm will be reviewed by the Superintendent prior to submission. Anticipated Completion Date: 2/21/2024

Finding 2023‐002 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. The School Corporation submitted two reports during the audit period; however, a single employee prepared and submitted the reports without evidence of a review or oversight process in place to prevent or detect and correct errors for the first report submission. Additionally, for the ESSER I Year 2 reporting, the ‘Total Mandatory Subgrant Amount Expended in Current Reporting Period’ was not supported by the School Corporation's records. Actual expenditures from a provided report did not agree to the amount submitted for the Annual Performance Reporting. The key line item ‘Total Mandatory Subgrant Amount Expended in Current Reporting Period’ for the ESSER I Year 2 report was determined to be overstated by $80,342. Contact Person Responsible for Corrective Action: Whitney Kuszmaul, District Treasurer & Tiffany Grant, Grant Coordinator Contact Phone Number and Email Address: (765) 342‐6641 Whitney.Kuszmaul@msdmartinsville.org & Tiffany.Grant@msdmartinsville.org Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Grant Coordinator works to collect the data from a couple different sources. The staff report information comes from our Payroll/HR department, the CE information comes from our Reporting Specialist and the financial data comes from District Treasurer. The Grant Coordinator requests a detailed report for the appropriate period and break down the detailed report by project/report categories. All of this information is then recorded in the DOE data sheet and is reviewed and tied back to the detailed reports provided by the District Treasurer. After review, the Grant Coordinator and the District Treasurer initial/sign off on the DOE data sheets. The Jot Form confirmation is retained with the DOE data sheets and supporting reports/documentation. Anticipated Completion Date: February 2024

Finding 2023‐001 Finding Subject: COVID‐19 ‐ Education Stabilization Fund ‐ Allowable Costs/Cost Principles Summary of Finding: The School Corporation paid security contractors without an invoice. Costs charged to grant funds must be adequately documented. The School Corporation had an accounts payable voucher signed by the contractor, but there was no invoice supporting the accounts payable voucher. Costs charged to grant funds must be adequately supported with documentation. Contact Person Responsible for Corrective Action: Tiffany Grant, Grant Coordinator Contact Phone Number and Email Address: 765‐342‐6641 ‐ Tiffany.Grant@msdmartinsville.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A contract is on file with the Martinsville City Police Department for the contracted police officers that work for the MSD of Martinsville. Going forward, contracted police officers will submit their timesheets directly to the MSD of Martinsville Assistant Police Chief. The Assistant Police Chief will verify hours worked and submitted to the schedule. The Assistant Police Chief will review and initial/sign the vouchers before submitting those to the Grant Coordinator for review and signature. Anticipated Completion Date: February 2024

FINDING 2023-002 Finding Subject: COVID-19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. 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 the Assistant Superintendent without an oversight or review process in place to prevent, or detect and correct, errors. Furthermore, the reported data on two of the reports could not be traced back to records that accumulate or summarize the data; therefore, the accuracy and completeness of the reports could not be verified. Contact Person Responsible for Corrective Action: Jim Diagostino, Superintendent, and Lori Bennett, Treasurer Contact Phone Number: 317-539-9200 Views of Responsible Officials: We agree with the finding. Description of Corrective Action Plan: The Superintendent, or designee, will prepare the annual data reports to be reported to the IDOE by using records that accumulate or summarize the data. Prior to the submission of the reports, the Treasurer will review the records and annual data report. The Treasurer will initial and date a hard copy of the report to ensure accuracy and completeness. Anticipated Completion Date: March 31, 2024

Recommendation: One City Schools, Inc. should design and implement appropriate internal controls for retaining support for claims in accordance with federal requireents. Action Taken: One City Schools has developed a new process to document meal counts per month, attendance and enrollment numbers per month, submission of claims, and the signature of a designated second approver, the COO. As each claim is made, the associated backup documentation will be presented to the second approver for their review and signature. Once approved, the entire packet of information will be retained. This process was initiated in December 2023.OCS completed the second designated approver review retroactively for all claims in the months of July, September, October, and November 2023.

FINDING 2023-001 – DOCUMENT RETENTION – Significant Deficiency Planned correcive action: The School through the educational service provider agreement with Entrepreneurial Ventures in Education (EVE) will provide additional training to school staff that are responsible for maintaining records that identify the poverty levels of students enrolled. Additionally, EVE shall conduct an internal audit to ensure that documents are being collected and stored appropriately. Responsible officers: Lili Cruz-Gilbes, Regional Director of Compliance and State Reporting Estimated completion date: March 15, 2024

Finding No.: 2022-011 AL Program: 10.542 - Pandemic EBT Food Benefits (P-EBT) Area: Activities Allowed or Unallowed Questioned Costs: $-0- Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: CNMI NAP respectfully disagrees with this finding. The April 2022 Compliance Supplement referenced by the auditor states: Special Tests and Provisions. 1. Verification of Free and Reduced-Price Applications (NSLP) Compliance Requirements: By November 15th of each school year, the LEA (or state in certain cases) must verify the current free and reduced-price eligibility of households selected from a sample of applications that it has approved for free and reduced-price meals, unless the LEA is otherwise exempt from the verification requirement. The verification sample size is based on the total number of approved applications on file on October 1st. A state agency may, with FNS approval, assume from LEAs under its jurisdiction the responsibility for performing the verifications. If the LEA performs the verification function it must be in accordance with instructions provided by the state agency. The LEA must follow up on children whose eligibility status has changed as the result of verification activities to put them in the correct category. CNMI NAP response: The 2022 Compliance Supplement states that the LEA, in this instance, PSS, is responsible for verifying the current free and reduced-price eligibility of households unless the LEA is exempt from the verification requirement. PSS is not exempt from the verification requirement and the CNMI NAP has never given instructions to PSS for data collection as it is the PSS’ responsibility to supply the data to NAP for P-EBT. NAP’s role is to distribute the benefits only. Similar to the SUN Bucks (S-EBT) program, PSS furnishes the student listing to NAP, after which NAP distributes the benefits according to the listing provided by PSS. Proposed Completion Date: Ongoing

Reporting: The College agrees with the finding. To address the repeat finding, the College will implement a standardized reporting check list and a calendar utilizing its Asana Project Management tool to track and monitor all required federal and grant deadlines.

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developing and implementing formal time and effort reporting procedures to ensure that personnel costs charged to federal grants are supported by actual activity records and certified by employees on a regular basis. This will include the adoption of time distribution systems that comply with 2 CFR Part 200 Subpart E and the requirement for supervisory approval of time reports. Additionally, the Organization will revise its expenditure review and approval processes to require that all costs charged to federal programs are supported by appropriate documentation, including vendor invoices and receipts. Staff involved in grant management and accounting will receive training on federal cost principles, documentation requirements, and period of performance compliance. A document retention policy in accordance with 2 CFR 200.334 will also be established to ensure that all supporting documentation is maintained and readily available for audit and program oversight. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

Management agrees with and will implement the recommendation that processes be in place to review and confirm the completeness and accuracy of intake forms within the regulations while also considering the needs and choices of the program participants. These file completeness processes will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.