Corrective Action Plans

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

Strengthen record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implement procedures to maintain institutional knowledge during employee turnover, including documented policies, cross-training, centralized recordkeeping, and formal transition protocols by March 31, 2026. Consider extending retention periods for documents supporting high-risk federal programs or key internal control activities beyond minimum requirements by April 30, 2026. Establish a centralized electronic filing system with version control and backup procedures for all federal award documentation by May 31, 2026. Create detailed internal control documentation templates and ensure all control activities are evidenced in writing by June 30, 2026.

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

Corrective Action: Snohomish County Food Bank Coalition will implement a formal document retention policy to ensure source documents are retained in accordance with the requirements of the Uniform Guidance. Anticipated Completion Date: December 31, 2025

Condition: The District has not retained transaction support for all expenditures related to federal programs. Auditor substantively tested 29 expenditures across all major programs noting that 10 items did not have proper supporting documentation. Criteria: 2 CFR 200.334. Cause of Condition: Records retention procedures were not sufficient to ensure fiscal year 2022 transactions were retained through October 2025. Effect of Condition: Records supporting expenditures of federal awards were not located. Consequently, the auditors could not adequately test these items. Questioned Cost: $ 35,017.55 Recommendation: Draft and adopt policies and procedures to ensure compliance with record retention requirements. Corrective Action Plan: The District will adopt updated record retention policies. Procedures will require all supporting documentation for federal expenditures to be retained for a minimum of five years after final closeout, in both electronic and hard-copy form. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 01/31/2026

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.

FINDING 2022-005Contact Person Responsible for Corrective Action: Lynn Leininger, Business ManagerContact Phone Number: (260) 367-3677Whitko Community Schools concurs with the finding and will implement internal controls for all grantrequirements and reporting compliances of the Education Stabilization Funds. All reporting will be a jointeffort between the Business Manager preparing the reports with the assistance of the business officepersonnel. Supporting paperwork and calculations will be maintained to support all report informationsubmitted. Prior to submission of Education Stabilization Funds, all information will be reviewed andsigned by the Deputy Treasurer to insure reporting compliance.The completion date for this corrective action will be May1, 2023.INDIANA STATE

FINDING 2022-005Contact Person Responsible for Corrective Action: William LutherContact Phone Number: (812) 330-7700Views of Responsible Official: We concur with this finding. This finding has been remediated as of the completion dateshown below.Description of Corrective Action Plan:All Education Stabilization Funds applicable to the reporting in this finding have been expended as of the completion datebelow. We will continue to submit all future Education Stabilization Funds annual reports with evidence to support thesubmission.Completion Date: September 30, 2022

FINDING 2022-010Subject: COVID -19 - Education Stabilization Funding - ReportingFederal Agency: Department of EducationFederal Program: Education Stabilization FundAssistance Listings Numbers: 84.425D, 84.425UFederal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013,S425U200013Pass-Through Entity: Indiana Department of EducationCompliance Requirement: ReportingAudit Findings: Material Weakness, Modified OpinionContact Person Responsible for Corrective Action: Chad Yencer, SuperintendentContact Phone Number: 76+5-348-7550Views of Responsible Official: We concur with this findingDescription of Corrective Action Plan:Internal Control:1. The grants specialist/data specialist will compile the information for state reporting in the ESSER grants.The grants specialist will maintain documentation to support the data being presented.2. The corporation treasure will review all compiled financial data for the reporting period and verify it foraccuracy prior to submitting to the superintendent.3. The Superintendent will review the information, supporting documentation and verify accuracy prior tosubmitting to the IDOE reporting.Anticipated Completion Date: July 2023

FINDING 2022-002Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensurereporting compliance requirements are met. The corporation will assure one individual is completing the reports andanother is verify the reports.Anticipated Date of Completion: March 2023

Name of Contact Person: Sue Nickerson, Town Accountant

Corrective Action Plan: The District has had turnover of personnel in the Business Office this past fiscal year. As the new Director of Business and Finance there will be procedures implemented to ensure that sufficient documentation for transactions for costs charged to federal programs is supported by documentation as required by the Uniform Guidance regulations. Additionally, there will be a review of current purchasing policies, to add or amend, which will further help support meeting the federal guidelines. Lastly, it should be noted that the Town/School financial system will be converting/upgrading to MUNIS ERP Solution for the Public Sector. This upgrade will be very instrumental in maintaining the necessary information to meet audit requirements.

Proposed Completion Date: Immediately

The Settlement agrees with the finding. The Assistant Controller prepares the form SF-425 reports and the Controller reviews and approves them for submission. These forms and supporting documentation are saved and retained in SharePoint. SF-425 due date reminders are posted in preparer’s calendar and adherence to the due dates is monitored by the Controller. Implementation began July 2022. Responsible parties: Assistant Controllers, Controller Completion date: 7/1/2022

The Settlement agrees with the finding. Fiscal and program staff will update CACFP Policies and Procedures to ensure that all CACFP records are retained for a minimum of three years. CACFP eligibility will be clearly documented and retained for three years by program staff. Fiscal and program staff will update CACFP Policies and Procedures to reflect subrecipient eligibility and related paperwork. Staff will be trained on completing and maintaining CACFP enrollment and eligibility paperwork via CACFP online workshops. Managers will complete management KidKare training to optimize electronic record-keeping of CACP documentation. The Compliance Director will complete an unannounced monitoring review of enrollment paperwork quarterly. Policies and Procedures will be edited to reflect rules and regulations for enrollment and eligibility paperwork. Implementation began October 2023. Responsible parties: Fiscal and Program staff, Compliance Director Completion date: 10/1/2023

The University concurs with the finding. The SNAP-Ed office experienced significant staff turnover during fiscal year 2022, and records could not be located. The University has established workflows and policies to ensure compliance and documentation currently and in the future.

The University concurs with the finding and has taken proactive measures to ensure compliance. Specifically, the University has established a digital folder dedicated to maintaining all records pertaining to HEERF funding and lost revenue calculations.