Corrective Action Plans

Finding: 2022-006: Significant Deficiency in Internal Controls over Compliance – Cash Management Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Corrective Action: Controller reviews and corrects billings received which includes backup by AR, then CFO reviews prior to submission to payment management system. Proposed Completion Date: 6/30/23

FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corrects reports received which includes backup by the Staff Accountant, then CFO reviews reports created by Controller prior to submission. Proposed Completion Date: 6/30/23

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expenditures will be fully supported and approved by staff before posting. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation had not properly designed or implemented a system of internal control, which, would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to the eligibility determination of a child receiving meals. Any child enrolled in a participating school or summer camp, who meets the applicable program’s definition of “child”, may receive meals under applicable programs. A child belonging to households meeting nationwide income eligibility requirements may receive meals at no charge or at a reduced price. Children that have been determined ineligible for free or reduced-price meals pay the fun price for their meals. A child’s eligibility for free and reduced-priced meals under a Child Nutrition Cluster program may be established by the submission of an annual application or statement which furnished such information as family income and family size. The School Corporation determines eligibility by comparing the data reported by the child’s household to published income eligibility guidelines. Annual eligibility determinations may also be based on the child’s household receiving benefits under SNAP, FDPIR, the Head Start Program, or, under most circumstances, the TANF program. A household may furnish documentation if its participation in one of those programs, or the School Corporation may obtaine the information directly from the State or local agency that administers those programs. Certain foster, runaway, homeless, and migrant children are categorically eligible for free school lunches and breakfasts. Direct Certified households do not need to complete an application. The School Corporation’s child nutrition program software company, Skyward, automatically imported the eligibility parameters into the system., There was no evidence of an oversight, review, or approval process to ensure that the eligibility parameters entered into the Skyward system were accurate and that eligibility statuses were being correctly determined. A Sample of students receiving free or reduced lunches as selected for testing. The following issues were noted with the first students tested: 1.) Six of the 14 students were determined to be processed at the incorrect eligibility. Errors noted were: a. Three students had an eligibility determination of free; however, their eligibility determination should have been reduced. b. One student had an eligibility determination of reduced; however, the eligibility determination should have been paid. c. Two students were determined to be reduced; however, their eligibility determination should have been free. 2.) One of the 14 students did not have a completed application on file; thus, a determination of eligibility could not be made. 3.) Two students were direct certified; however, the School Corporation did not retain the monthly direct certification reports ran to support this determination, nor could the reports be recreated. Due to the number and magnitude of exceptions, per auditor judgement, we concluded it would not be appropriate to examine the remaining 26 students. The lack of internal controls and noncompliance were isolated to the 2022-2023 school year. We recommended that the School Corporation's management establish a proper system of internal controls and develop policies and procedures to ensure student eligibility for free or reduced price lunches is accurately determined and that all documentation is retained. Contact Person Responsible for Corrective Action: Contact Phone Number and Email Address: Stefanie Grandstaff, Director of Business Services stefanie.grandstaff@epulaski.k12.in.us Views of Responsible Officials: We concur with the finding . Description of Corrective Action Plan: The Food Service Director has been in contact with Skyward to find which reports can help with the Eligibility compliance requirements. The corporation has found a few more reports that can be of assistance with this finding. The Director of Business Services has also reached out to other Skyward users who use the food service module to ask for suggestions on what reports should be pulled and how to locate supporting documentation of students that received free or reduced-priced meals. At the end of each year when the corporation completes the roll-over process, all the reports are saved to a Google Drive folder. The Direct Certified Reports will be kept upon processing for future use and documentation purposes. An additional review of the applications will be performed to verify that the system is calculating properly. The Food Service Director and Director of Business Services are going to continue to reach out to other Skyward food service users and ask if any other reports should be saved, printed or kept for future audits. Anticipated Completion Date: Projected completion date of major tasks for the planned corrective actions is June 30, 2024

Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a document retention policy that is consistent with federal document retention requirements.

FINDING 2022-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: An effective internal control system was not designed, nor implemented at the School Corporation to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. The annual Elementary and Secondary School Emergency Relief (ESSER) Data Collection reports were complied, prepared and submitted by three different staff members; however, this process was not properly designed or implemented to prevent, or detect and correct, errors. The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For two of the three reports tested, the report was 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 their accuracy. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Matthew Miles, CFO Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improved record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: The School District will implement changes described in the Corrective Action Plan in February 2024.

FINDING 2022-007 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Summary of Finding: Finding: No oversight of reports and supporting documentation did not agrees to report submitted Recommendation: Provide oversight of reports submitted and retain supporting documentation that agrees to reports submitted Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Deb Martin, Director of Student Learning & Title I Contact Phone Number and Email Address: Kareemah Fowler (574) 393-6088; kfowler@sbcsc.k12.in.us Deb Martin (574) 393-6053; dmartin@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports and supporting documentation, which supports each report submitted, will be reviewed/approved by the program director. All supporting documentation will be retained for future audits. Anticipated Completion Date: December 8, 2024

FINDING 2022-006 Finding Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 3 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 3 employees. We provided sufficient alternate documents that would allow the State to validate the contract amount being paid, and whether the proper employees were paid from or should have been paid from the Education Stabilization Funds. The documents provided sufficient data to support the questioned cost of $26,207 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024

FINDING 2022-004 Finding Subject: Title I Grants to Local Educational Agencies - Reporting Summary of Finding: Finding: Detail data on the Form 9 and Reimbursement Request was not provided to knowledgeable individuals for review. Recommendation: Design control that provides sufficient data to knowledgeable individuals for review. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Form 9 Data The Human Resources Department has added a second review to verify all employee distribution codes are correct when recording/updating employee requisitions. Additionally, detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed December 8, 2023, and May 2023 Reimbursement Requests Summary level payroll data is no longer being used to support reimbursement requests. Detailed expense reports and payroll distribution reports that support each reimbursement request are being provided to knowledgeable employees to review. Anticipated Completion Date: Completed May 2023.

FINDING 2022-003 Finding Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Summary of Finding: Finding: Documentation for 10 employees was not available to verify the contract amounts. Recommendation: Documents be retained to support amounts paid. Contact Person Responsible for Corrective Action: Kareemah Fowler, Assistant Superintendent of Business and Finance Contact Phone Number and Email Address: (574) 393-6088; kfowler@sbcsc.k12.in.us Views of Responsible Officials: We disagree with the finding. Explanation and Reasons for Disagreement: While we agree that the single source document used by the State to validate a teacher’s contract was not available for 10 employees. We provided sufficient alternate documents that would allow the State to validate the contract's amount being paid, and whether the proper employees were paid from or should have been paid from the Title I funds. The documents provided sufficient data to support the questioned cost of $203,488 outlined in the finding. We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State for future audit. Description of Corrective Action Plan: We will be working with our software vendor to rectify the glitch that prevented us from providing the documentation requested by the State. Anticipated Completion Date: January 2024

In December 2022, the Office of Financial Aid strengthened its internal control over the reporting requirements for the Higher Education Emergency Relief Fund (HEERF), by adding the report due dates to the internal operational calendar. Additional level reviews were also added to the submission process before the required reports will be sent to the Department of Education and posted on the financial aid website.

Condition: Administrative costs are submitted to the state monthly for reimbursement on the Record of Expenditures under the TEFAP Financial Assistance form ("FD-32D"). The State reimburses the Organization for administrative costs as determined by the state on a monthly basis. Typically, the monthly reimbursement amount is significantly less than the actual amount of allowed administrative expenses incurred by the Organization. During our procedures, we noted that certain expenditures, amounting to approximately $3,290, which were included on the FD-32D of which supporting documentation the Organization is required to retain under 2 CFR part 200 was lacking. As such, we could verify these costs related to activities allowed for reimbursement under 2 CFR part 200. Views of Responsible Officials and Corrective Actions: We agree with the auditor's comments and the following action will be taken to improve this situation. The Finance and Administration Manager and the Director of Logistics, who prepare the FD-32D, will work together to ensure that all supporting documentation is retained for all allowable expenses monthly. The corrective actions will be implemented by July 1, 2023.

FINDING 2022-016 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: The approved grant budgets for all federal grants will be input into the financial management system and with all expenditures reported monthly from the Treasurer to the Director overseeing the federal grant for review and final approval. The Director shall be one of the approvers within the approval chain of federal grant funds the Director oversees. The Director shall be responsible for reviewing and utilizing actual expenditure reports to complete the annual reports, or any other reports, prior to another documented review by the Treasurer or CFO. All documentation related to the reports shall be maintained for future audit purposes. Anticipated Completion Date: April 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: Immunization Cooperative Agreements Federal Financial Assistance Listing Number: 93.268 Federal Grantor: U.S. Department of Health and Human Services Passed-Through: California Department of Public Health Award No. and Year: 17-10336 A02 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.334, Retention requirements for records, states that financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a federal award must be retained for a period of three years from the date of submission of the final expenditure report, or, for Federal awards that are renewed quarterly or annually, from the date of submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. Condition: During our testing of the HCA?s provisions for reporting requirements, we noted the following instances for two (2) out of two (2) reports: ? The performance reports were not reviewed or approved prior to submission to the State. ? The department did not retain any supporting documents for the performance reports. Cause: The HCA department personnel prepared program required performance reports and submitted to the State without retaining evidence that the reports were reviewed and approved by a separate individual prior to submission. The HCA department did not retain any supporting documents for the performance reports submitted. Effect: The County?s control was not consistently followed, which requires reports to be reviewed and approved by a separate individual prior to submission to the State. Additionally, the HCA department did not adhere to their policies and procedures in place requiring record retention of supporting documentation. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) performance reports were selected for report testing for the Immunization Cooperative Agreements program. Repeat Finding from Prior Years: No. Recommendation: We recommend the HCA adhere to their policies and ensure the review and approval of reports are clearly documented prior to the report?s submission and adhere to their policies of record retention of supporting documents for the performance reports submitted to the State. Management Response and Corrective Action: Health Care Agency: 1. Person Responsible: Joshua Jacobs, HCA Public Health Services - Communicable Disease Control Division Director 2. Corrective action plan: HCA Public Health Services Communicable Disease Control Division will ensure retention of proper documentation supporting the performance reports and substantiating the review/approval prior to report submission to the State for the Immunization Cooperative Agreement. 3. Anticipated Implementation date: March 27, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree to the accounting records. The annual reports prepared by the Corporation Treasurer will be provided to the Director of Learning who oversees the Elementary and Secondary School Emergency Relief (ESSER) grant to review and approve the amounts reported are accurate. After review and approval from the Director of Learning, the annual reports will be submitted by the Corporation Treasurer. Anticipated Completion Date: May 2023

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.

FINDING 2022-002 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 work with non-public schools to make sure that their enrollment is properly reported. Description of Corrective Action Plan: School Corporation personnel will work with non-public school representatives to secure accurate enrollment information and maintain the proper documentation for audit purposes. Additionally, enrollment data entered on the Title I application portal will be reviewed prior to submission to ensure that data entered agrees with supporting documentation. Anticipated Completion Date: During submission of the 23-24 Title I application.

Finding Number: 2022-002 Condition: The College did not retain underlying support related to the student emergency grants information reported by the College on the annual and quarterly basis. Planned Corrective Action: Support used for reporting will be retained for all future reports moving forward including the fourth quarter 2022 report and the 2022 annual report. Contact person responsible for corrective action: Tom Reynolds, Associate Vice President of Business Services and Deputy Treasurer Lakeland Community College Anticipated Completion Date: As soon as possible moving forward for future quarterly and annual reports starting 12/19/2022

FINDING 2020-002 Contact Person Responsible for Corrective Action: Shelly Harrison, Corporation Treasurer Contact Phone Number: 765-492-5102 Views of Responsible Official: We concur to the findings; however, while completing the ESSER Reports, some formatting errors of the provided spreadsheet created some questions by the North Vermillion officials prompting a clarification email to the DOE. Since the formatting errors were not addressed and all completed boxes on the North Vermillion ESSER Report spreadsheet turned green (indicating the correct amounts on the spreadsheet), the North Vermillion officials felt the ESSER report submitted was correct. Description of Corrective Action Plan: To correct the internal control issue, the Superintendent and Corporation Treasurer will work independently as well as collaboratively on the ESSER Reports. Prior to submitting any future report, the corporation officials will document their work by signing off and dating the report prior to submission to the DOE. To rectify the incorrect dollar amount on the Yearly ESSER Report Spreadsheet, the corporation treasurer and superintendent will work collaboratively to correct the amounts on either the ESSER I Year End Report and the ESSER II Year 2 and/or Year End Report. Anticipated Completion Date: Both the Internal Control and ESSER I corrective actions have been corrected, with the ESSER I Final Expenditure Report being completed and signed off on. The ESSER II corrective actions will be completed on the upcoming ESSER III Year End Report when that report is due.