Corrective Action Plans

FINDING 2023-010 Finding Subject: Education Stabilization Fund – Allowable Cost/Cost Principles Summary of Finding: To receive reimbursement for ESSER expenses paid, the School Corporation’s Treasurer completed a reimbursement request, and the Director of Curriculum reviewed it. The documentation attached to the reimbursement request; however, did not include the following items: 􀁸 For one teacher, the School Corporation did not provide a Board approved contract or Salary Ordinance showing the approval of this teacher's position as a part-time tutor at $50 per hour. There was only an offer letter to the teacher from the Director of Curriculum. 􀁸 For the purchase of equipment in the amount of $318,922, the School Corporation did not provide a contract instead only a PO with a quote and a letter with the School Board’s approval to purchase. Additionally, there was no indication in the board minutes that this purchase had been put out to bid to the suppliers. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When the Business Manager and Director of Curriculum review the reimbursement form each month, an additional check for contracts of all employees paid will be added. All procurement documentation, including contracts, will be added to the archived documentation for purchase orders. Anticipated Completion Date: March 31, 2024

FINDING 2023-004 Finding Subject: Child Nutrition Cluster – Allowable Costs/Cost Principles Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. The School Corporation paid $23,682 of administrative salaries that were allocated to the School Lunch fund based on fixed percentages. There was no supporting documentation to indicate how the percentages were determined or time records indicating time spent on the program by the applicable administrators. INDIANA STATE BOARD OF ACCOUNTS 40 􀀃 “Meeting􀀃students􀀃where􀀃they􀀃are􀀃and􀀃leading􀀃them􀀃forward…every􀀃student,􀀃every􀀃day”􀀃 Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently 50% of Pam Frost’s salary is paid from the Lunch Fund. A new internal control will be created to document that 50% of her time is spent on food service work and 50% of her time is spent as the ECA treasurer for the elementary school. Anticipated Completion Date: August 31, 2024

Plan: Contracts are reviewed and updated annually by the compliance officer. Anticipated Date of Completion: 4/28/2025 Name of Contact Persons: Michael Holmes Management Response: Due to the repeated extensions of certain government grants and contracts, there were delays in securing contract renewals with updated budget allocations. This issue has now been addressed with the completion and submission of revised budgets and grants.

Plan: BCPN confirms that indirect costs are calculated in accordance with government guidelines outlined in 2 CFR Part 200. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: Due to adopting to use a calendar year instead of a fiscal year, BCPN's indirect costs for FY24 will be reflected in the financial statements for the period ending June 30, 2024, rather than December 31, 2023. We confirm that the indirect costs are being billed and spent in compliance with the guidelines outlined in the government contract and there is no need for funds to be returned.

The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control process to monitor and review additional invoice samples from Branches after they have been processed and reviewed by Branch Program Technicians and Branch Auditors. Additionally, the DDSD Central Support Services Branch implemented a secondary audit process and created a new Auditor role to routinely sample additional Medical Evidence of Record (MER) and Consultative Examination (CE) contracts. Findings are provided to branches to reinforce accuracy and assure compliance. The DDSD, also transitioned from MIDAS to DCPS, which provides more sophisticated fiscal controls. To remediate any inaccuracies, DDSD’s centralized auditor will assess findings and develop an action plan to prevent erroneous invoices. The CDSS ensures that all necessary controls are in place to verify the accuracy and proper documentation of invoices. The CDSS concludes that the sample size of 15 MER cases does not provide sufficient audit evidence that controls are not operating effectively resulting in a calculated $54,398 in potential costs. However, CDSS agrees with the finding and is committed to the control and mitigation of risk related to the audit recommendation. Estimated Implementation Date: Implemented Contact: Bernice Stanfield, Fiscal and Procurement Section Chief Central Support Services Branch Disability Determination Service Division California Department of Social Services

The deficiency occurred due to such documentation not received or forwarded from former personnel, and perhaps inadequate training by former personnel on compliance requirements. Mana Maoli plans to facilitate increased training for all personnel using debit cards to increase competency and compliance under 2 CFR § 200.302(b)(3) and 2 CFR § 200.403(g). Prior to and during the course of the FY2023 audit, Mana Maoli has already taken steps to train our personnel before issuing debit cards to better ensure staff understand the importance of receipt retention. Staff training focuses on how to implement and comply with federal documentation retention policies. As our new training protocols continue to be implemented, we will monitor for more comprehensive receipt retention and approvals. Mana Maoli’s management will evaluate and monitor the training’s effectiveness in producing more timely receipt retention. The responsible persons for training staff are Ruth Faioso Leau, Finance Manager, and Erik Yoshimoto, Office Manager. We will assess, monitor, and verify ongoing compliance for the second half of FY2025 and will have the new training protocol fully implemented by the first half of FY2026. Each quarter, the Finance Director will review a sample of federal disbursements that supporting documentation is maintained. The results will be reported to senior management. In conclusion, we will be taking steps immediately to address the findings in the audit. If additional information is needed, please contact Ruth Faioso Leau, Finance Director at faioso@manamaoli.org or 808-753-8746.

Finding Number: 2023-006 Planned Corrective Action: The corrective action in 2023-005 will assist in providing accurate financial information when completing the Schedule of Expenditures of Federal Awards. Anticipated Completion Date: March 1, 2025 Responsible Contact Person: Ashley Miller

The Sheriff’s Department separated from the individual that handled the grant funding as of the first of 2025. We have worked diligently to get these reports correct as of December 31, 2024.

Views of Responsible Officials and Planned Corrective Actions: The Organization will update policy to ensure that all payments made in any form have appropriate documentation. Additionally, policy on review of invoices prior to payment will be reviewed by Executive Director and Business Manager. Monique Johnson, Executive Director of Allen County Drug & Alcohol Consortium, is responsible for this corrective action. The anticipated completion date is May 31, 2025.

Finding: 2023-006 • Condition: We identified costs incurred in 2022 that were incorrectly recorded as 2023 costs and charged to federal awards. • Planned Corrective Action: Corrected during the process of the audit and new policies implemented moving forward. Contact Person: Katherine Jaeger Anticipated Date of Completion: 2/21/2025

Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.

Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost Principles, Cash Management, and Matching, Level of Effort, and Earmarking Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

No payments will be made for purchases until the proper documentation is received and attached to the purchase order

Recommendation 1: Comment: We appreciate the recommendation and fully agree with the importance of having a clear documentation process for all deliveries. To address this, we will implement a policy that ensures all deliveries to the Organization and Units are properly documented. A designated employee responsible for receiving deliveries will be tasked with ensuring that all receipts and receiving reports are accurately matched with the corresponding invoices. This process will enhance our internal controls and improve the tracking and accountability of all deliveries. Recommendation 2: Comment: We will implement a policy requiring Unit Directors to submit daily "End of Day Reports" using a standardized template. This template will capture essential information, including activities conducted, materials distributed, and deliveries received. We will also establish a policy for maintaining and utilizing sign-in sheets at each Unit, outlining the required information such as the activity or event description, number of children involved, materials distributed, and the names of the Unit Director and Assistant Director. These sign-in sheets will be submitted to the appropriate parties promptly and saved in an online repository, organized by Unit and grant year. Additionally, supporting documentation will be collected and stored as part of the overall documentation process. We are committed to enforcing these policies to ensure timely submission and proper maintenance of all required documentation, further reinforcing our dedication to transparency, accountability, and effective use of grant funds.

FA 2023-002 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021) S425U210012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: $98,807 Repeat of Prior Year Finding: FA 2022-002 Description: A review of expenditures charged to the Elementary and Secondary Emergency Relief Fund program revealed that the School District's internal control procedures were not operating to ensure that expenditures were appropriately documented to support allowability. Corrective Action Plans: District office will review payroll process and develop a procedure to ensure proper documentation is kept in an orderly manner. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2023-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010-21A (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: $6,942 Repeat of Prior Year Finding: FA 2022-001 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawbacks are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will included detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2023-002 Strengthen Budgetary Controls over Expenditures Internal Control Impact: Significant Deficiency Compliance Impact: Activities Allowed or Unallowed Allowable Costs/Cost Principle Prior Year Finding: None Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed instances in which expenditures has not been properly approved by the pass- through entity. Corrective Action Plans: the School District will work with all entities to confirm that all existing controls are adhered to by developing and implementing an improved monitoring process. This process will ensure that all expenditures comply with all applicable policies and regulations. Estimated Completion Date: June 30, 2024 Contact Person: Daisy M. Prather, Finance Director Telephone: (478) 836-3131 extension 106 Email: daisy.prather@crawfordschools.org

CONDITION: The Regional Office of Education No. 39 did not ensure costs or expenditures were adequately documented, reviewed, and approved to ensure allowability under the federal award. PLAN: Although procedures were put into place in March 2023 to ensure that all expenditures were signed by the Program Directors, or Assistant/Regional Superintendent the previous Business Office Manager and Accounts Payable employee were not consistent on ensuring that all receipts/invoices were reviewed if a PO was created and approved or if it was approved with prior requisition form. A new purchasing process will be implemented that will document all expenditures have been reviewed, approved, and ensured that they are allowable under the federal and state award. This process will be consistent across all purchases to ensure that all approvals and reviews are conducted and documented. ANTICIPATED DATE OF COMPLETION: Implemented May 2024 CONTACT PERSON: Jill Reedy, Regional Superintendent

2023-007 Assistance Listing No. 96.001 , 96.006 and Social Security Disability lnsurance Cluster Type of Compliance Requirement: Period of Performance lnternal controls over period of performance were not consistentlv performed Response: Of the five instances noted in the auditor's "Period of Performance" test work, we concur with four. With one of the sample items, however, we argue that since the service was invoiced on a State Fiscal Year, it was impractical to further split the invoice into the various appropriate Federal periods of performance, especially given the way those specific invoices are allocated between other shared program areas within our agency, etc. Corrective Action Plan: Our agency takes these findings seraously and will continue to evaluate ways of improving controls. At a minimum, it is our intent to increase and provide additional training to the staff overseeing and approving these types of transactions so that they can accurately apply transactions to the appropriate periods. This was something we had already begun (i.e. provrding additional guidance and training to stafD during the current fiscal year. So, we hope our agency is already on a corrective path. But, we will continue to push for more training in the immediate future and strive for improvement in all other aspects. We also think it is important to note that, of the findings identifled by the auditors related to "Period of Performance," those items were discovered out of a total sample size oI 120 items (i.e. 60 sample items related to thejr "Period of Performance" test work and 60 sample items related to "General Disbursements" test work). So, a slightly larger sample size than that of the 60 referenced in the auditor's schedule of flndings. Additionally, the auditor's sample appeared to selectively target the specific periods and transactions that would have been most susceptible to these types of potential errors. And, although we are not objecting to the way in which the sample was selected, we would.just point out that this approach of sample selection may not be truly reflective of a purely random sample covering all transactions across the entire fiscal year. Therefore, although we ultimately concur with the findings here, we do not necessarily believe these results paint the fairest picture on the overall effectiveness of our agency's controls across the more than '100,000 transactions that would have been processed during the period of audit for this program. Again, we take these findings seriously. But, based on the audit test work and results, we feel the controls we have in place are ultimately working adequately enough to mitigate the potential for material misstatements. Regardless, we will continue to monitor and evaluate our controls to help further reduce the risk of these types of issues moving forward. Planned completion date for corrective action plan: lmmediately. But, additional training for managers to be provided by September 30, 2024.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

The contracted executive director will document time spent on federal awards with date, hours, and purpose. The contracted accountant will allocate the indirect expenses. Both the executive director wage expenses and the indirect allocations will be reviewed and approved by the contracted grant administrator.

Catholic Charities of Central and Northern Missouri agrees with this finding and as of July 1, 2024 has altered procedures so that invoices and documentation related to expenditure of federal funds are now scanned and attached to the accounting entry recording the payable.

We will maintain a schedule that details all salary and benefit expenses charged against each Federal award and ensure that these totals are reconciled back to the general ledger and the Final Expenditure Report. We take some exception with this finding, as we believe the audit sample was pulled and formatted in a cumbersome manner and did not facilitate the process of clearly identifying all of the expenditures cited, which often represented portions of benefit costs paid for personnel and reflected in total on related insurance invoices, etc. The Director of Federal Programs and the Payroll Coordinator will be charged with ensuring the accuracy of this information and the related processes moving forward.