Corrective Action Plans

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jessica Thome, Controller Contact Phone Number and Email Address: (812) 244-2360 and Jessica.thome@terrehaute.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Controller will review any previously entered contracts that are paid from our federal grants including ARP to ensure we are in compliance. Anticipated Completion Date: October 2024

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Allowable Costs/Cost Principles Summary of Finding: The County Council did not have an Allowable Cost policy in place during the audit period and supporting contracts for agreements with recipients of the grant funds could not be provided for the audit. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: 812-268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We concur with the finding. The County will adopt an allowable cost policy and the County Auditor will review all supporting documentation with claims to ensure that proper contracts or interlocal agreements are included with the claims for of the grant. Anticipated Completion Date: October, 2024

1)The duplicate invoice for $92,880.00 was removed from the Tracker worksheet which was submitted in 11/27/2023. 2)The duplicate invoice for $91,511.66 will be removed from the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024. 3)The discounts taken for early payment of contract labor invoices for a certain vendor will be corrected on the FEMA Project 140215 Tracker worksheet which will be submitted by the end of September 2024.

Responsible: Thomas Hoover, Chief Financial Officer Corrective Actions: Updated Finance policies: Specify that documentation of review and approval of costs charged to federal grants be maintained and that costs are recorded in the appropriate grant funding period. Completion Date: July 10, 2024. Explanation: Policies have been in place over the coding of costs allocated to federal grants in compliance with CFR 200 and were enhanced in 2023 in response to an OJJDP/OCFO recommendation. Review and approval of costs after being approved by an authorized signer takes place in multiple steps and concludes with preparation of reimbursements and financial grant reports (FFR). In order to further demonstrate compliance as recommended, Management updated Finance policies to capture the documentation and approval of cost allocation methods and coding of costs to federal grants and maintenance of such documentation of Supervisory review and approval. Policies already in place specified that supporting and source documentation be maintained for at least 3 years, in compliance with federal grant requirements. In addition, the updated policy specifies that grant costs be recorded in the appropriate grant funding (fiscal) period. Four transactions sampled were partially or fully recorded in the incorrect funding (fiscal) period, though they were within the grant period.

Management Response Management acknowledges the recommendation of placing internal controls in place to ensure that costs are charged and allocated to the proper grant period. REMEDIATION PLAN Management has hired Jess Vaughn-Jansen as Director of Financial Strategy (Director) to ensure transactions are charged and allocated to the individual grants in the proper grant period. The Director has reviewed the process documents that are in place to assist in recording transactions. Excel Tracking Sheets have been created and are maintained by the Director for each grant. Per the grant agreements, the Grant Period (i.e., Effective Date and Expiration Date) has been documented on all the Tracking Sheets. This will allow the Director to properly include and exclude items that may occur before the Effective Date or after the Expiration Date. These Tracking Sheets have been used by the Director since February 2023. The 1 selection not in compliance was posted prior to the Director’s hire date. No findings have been identified after the Director’s hire date. The Director has and will continue to be cognizant of including and excluding items that may occur before the Effective Date or after the Expiration Date.

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a secondary person review the reports and in a timely manner. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2023 Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

Finding Number: 2023-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Extensive research was done on this topic and position of the County is that cities and townships are non-entitlement units (NEUs) who report to the Treasury directly. SLFRF Compliance and Reporting Guidance published by The Department of the Treasury states that NEUs are not subrecipients under the SLFRF program; they are SLFRF recipients that report directly to the Treasury. Recipients of the County’s ARPA Broadband grants: -provided the specific unserved or underserved areas located within the County where therequested ARPA funds would be used to deliver high-speed, reliable, and affordable internet(typically accompanied by the consultant report coordinating the construction) on their grantapplications to the County Board; and -have certified they are complying with “all federal, state, and local laws and all requirementsand published guidance set forth regarding the usage of any and all monies appropriated underthe ARPA” in their signed grant agreements with the County; However, beginning in 2024 the County will collect itemized support for the expenditures incurred related to the ARPA Broadband Grant Program. Anticipated Completion Date: Immediately

CORRECTIVE ACTION PLAN Finding 2023-001 - Controls Over Payroll Expenditures (Material Weakness) Criteria: 2 CFR 200.403 establishes principles and standards for determining costs for federal awards carried out through grants, cost reimbursement contracts, and other agreements with state and local governments. To be allowable, under federal awards, cost must meet certain criteria: a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles. b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. c) Be consistent with policies and procedures that apply uniformly to both federally-financed and other activities of the non-Federal entity. d) Be accorded consistent treatment. A cost may not be assigned to a Federal award as a direct cost if any other cost incurred for the same purpose in like circumstances has been allocated to the Federal award as an indirect cost. e) Be determined in accordance with generally accepted accounting principles (GAAP), except, for state and local governments and Indian tribes only, as otherwise provided for in this part. f) Not be included as a cost or used to meet cost sharing or matching requirements of any other federally financed program in either the current or a prior period. g) Be adequately documented. h) Cost must be incurred during the approved budget period. Additionally, 2 CFR 200.303 indicates that non-Federal Entities receiving Federal awards 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 terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Context: A summary of allowable charges for the grant was prepared for submission. Within a sample of 45, we noted that 25 timecards did not have a documented review. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The Transportation Department provides a spreadsheet that details time operators work by route. This process is used to align FTA funding streams with routes driven. The spreadsheet is kept by the Transportation Manager and reviewed by the Director of Transportation. These two positions approve time prior to submitting it for processing. The Gary Public Transportation Corporation management had hoped to get its payroll provider to provide a solution to this particular timesheet approval matter. However, the complexity of these timesheets made a resolve too complicated for reasonable implementation. So, a simple solution has been devised. The Transportation Manager and Director shall sign off on a document to stating their review and approval of those timesheets.

The Authority will limit advancing funds from the Section 8 Housing Choice Voucher and Emergency Housing Voucher Programs, to allowable Fees only. The Authority’s Executive Director, Trey George, has assumed the responsibility of executing this corrective action as of November 1, 2024.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to document a standardized process for documenting expenditures and retaining receipts. For instance, invoices cannot be processed without adequate documentation. Additionally, credit card holders are responsible for submitting electronic credit card receipts to the fiscal office monthly. In 2022, an updated credit card policy was provided to all employees. The adherence to the credit card policy is monitored by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

Management Response The documentation provided to the auditors did not make it easy for the auditors to trace the general ledger totals to the amounts billed to cost reimbursement contracts. The Garden records all expenses incurred for a given award in its general ledger, regardless of whether full funding of the expenses is available. This is so the Garden can see the full cost of the activity and make informed decisions in the future. The reports used to bill the federal awards only pulls expenses in the period of the award. In all cases, no amounts were billed to any federal award after the award had expired. Corrective Action Plan Education and reverification of the processes documenting the flow of information from the general ledger to the federal award billings has been provided to accounting personnel involved in federal award accounting and billing. Contact person(s) responsible for the corrective action: Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org Anticipated Completion Date: Education on the above has already started and will be completed August 31, 2024.

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.

FINDING 2023-003 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – Body Camera – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: The City entered into a grant agreement on 03/03/2023 for the purchase of body cameras. The invoice for the body cameras was dated 10/28/2022, prior to approval from the state. The purchase was outside the period of performance. Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 Ext. 2006 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: In order for the City to insure that internal controls are in place to prevent noncompliance with federal awards, the City Controller’s office will review and discuss with department personnel, all federal grant applications to ensure compliance with allowable costs and period of performance. Anticipated Completion Date: 08/26/2024

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

Boston Public Schools (BPS) has updated its’ training and guidance for timekeepers. Timekeepers participated in enhanced trainings during August of 2024 in preparation of the new school year. Anticipated Completion Date: August 31, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Management’s Response and Corrective Action Plan: As of August 2023, this finding has already been corrected by the following correction plan: When credit cards are being used to pay for VBR related items, the employee purchasing the item documents the business purpose to verify that the purchases are allowable under Uniform Guidance. This is documented on the invoice or receipt. During the monthly reconciliation of credit card statements, the bookkeeper matches up all receipts for expenditures recorded on the monthly statements. The Director of Operations or Executive Director then reviews that backup documentation is received for all expenditures. The reviewer signs off on the reconciliation to show that documentation for all expenditures has been reviewed. The Executive Director reviews all expenses in the monthly general ledger report for allowability and document her approval by signing the monthly reports. This review is completed for all credit card transactions in second half of 2023 and future years.

Corrective Action: Monroe County Schools will take the following corrective actions to improve the allowable costs and cost principles – ESSER. • The new CSBO will work with WVEIS technicians to determine if shipping can be shown in a different manner that accurately depicts the charges recorded in the grant. Effective Date: November 30, 2024 Person(s) Responsible: CSBO & Director of Federal Programs, Monroe County Schools

Corrective Action: The district concurs and understands the importance of maintaining internal controls related to Education Stabilization Fund requirements. However, due to turnover of half the Business Office staff in June 2023, the district procedures could not be effectively followed. That said, by September 1, 2024, the Assistant Superintendent for Business will, together with the pertintent Business Office staff, review the existing procedures for these internal controls to ensure all are being implemented properly for the coming fiscal year. Additionally, the Assistant Superintendent for Business will have monthly reviews with the Treasurer to ensure these internal control processes are being correctly followed.

Corrective Action: The district concurs and understands the importance of maintaining internal controls related to Education Stabilization Fund requirements. However, due to turnover of half the Business Office staff in June 2023, the district procedures could not be effectively followed. That said, by September 1, 2024, the Assistant Superintendent for Business will, together with the pertintent Business Office staff, review the existing procedures for these internal controls to ensure all are being implemented properly for the coming fiscal year. Additionally, the Assistant Superintendent for Business will have monthly reviews with the Treasurer to ensure these internal control processes are being correctly followed.

Berrien County BOE FA 2023-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 225GA324N1199 (Year: 2023), 225GA324N1199 (Year: 2023) Questioned Costs: $3,381 Description: A review of expenditures charged to the Child nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were reviewed and approved and that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: The new program director will attend training and review compliance requirements to ensure appropriate documentation is maintained. Estimated Completion Date: 30-Jun-24 Contact Person: Jolyn Schultz, Finance Director Telephone: 229-686-2081 Email: jolyn.schultz@berrien.k12.ga.us

Status: Corrective action in progress Corrective Action: The City agrees with the finding. DDPHE will implement additional trainings and guidance for contract monitoring including invoice review and encourage a standard template in Excel to avoid calculation errors. The City is also currently implementing a city-wide grants management system and we hope to include invoice review and tracking in this new system by 2025. Person(s) Responsible for Implementing: DDPHE – Paige Cheney Implementation Date: September 2024 and potentially January 2025