Corrective Action Plans

Department: Health and Human Services Title: Internal control over Medicaid cost of care deductions needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department’s State Adjustment Supervisor and Provider Relations Manager will work with OFI to request the COC manual change report be sent to the State Adjustment Unit. The State Adjustment Unit will QA the claims report received by the vendor and compare it to the OFI report to assure accurate reporting of cost of care changes for affected members. Completion Date: April 30, 2024 Agency Contact: Michelle Probert, Director, Office of MaineCare Services, DHHS, 207-287-2093

Department: Health and Human Services Title: Internal control over the Adoption Assistance – Title IV-E eligibility and benefit determination process needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department’s Adoption Program Manager will educate and train the Adoption FRS workers on the proper completion of the Application for Adoption Assistance Checklists. The Department’s Adoption Program Manager will review the final Adoption Assistance Packet for completeness before approving. The Department’s Adoption Program Manager will educate and train the District Caseworkers and Supervisors on the proper completion of the Application for Adoption Assistance Checklist. The Department’s Adoption Manager will work with the OCFS team on enhancing the Adoption Policy. The Department’s Adoption Program Manager will update the Adoption Assistance Checklist in Katahdin to state it will be returned to the district if not completed and signed by the caseworker and supervisor. The Department will organize a workgroup to evaluate how to improve the financial review process and define any changes needed to be implemented in Katahdin to support validating that payments are processed appropriately. Completion Date: April 1, 2024 (first and second items), June 1, 2024 (third item), September 1, 2024 (fourth and fifth items) and October 1, 2024 (sixth item) Agency Contact: Karen Benson, Adoption Program Manager, DHHS, 207-561-4208

Department: Health and Human Services Title: Internal control over the Foster Care – Title IV-E eligibility and benefit determination process needs improvement Questioned Costs: Known: $8,006 Likely: $220,373 Status: Corrective action in progress Corrective Action: The Department’s Title IV-E Program Manager will educate and train the FRS staff on the proper completion of Title IV-E Initial Determination checklists for their FRS files. The Department’s Title IV-E Program Manager will include a verification of this item in our Internal Quality Assurance review checklist. The Title IV-E Program Manager will educate and train the FRS staff on this update to the review tool. The Department’s Title IV-E Program Manager will update the FRS Manual to describe the proper completion of the "Title IV-E Determination Checklist". The Title IV-E Program Manager will educate and train the FRS staff on this update to the manual. Completion Date: April 1, 2024 Agency Contact: Manisha Donahue, Title IV-E Program Manager, OCFS, DHHS, 207-592-1268

Department: Health and Human Services Title: Internal control over CCDF provider payments needs improvement Questioned Costs: Known: $3,101 Likely: $32,099 Status: Corrective action in progress Corrective Action: The Department’s Program Managers will review findings with the CCAP program staff. The Department’s Program Managers will update the FRS Manual (standard operating procedures). The Department’s QA team will be informed of findings and updates to the CCAP manual. Completion Date: May 13, 2024 Agency Contact: John Feeney, Chief Operating Officer, OCFS, DHHS, 207- 626-8614

Department: Health and Human Services Title: Internal control over payments made to and on behalf of TANF clients needs improvement Questioned Costs: Known: $4,721 Likely:$279,992 Status: Management’s opinion is that corrective action is not required Corrective Action: OFI disagrees with this finding. OSA's interpretation of federal regulation regarding the recoupment of overpaid funds is incorrect, and benefit overpayments are identified and processed by OFI in compliance with federal regulation and policy. Overpayments are required to be recouped in the shortest timeframe possible, but the recoupment amount cannot exceed the standards as set by policy. Neither state policy nor federal regulation requires an overpayment to be recouped within the same state fiscal year it is identified, so it was not appropriate for OSA to include as questioned costs on that basis the two cases where recoupment did not occur in the same fiscal year that the overpayment was established. Further, OFI disputes how OSA calculated the questioned costs. Three of the payments tested by OSA were found to be correct at the time of issuance. OSA then reviewed all payments during the state fiscal year for the three cases and stated that parent fees should have been adjusted based on documentation in DocuWare. Transitional Child Care does not require changes in income to be reported during the certification period unless the gross income exceeds 250% of the federal poverty level (MPAM, Ch. V, A, (6)), and adjustment of the parent fees were not required for these cases. They should not be included in the list of exceptions. While OSA cites MPAM, Ch. V, A (6), "TCC payments remain constant until a redetermination is completed, or until the recipient or child care provider reports a change that affects the amount of TCC benefits (emphasis added)" the reported change did not affect the amount of TCC benefits. Completion Date: N/A Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481

Department: Administrative and Financial Services Health and Human Services Title: Internal control over DHHS allocated costs needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The DHHS Financial Service Center will implement additional procedures for communicating back and forth with OCFS regarding changes to the Cost Allocation Plan. The DHHS Financial Service Center will review and enhance current monitoring procedures to ensure costs are being allocated as expected within Federal regulations. Completion Date: December 31, 2024 Agency Contact: Sarah Gove, Director, DHHS Service Center, DAFS, 207-458-6626

Department: Education Title: Internal control over ESF expenditures needs improvement Questioned Costs: Known: $161,468 Likely: $7,308,277 Status: Management’s opinion is that corrective action is not required Corrective Action: The Maine Department of Education (MDOE) disagrees with the identified questioned costs. The FERP utilized guidance provided by the U.S. Department of Education (grantor) and conferred in writing with Maine’s assigned U.S. Department of Education program officer throughout the Education Stabilization Fund application review process. The Maine Department of Education’s FERP provided the auditor with the grantor’s guidance which clearly states that the questioned costs were allowable, reasonable, and necessary to prepare, prevent, and respond to the COVID-19 pandemic. Throughout the application review process, FERP utilized ESF federal statutory language and the grantor’s published guidance to determine allowability. Once funding applications were approved, SAUs requested reimbursement from the FERP for the approved costs outlined in the school administrative unit (SAU) application. The FERP reviewed SAU reimbursement requests and provided payment for approved expenses. The ESF costs outlined in this finding were allowable, reasonable, and necessary to prepare, prevent, and respond to the COVID-19 pandemic. Completion Date: N/A Agency Contact: Shelly Chasse-Johndro, Director of OFERP, DOE, 207-458-3180

Department: Education Administrative and Financial Services Title: Internal control over Special Education period of performance needs improvement Questioned Costs: Known: $2,446,391 Likely: Undeterminable Status: Corrective action in progress Corrective Action: In FY22, Maine DOE implemented a new grants management system. The implementation of the new system and staffing created delays in final payments. The Office of Special Services and Inclusive Education will review and implement stronger internal controls to monitor final payments for timeliness. Completion Date: June 30, 2024 Agency Contact: Nicole Denis, Director of Finance, DOE, 207-530-2161

Department: Economic and Community Development Title: Internal control over CSLFRF expenditures needs improvement Questioned Costs: Known: $591,845 Likely: $591,845 Status: Corrective action in progress Corrective Action: The Department will review internal processes and procedures to ensure that they properly address questions of compliance and allowable expenditures for similar programs that may arise in the future. The Department will identify the appropriate allowable expenditure categories and create business cases that will address the questioned costs by placing them into the proper expenditure categories. Completion Date: June 30, 2024 Agency Contact: Denise Garland, Deputy Commissioner, DECD, 207-624-7496

Department: Labor Title: Internal control over UI claim payments needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will review the single case where the claimant received multiple consecutive two-week work-search waivers by answering they were starting new employment. We will review to formulate new controls once the initial two-week period ends and the claimant continues to file for benefits to determine why the new employment did not commence as reported. The Department will conduct refresher training for staff to address the findings that were the result of staff errors. Completion Date: December 31, 2024 and November 11, 2024 respectively Agency Contact: Laura Boyett, Director, Bureau of Unemployment Compensation, DOL, 207-621-5156

Department: Education Title: Internal control over CACFP eligibility determination and claim reimbursement procedures needs improvement Questioned Costs: Known: $19,362 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Department will create a property type form, using USDA Regulations, and will share the form with small facilities. The Department will add the form to the new application and will be stored throughout the year. The Department will add an enhancement request for a warning and attestation for the collection of “in and out” records to substantiate the claiming of meals over the licensed capacity. The Department will implement a two-step claim verification process for each sponsoring agency which requires a two-person internal approval prior to a claim submission. Completion Date: July 31, 2024, October 31, 2024, April 30, 2024 and August 31, 2024 respectively Agency Contact: Jane McLucas, Director of Child Nutrition, DOE, 207-624-6880

Department: Education Title: Internal control over CNC claim reimbursements needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will adjust the one-time exception procedure to include the procedure for downward adjustments and tracking of sponsor requested downward adjustments. The Department will adjust the SFSP application/site information sheet approval and update procedures to include instructions on documentation needs. Requests for site information sheet changes will be documented and maintained in CNPweb. CNPweb ticket requests have been submitted to ensure downward adjustments are tracked in CNPweb. CNPweb ticket requests have been submitted to ensure site information sheet changes are date stamped. Completion Date: March 12, 2024 (first and second items), March 1, 2025 (third item) and June 9, 2022 (fourth item) Agency Contact: Adriane Ackroyd, Assistant Director Child Nutrition, DOE, 207-592-1722

Department: Health and Human Services Title: Internal control over automated SNAP eligibility certification periods needs improvement Questioned Costs: Known: $18,090 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Department has the necessary policies and procedures in place regarding providing households with correct certification period lengths. The Department has previously identified that some household’s six-month reports would be withdrawn incorrectly, at times. Over the course of approximately three years the Department has identified the causes of this error, the final of which is scheduled to be completed June 7, 2024. Completion Date: June 7, 2024 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481

Department: Health and Human Services Title: Internal control over Medicaid and SNAP deceased client cases needs improvement Questioned Costs: Known: $8,329 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The Department will complete a follow up of cases noted in the "condition" section of the finding. Responsible party: MC Program Integrity and ES Special Project teams. The Department will review and update standard operating procedures (SOP) clarifying the Program Integrity team as responsible for working on DOD reports timely with enhanced oversight procedures. Responsible party: Program Manager team Completion Date: June 30, 2024 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481

Department: Health and Human Services Title: Internal control over SNAP eligibility determinations and benefit calculations needs improvement Questioned Costs: Known: $7,491 Likely: Undeterminable Status: Corrective action in progress Corrective Action: The management of OFI will review the operating procedures to identify opportunities for improvement and distribute to all staff involved. Completion Date: June 1, 2024 Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481

Department: Health and Human Services Title: Internal control over P-EBT Food Benefits needs improvement Questioned Costs: Known: $4,271 Likely: $4,862,998 Status: Management’s opinion is that corrective action is not required Corrective Action: The Department disagrees with the following Conditions: For 22 students, MDOE was not able to identify the specific student whose continuous absence established those students’ schools’ eligibility date. The P-EBT state plan required at least one student to be absent or remote for at least five consecutive days to establish a school eligibility date and MDOE in fact applied this test and established a school eligibility start date at the time the eligibility files were generated. While the school eligibility start date was captured and preserved in the original files provided to OSA, no student was named. The name of the student was not relevant to other students’ eligibility, and creating or preserving a record of the particular student whose absence conferred eligibility was not a requirement of Maine’s P-EBT plan with FNS, the Department’s MOU with MDOE, or federal P-EBT policy. Further attaching that kind of Personal Identifying Information (PII) to other students’ records would not be appropriate. Additionally, since local educational agencies (LEAs) update the core database throughout the school year and beyond, the results could not be replicated in the course of this audit to retrospectively identify the particular students whose absences conferred eligibility. Neither the omission of the students’ names in the original file nor DOE’s inability to identify such students during the audit establishes that it was improper to issue P-EBT benefits in connection with those students. These students were found eligible based on the best data available to MDOE at the time. Likewise, the Department acknowledges that for four students, MDOE was unable – when requested to do so by the OSA – to locate their economically disadvantaged status in the database updated by LEAs throughout the school year. That does not mean, however, that it was improper to issue P-EBT benefits in connection with those students. These students’ economically disadvantaged status was verified by MDOE and captured in the files at the time of issuance. The Department disagrees that tracking benefit issuance by child identification number is inadequate to monitor benefit issuances and ensure benefits are not duplicated. Child identification numbers are the most reliable way to track and deduplicate issuance. As pointed out in this finding, many households had more than one child. Additionally, some children may have moved from one household to another during the period in question. The Department disagrees with the Context and Likely Questioned Costs: For the reasons detailed above, only three – not 29 – of the students sampled were established to have been issued benefits in error. OSA’s calculations should be adjusted accordingly. The Department disagrees with the Causes: OSA is incorrect to conclude that OFI should have reviewed, reconciled, and verified data provided by MDOE prior to issuance for at least two reasons. First, contrary to OSA’s characterization of the partnership, the Department and MDOE were jointly responsible for administering the P-EBT program, with delegated duties defined in the state plan. That federally approved plan considered MDOE data to be accurate and actionable, and it did not contemplate OFI independently validating such data. Second, the Department is not permitted access to the local educational agency data that would have been necessary for the type of review and reconciliation proposed. The Department disagrees with the Recommendations: The three bulleted recommendations cannot be implemented. The P-EBT program ended December 31, 2023. It will not be possible to take corrective action in the implementation of a program that no longer exists. The State is confident that all issuances in the audit period, including those raised by OSA, were issued correctly based on the best information available at the time by the Departments responsible for implementing the P-EBT program. As such and following FNS guidance that no benefits are to be recouped unless the household applied for them directly, OFI will not revisit prior P-EBT decisions as suggested in OSA’s additional recommendation. Completion Date: N/A Agency Contact: Ian Yaffe, Director, Office for Family Independence, DHHS, 207- 592-1481

Finding 2022-004 – Coronavirus State and Local Fiscal Recovery Funds – Allowable Cost/Cost Principles (Significant Deficiency) Management’s Response or Department’s Response Management agrees with the finding and recommendation. Views of Responsible Officials and Corrective Action The County processed a transfer of revenues to ISD in anticipation of the expenses to be incurred for cybersecurity improvements in FY 2022-2023; however, the fund was not fully spent. The Auditor-Controller’s office will work with the CAO’s office to review and address the inefficiencies in the County’s internal control system. We will review the identified transactions and will work with ISD to reclassify the identified expenditures to the appropriate period. Going forward, the County will ensure that proper documentation, such as receipts, invoices, and proof of payments, are received from departments prior to processing. This implementation will be effective immediately. Anticipated Completion Date March 2024 Contact Information of Responsible Official Name: George Uc Title: Principal Administrative Analyst Phone: 559-600-1231

We agree with the recommendation that expenses should have been reviewed not only in total but should also been reviewed under the two categories of expenses (1) General and Administrative Expenses and (2) Health Care-Related Expenses and the additional subcategories of expenses as defined in HRSA’s Post-Payment Notice of Reporting Requirements for PRF grants to ensure that individual expenses were not double counted. While management will attempt to see if we can refile expenses in the HRSA PRF portal to clearly show that more than enough qualified expenses exist to apply to funding received under both PRF grants and FEMA awards, our understanding is that the PRF portal is closed and restatements cannot be made. Management believes while expense reporting was duplicated for both of these funding sources, because more than enough expenses exist in total to be applied to both sources of funding, this is a reporting matter only and no funds need to be returned under either program. Further, there was numerous and changing guidance from HRSA as to whether expenses needed to be applied to PRF grants prior to applying lost revenue to these grants. Effective with PRF Reporting Period 2, lost revenue was first applied to PRF grants. Fresno did not apply expenses incurred to PRF grants after the date of June 30, 2021, thus this issue does not exist for costs incurred during periods subsequent to June 30, 2021.

Finding # 2023-022 Title of Finding Activities Allowed or Unallowed Contact Person Jody Johnson, Sarah Wills and Christine Miller Anticipated Completion Date FY 2024 Corrective Action planned to be taken: The Board has developed procedures to ensure that all purchase orders are approved before orders are placed, all expenditures are properly authorized by the respective program director and supporting documentation is adequately maintained. The Board is using a requisition form in Droplet to achieve this goal. All employees authorized to make or approve purchases have been trained on purchasing procedures outlined in the Purchasing Policies and Procedures Manual for Local Educational Agencies in the State of West Virginia by the WVDE Office of School Finance on 2/23/2024.

Planned Corrective Action: Meals on Wheels of the Monterey Peninsula (MOWMP) will address the finding by taking the steps outlined below: 1. Expenditure Allocation: Controller and/or bookkeeper will allocate expenditures based on the number of meals prepared each month and the percentage of meals prepared for each program and funding. Yearly reviews of the allocation process will be conducted to ensure accuracy and relevance. Adjustments may be made based on changes in meal demand, program requirements, funding sources, or other factors affecting meal preparation costs. 2. Payroll Reporting: On a yearly basis, Managers and/or Directors will allocate the amount of time each employe works based on tasks performed and the amount of time worked on federal award activities. This allocation will be expressed as a percentage of total work hours performed. Periodic adjustments to time allocations may be necessary to reflect changes in project priorities, staffing levels, or other factors affecting workload distribution. Person Responsible for Corrective Action Plan: Leadership Oversight – Christine Winge, Executive Director Operational Oversight – Kay Smith, Controller Anticipated Date of Completion: MOWMP will complete the Corrective Action Plan by June 1, 2024. We will implement the Corrective Action Plan beginning July 1, 2024.

2023-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Taken: The Board is taking adequate action to review and approve all charges to the federal programs. The Board’s steps have been reviewed with Workforce WV and has approved our procedures. Supporting documentation is kept both in physical and electronic forms. Each check the Board distributes has an approved Purchase Order attached, (if applicable), Invoice, or if it is a monthly recurring charge, statement or bill attached and once the bill is entered into our system and the bill is paid, the check has the Executive Director’s initials and date showing it is approved in our accounting system. Also, if the expenditures are questionable, we will receive approval before submission of the bill from our liaison in the Workforce WV office.

Finding 2023-006 Period of Performance Condition: Northern Illinois University (the University) charged an expenditure to the grant whereby a portion of the expenditure had a service period extending beyond the grant's period of performance, and the University’s controls did not detect the error. Corrective Action Plan: University has taken the following corrective actions that will eliminate all material exceptions: 1) The University will provide additional training on cost allocation to staff. 2) University is taking immediate steps to resolve the questioned cost. Individual(s) Responsible for Corrective Action: Sponsored Programs Staff Anticipated Completion Date: June 30, 2024

FINDING 2023-007 Subject: Title I Grants to Local Educational Agencies - Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A190014, S010A200014, S010A210014, S010A220014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs/Cost Principles Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Terri Chance Contact Phone Number and Email Address: 219-924-4250 tchance@griffith.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Griffith Public Schools will be developing, implementing, and documenting, a system of internal controls, including policies and procedures that provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Anticipated Completion Date: June 30, 2025

FINDING 2023-003 Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions - Non-Profit School Food Service Accounts Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, COVID-19 National School Lunch Program; Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Finding: Material Weakness, Modified Opinion Summary of Finding: Material Weakness, Modified Opinion Repeat Finding This is a repeat finding from the immediately prior audit report. The prior audit finding number was 2021- 003. Contact Person Responsible for Corrective Action: Terri Chance Contact Phone Number and Email Address: 219-924-4250 tchance@griffith.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Griffith Public Schools will be developing, implementing, and documenting, a system of internal controls, including policies and procedures that provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place to ensure compliance. Anticipated Completion Date: June 30, 2025

Department of Health and Human Services 2023-005 Value-Based Medical Student Education Training Program – Assistance Listing No. 93.680 Condition: Indirect cost expense was improperly calculated. Auditors’ Recommendation: We recommend the institution strengthen its internal controls to ensure that calculations are reviewed and adjusted for, if necessary, in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: UMMC’s transition to Workday resulted in the need for multiple F&A bases to be created in Workday to accommodate our DHHS negotiated agreement. However, since our go-live we have only been using one modified total direct cost base to calculate F&A. UMMC is in the process of engaging a Workday Certified consulting firm to review the operational efficiency of Workday for Post-Award Accounting. The scope of this engagement will be to align our usage of Workday to industry best practices, including best practices for F&A calculation. During the scope of this project, we will review these established bases to ensure they meet the needs of our negotiated rate agreement provisions. In the meantime, we are reviewing the F&A calculations on existing projects when an invoice or financial report is prepared to ensure accuracy. F&A will be recalculated with each invoice and/or financial report and any necessary adjustments will be made before the invoice or financial report is submitted to the sponsor. Name(s) of the contact person(s) responsible for corrective action: Julie Schwindt, Director, Post-Award Accounting Planned completion date for corrective action plan: June 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Julie Schwindt at 601-984-1058.