Corrective Action Plans

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.

Finding 2023-002: Internal Control Deficiency and Noncompliance over Activities Allowed/Allowable Costs Principles, Period of Performance Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: Management did not have adequately designed internal controls in place over expenses charged to the federal program. Management also did not consistently retain evidence to support the existence of certain expenditures and thus the expenses were not adequately documented. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-01 finding, to ensure expenditures are appropriately reviewed and approved prior to entering into the expenditure or requesting reimbursement from the federal program. Documentation will be maintained to support that expenditures were reviewed for appropriate period of performance. Management will ensure all duties are appropriately segregated. In addition, following the October 2023 implementation, care will be taken to ensure that invoices for vendors using electronic invoicing systems will be downloaded in a timelier manner to ensure electronic invoices do not expire within those systems. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

CONDITION: The District did not comply with the laws and regulations related to its participation in it’s various federal grant program reporting requirements. Personnel did not complete and submit the required ‘quarterly cash on hand reports’ and ‘final expenditure report’ (FER) for the grant programs based on supporting accurate general ledger expenditures as required by Section 2 CFR 200.403(g) of the Uniform Guidance. CRITERIA: The PA Department of Education (PDE) and Section 2 CFR 200.403(g) of the Uniform Guidance requires the completion and submission of a ‘quarterly cash on hand report’ quarterly as needed and a ‘final expenditure report’ (FER) at the conclusion of each grant program year (including any carryover period) based on information contained in the School District’s financial management system and supported by all underlying documentation. MANAGEMENT’S CORRECTIVE ACTION PLAN: The School District concurs with the above noted finding. The School District has employed a new Business Manager whose responsibilities include the oversight of accounting records and preparation of all required financial reports related to PDE federal grant programs in a timely manner, and to ensure that the information reported to PDE is supported by the underlying documentation contained in the District’s general ledger. Procedures will be put into place during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for ensuring federal program reports are prepared accurately and agree with the financial management system and supported by all underlying documentation.

Assistance Listing 14.267 Continuum of Care Program Views of the Responsible Officials and Corrective Action Plan: OHS agrees with the issues outlined, which stem from the delayed processing of invoices and untimely payments. These challenges are largely the result of longstanding issues with over-allocations and the need to catch up on processing a backlog of documents. We appreciate you bringing this to our attention, as it provides an opportunity to refine our procedures and put in place measures to prevent these issues from recurring in the future. This feedback will be valuable as we work to improve our processes and enhance our ability to manage workloads more effectively. Contact Person: Jerome R. Hill, Director of Compliance, Office of Homeless Services, 215-686-0371, 215-520-3556

This matter was investigated by both the AOS, the Allen County Auditor’s Office, and by board members of the RPC. GLCAP was met with and records from both RPC and GLCAP were scrutinized and matched. As a result, the duplicate payment made in the amount of $4,386 was returned by GLCAP to RPC and was deposited on 10/03/2024 into the Allen County Community Development Fund.

Condition: As a precondition to receive federal awards, prospective recipients must have effective internal controls over the federal award. As described in 2 CFR, Part 200.303, nonfederal entities must have certain written policies and procedures surrounding the management of their federal awards. Such policies should include procedures for collecting payments of federal funds per 2 CRF 200.305, cash management (i.e., minimizing the time between draws and actual disbursing of federal awards) per 2 CFR 200.302(b)(6), allowable cost per 2 CFR 200.403, and conflict of interest per 2 CFR 200.318. Per 2 CFR 200.319(d), the non-Federal entity must have written procedures for procurement transactions. Recommendation: The Authority should adopt written policies and procedures over cash management and allowable costs required under the Uniform Guidance. Planned Corrective Action: The Authority implemented these policies during the FY 2024 (BA054 Cash Management Policy and BA059 Authorization of Purchases). Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

Name of Responsible Individual: Bruce Jones, Vice President of Research, Marchon Jackson, Associate Vice President of Research, Dana Hector, Assistant Vice President, Sponsored Grants & Programs Corrective Action: The process to review subrecipient invoices will be improved by requiring the review of supporting documents to ensure expenses are allowable by the newly established Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, reasonable and recorded in the proper period according to university policies and grant terms. Invoices will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. The Director of Compliance will conduct spot checks on all sponsored transactional activity, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO post-award office. The Director of Post Award Compliance will be hired by March 2025. Anticipated Completion Date: March 31, 2025

FINDING 2023-005 Finding Subject: COVID-19 – Education Stabilization Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles. Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements. Across-the-board stipends were paid without documentation or justification for additional duties or work performed on which to base the stipends. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We disagree with this finding. We did not offer an across the board stipend with ESSER II. We paid it to employees who had met certain length of employment requirements and effectiveness requirements. The IDOE guidance states that staff may be paid extra for added COVID-related work. However, this list is not exhaustive and we believe there are other reasons that allowed us to proceed. a. Incentives paid with federal funds must comply with 200.430(f). The federal regulations explicitly state that the bonus is allowed for efficient performance, which was our criteria. Explanation and Reasons for Disagreement: The USDOE gave what we did as a recommended best practice and example for others, of addressing staffing shortages and offering premium pay. In regards to Cafeteria workers please see this research brief released by USDOE regarding pandemic funds (ARP but also other federal pandemic funds, which would include ESSER II) State and Local Practices for Cafeteria and Custodial Staff • Waco Independent School District in Texas will give custodians and cafeteria workers up to $1,000 in bonuses, based on years served with the district. Those who have worked for 10 or more years will receive $1,000, divided in three payments beginning in December 2022. Those who have worked for five to nine years will get $750, and those with the district fewer than five years will get $500. The district expects $500 in bonuses to go to custodians and cafeteria workers. INDIANA STATE BOARD OF ACCOUNTS 46 • North Carolina is using ESSER funds to help local school nutrition operations across􀀃North􀀃Carolina􀀃 recruit􀀃and􀀃retain􀀃needed􀀃staff.􀀃 ESSER states, any activity authorized by the ESEA of 1965 (Titles I, II, III, IV IC Migrant, ID Neglected and Delinquent, 21st Century Community Learning Centers, and Rural and Low-Income Schools Grant) is allowable. Title II has explicit language about paying teachers and admin (but not cafeteria) more as a recruitment or retention bonus

1. Implementation of Sage Accounting Software: We have since implemented a comprehensive financial accounting software system, Sage, which allows us to track expenditures more accurately and ensure compliance with federal grant requirements. The system includes built-in safeguards to flag non-compliant expenditures.

2. Review and Strengthening of Internal Controls: Life Source International Charter School will be implementing additional internal control systems & processes that include an additional review of back up documents before monthly reports are filed. A copy of all backup documents in support of all monthly reports will be kept at both Life Source International Charter School and the outside entities providing services and making reports on behalf of Life Source International Charter School.

3. Staff Training and Capacity Building: Our staff has received training on federal grant compliance, including the specific criteria governing the period of performance and allowable costs under federal awards. Additionally, with the Sage system in place, staff are now better equipped to manage compliance and reporting accurately.

4. Commitment to Ongoing Compliance: We are committed to continually improving our internal control processes to ensure compliance with all federal regulations.

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over non-payroll transactions such that all expenditures can be properly explained with supporting documentation, and all expenditures are reviewed and approved prior to payment. Additionally, the Organization only submits expenditures for reimbursement that have been paid. While the Office of Management and Budget allows the reimbursement of expenditures that have been incurred, the pass-through entity will only reimburse expenditures that have been paid. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Already implemented.

Views of Responsible Officials and Planned Corrective Action - The County will create a documented process in the new policy and procedures manual for federal guidelines and charging of administrative costs for documented time spent on grants with supporting calculations will be documented for clarity and consistency. Responsible Official - Andrea Montoya, Deputy County Manager and Robert Placencio, Finance Director Timeline and Estimated Completion Date -November 2024.