Corrective Action Plans

We are aware of the findings from the report and we will take the necessary steps to mitigate the issues.

Action taken in response to finding: 1. Create a standard procedure for tracking grant expenses: Completed 2. Train staff on procedures: Completed 3. Create an independent review process for all grant tracking: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

1. Cleveland UMADAOP will obtain written prior approval for any expenditure deviations from the originally approved budget. This topic will be covered when training occurs during the quarterly review of grant guidelines. 2. As part of its updated financial policies and procedures, Cleveland UMADAOP will seek to document all financial activity to ensure compliance with grant and federal guidelines. 3. As part of the updated financial policies and procedures, Cleveland UMADAOP will seek written confirmation from funders whenever there is a deviation from the terms outlined in the original award documentation. 4. As part of the updated financial policies Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

Finding 2023‐004 – Material Weakness, Material Noncompliance – Allowable Costs/Activities Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management will improve policies and procedures to record the purchase of gift cards as a prepaid transactions and expense the gift cards when all allowable cost criteria are met. We will also get input from our funders when necessary. Proposed Completion Date: October 31, 2024

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County review its procedures relative to allocating costs to Federal programs, and ensure only cost within the grant period are included. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements regarding period of performance. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

Apart from the audit observation that the work from home environment has impacted existing processes and retention of information, the issues with staff retention and turnover have presented multiples challenges in relation to continuity of knowledge base and consistent work routines. A key vacancy in the Budget & Compliance area is impacting the ability to move forward on several planned initiatives including i) develop a comprehensive key-data repository, easily accessible to parties requiring this information, ii) centralized accounting records i.e., journal entries, directly related to Federal contracts tracking and bookkeeping and iii) digitalization of underlying legal grant contracts, documents and files, as well as other important data. We are targeting full staffing no later than March 31, 2025, and these items will form part of this new hire’s cri􀆟cal path in the first 90 days at JVS.

We will implement procedures to ensure that our policies and procedures requiring the maintenance of documentation to support expenditures claimed under federal awards be followed consistently for all claimed expenditures in October 2024.

2023-009- Significant Deficiency in Internal Control and Non-material Noncompliance - Supporting Documentation for Expenses Incurred during the Year WPHW understands this finding and has already taken steps to ensure this issue does not come back up for FY24. WPHW keeps an extensive filing system which is mostly paper and not electronic. Our initial plan was utilized in NetSuite program as part of the electronic filing keeping system. After the transition away from NetSuite, we recognized the need for electronic filing keeping. In FY24 we did transition utilizing our share file to keep electronic copies of everything that we have paper copy. This includes AP items, AR items along with journal entries, bank reconciliations anything else deemed necessary. We understand the importance of having all documentation readily at hand for our monthly review’s yearly reviews and especially for the audit. Our process includes the following: 1) As items are entered into the vendor center of our accounting software, they are then scanned into the following system labeled by the individual in which it's entering the information into the system. 2) Invoices are prepared within the accounting software printed and then scanned with all supporting documentation into this electronic filing system. 3) Journal entries once prepared are printed attached with supporting documentation and then scan it to the electronic filing system. 4) Other items in which we keep electronic documentation following similar process these include bank reconciliations, contracts, and other pertinent files. All documentation is also kept within a filing system here within our department. Each group of documented items are labeled and filed chronologically in a centralized location. As we move through FY24 into FY25 we will continue to review and improve this internal process.

Management’s Corrective Action Plan For the Year Ended December 31, 2023 Contact Person(s): Sophia Hernandez, Chief Operations Officer Sophia.Hernandez@youthcare.org Amber Aman, Deputy Operations Office - Finance Amber.Aman@youthcare.org Finding Number: 2023 - 002 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action taken: • Develop a contract expenditure compliance review process created with final review and approval by Deputy Operations Officers. To be established by September 30th, 2024, and implemented in 2025 annual operating plan Anticipated completion date: In Process

Corrective Action: ABHS plans to optimize technology to improve the month-end closing process and allow for reconciliations to be performed on a consistent basis. Person Responsible: Alethea Velasquez, Chief Financial Officer, and CLA Estimated Completion Date: December 31, 2024

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended 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 implement procedures to better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Grantor no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

Audit Finding Number: 2023-002 Responsible Person: Carrie Smith, AVP of Regulatory Response to Findings: The Accounting Team performed an internal review and agrees with the Uniform Guidance audit findings. An adjustment was recorded as of 12/31/2023. In addition, the finding was communicated to the State auditors. Corrective Action to be Taken: 1. VillageCare will continue to utilize project ID when recording grants revenue and grants expenses. 2. Only appropriate, non-duplicative, and verified invoices will be submitted by the Accounts Payable Department for reimbursement. The AVP of Regulatory will receive and review all invoices from AP prior to submission to the funding source. 3. For material reimbursement, the Procurement Department will ensure the goods are received. 4. The Accounting Team will maintain all potential reimbursement schedules and cross check against current and past grants to ensure no prior approved expenditures are resubmitted for reimbursement. 5. The Director of Accounting and Finance and/or Controller will only approve grants receivable accrual based on allowable, confirmed, and validated invoices. Completion Date or Anticipated Completion Date of the Action to be Taken: September 1, 2024.

Over the past year, we have made significant improvements, reducing the occurrence of these findings compared to 2022. To continue to improve on and address this, we implemented a new HR solution, Rippling, in 2024, which will ensure all future agreements and rate changes are properly tracked and documented. This system will enhance our document retention process and ensure compliance with federal regulations moving forward.

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