Corrective Action Plans

March 27, 2024 2023-005: Significant Deficiency in Internal Control / Immaterial Noncompliance – Reporting Condition: During our review it was noted that documentation supporting reports filed by the Consortium were not maintained by management. Corrective Action: We agree with the finding. As we work towards developing our procedures, we are currently developing a list of required documentation as mandatory sourcing for quarterly reports. We do not anticipate this issue in our 2024 Single Audit when several cycles of closeouts have been completed. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: June 2024 Respectfully, Shamar Herron

Action taken in response to finding: The finance department has taken action in response to the circumstances which led up to this finding. We have added an accountant position to the team whose primary responsibility is to organize and invoice all grants for the organization. The additional staff person allows a more thorough and detailed review of allowable grant costs, specifically prorated payroll charges. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Nelson, Accounting and Financial Analysis Director Planned completion date for corrective action plan: 9/30/2023

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

Identifying Number: 2023-001 – Activities Allowed or Unallowed; Allowable Costs/Costs Principles Finding: The Code of Federal Regulations (CFR) Section 200.403(g) states that for costs to be allowable under federal awards, they must be adequately documented and there must be sufficient documentation. Additionally, CFR Section 200.430 states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed and are supported by a system of internal control which provides reasonable assurance that the charges are accurate and allowable. The Florida’s Division of Accounting and Auditing Reference Guide for State Expenditures states that supporting documentation shall be maintained in support of expenditure payment requests for cost reimbursement contracts including that approved timesheets support the hours worked on the project or activity must be kept. During our testing of payroll disbursements, we noted that seven of the 120 payroll expenditures selected for testing did not have a properly approved timecard for the pay period selected. Corrective Actions Taken or Planned: All of the timecards noted in the finding above have been reviewed for accuracy and retroactively approved by the Chief Talent Officer. The following corrective actions are in the process of being implemented: • CHS’s Payroll and Talent teams will conduct a review of timecards completed after July 1, 2023. The accuracy of any unapproved timecards identified will be verified and retroactively approved by the designated supervisor, or the Chief Talent Officer if the designated supervisor is no longer available. • After each payroll period, a list of unapproved timecards will be provided to the Talent Team so the respective Talent Business Partner may follow up with corrective action with those supervisors who have two or more repeat occurrences. Such corrective action will include: o A thorough review with the supervisor of the CHS policies and practices relative to supervisory duties regarding the management and approval of employee timecards. o Mandatory refresher education and training on the supervisory timecard review and approval process in the CHS HRIS, Paylocity. In addition, CHS is formally implementing a new HRIS, UKG PRO, in July 2024. This system has advanced notification and tracking features that will assist supervisors in proper management and approval of timecards. Person(s) Responsible for Corrective Actions: Barbara McDonald, Chief Financial Officer and Chief Administrative Officer and Heather Vogel, Chief Talent Officer Anticipated Completion Date for Corrective Actions: Implementation of the Corrective Actions outlined above will begin immediately to be completed by June 30, 2024.

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Views of Responsible Officials and Planned Corrective Actions: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will implement testing of our inventory system (Lawson) to ensure calculations are accurate. All review and approvals of capital equipment will be maintained in Strata. Responsible Party: Jill McCart, VP Accounting and Reporting Date of Completion: By 6/30/24

FINDING 2023-003 Finding Subject: Special Education Cluster (IDEA) ‐ Earmarking Summary of Finding: Proportionate Share Reporting could not be verified Contact Person Responsible for Corrective Action: Kevin Frank Contact Phone Number and Email Address: 812-254-5536 kfrank@wcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Washington Community Schools will require the Director of the Daviess Martin Special Ed Cooperative to provide Proportionate Share expenditure data and emphasize the importance of having this information available for SBOA. Unfortunately, due to our configuration, WCS doesn’t have access to this data and it is up to the Coop to complete the requirements. Mr. Frank will offer training to DMSEC staff to ensure compliance. Anticipated Completion Date: 02/01/2024

2023-001 Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: We have controls in place to ensure that costs charged to a grant are incurred within the grant period of performance. This finding exposed a vulnerability that circumvented our controls. We will use this finding to pinpoint the cause(s) and make the necessary corrective adjustments. Name(s) of the contact person(s) responsible for corrective action: Deborah Grupp-Patrutz and Steve Simmons Planned completion date for corrective action plan: Prior to June 30, 2024

FINDING 2023-009 Finding Subject: Special Education Cluster - Earmarking Summary of Finding: The School Corporation is a member of the Wabash Miami Area Programs for Exceptional Children (Cooperative). During fiscal year 2021-2022 and 2022-2023, the Cooperative operated the special education programs and spent the federal money on behalf of all its members. As the grant agreements were between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. However, there was inadequate oversight performed by the School Corporation in order to ensure compliance with the Matching Level of Effort, Earmarking compliance requirement. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the earmarking requirements. The Cooperative did not have adequate procedures in place to ensure that the required level of expenditures for non-public school students with disabilities was met for each member school. The Cooperative did not have effective internal controls to ensure non-public school expenditures were appropriately identified and reported. The Non-Public Proportionate Share expenditures for the 20611-054-PN01, 20619-054-PN01, 21611- 054-PN01 and 21619-054-PN01 grant awards could not be verified for the individual member schools. The non-public school share funds for all member schools were comingled and the aggregate amount of expenditures was then allocated to the member schools on a percentage basis. These allocations were the amounts reported to IDOE. As such, we were unable to identify which expenditures were for each school in order to verify the minimum amount per the grant award was expended and properly reported to IDOE as required. The lack of internal controls and noncompliance were isolated to the 20611-054-PN01, 20619-054- PN01, 21611-054-PN01 and 21619-054-PN01 grant awards. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: The district will collaborate with the SPED co-op to implement controls to ensure compliance with earmarking requirements. Anticipated Completion Date: To be completed by July 2024

March 27, 2024 Federal Audit Clearinghouse Re: Corrective Action Plan for Community Action Partnership of Mercer County To whom it may concern: Views of Responsible Officials and Planned Corrective Actions: 2023-01 There is no disagreement with the audit finding regarding costs allowed or allowable reviewed. The Organization’s fiscal policy manual policies and procedures states Audit costs are direct charged to each program and are billed separately to each program at a cost of 2% of the total budget of the program or grant. This policy has been enforced for years with an agreement between auditors and the organization. Management will review and update the Organization’s fiscal policy manual and procedures for consistency and compliance with GAAP and Uniform Guidance. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: May 31, 2024 Respectfully Submitted, Michelle Clarke VP/CFO

MANAGEMENT’S PLANNED CORRECTIVE ACTION: The School District’s will ensure that purchase order documentation is maintained as part of internal purchasing procedures. Regarding the timeframe for completion, the District has already implemented procedures regarding the documentation of costs and will continue to follow and improve them going forward. The District has contracted J. Martin & Associates, LLC (JMA) to provide business office accounting services.Representatives from JMA and the rest of the business office staff will monitor documentation procedures to ensure that they are followed appropriately.

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 2021. Payroll expenditures that were incurred or obligated before March 3, 2021, will be removed from the CSLFRF claims. 3. Anticipated implementation date: June 28, 2024

2023-004 Student Eligibility – Control Deficiency View of Responsible Officials Management agrees with the finding and provides more context regarding the finding. Participant eligibility procedures are based on USC §3272 and §3102 were created for Adult Education Family Literacy Act (AEFLA)-funded adult schools. The procedures were distributed, and training was provided on March 31, 2023 to address prior audit Finding No. 2022-03. The enrollment record that did not meet the criteria for eligibility in the Single Audit Fiscal Year Ending 06/30/23 had an intake date of September 15, 2022, approximately six months before the procedures were distributed and training provided. A corrective action has already taken place through the March 31, 2023 procedures distribution and training. The AEFLA-funded adult schools are aware that all participants reported in the AEFLA reporting system, known as the National Reporting System, including participants in workplace adult education and literacy activities as defined in United States Code, Title 29, Chapter 32 Workforce Innovation and Opportunity Act §3272, must meet AEFLA eligibility requirements. Corrective Action Plan Participant eligibility procedures for AEFLA-funded adult schools based on USC §3272 and §3102 will be reviewed annually with AEFLA-funded adult schools through a technical assistance session. The procedures inform the staff of the AEFLA-funded adult school of the following: • The Workforce Innovation and Opportunity Act • The Adult Education and Family Literacy Act • The relevant US Code and Code of Federal Regulations • A definition of AEFLA-eligible individuals • Categories of funding and their purpose • The role of the US DOE Office of Career Technical and Adult Education • The role of the Hawaii state director for adult education • The role of the AEFLA-funded local service providers Contact Person: Dan Miyamoto, TA Community Education Specialist Curriculum Innovation Branch Office of Curriculum and Instructional Design Anticipated Completion Date: August 31, 2024

Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As a part of this plan, EmployIndy’s Financial Operations Team, led by the Controller, has already begun to update the expenditure approval process. This process requires that supporting documentation be retained within the financial management system. Additionally, the review and approval process consists of multiple review and approval steps by program management and financial operations staff with specific focus on retention of supporting documentation and clear connections between expenditures being allocated to WIOA and other funding clusters and documentation supporting such allocations. All EmployIndy staff will be retrained on the updated expenditure submission, review, approval, and documentation processes. Additionally, EmployIndy’s Financial Operations, Grants & Contracts, and Program Management teams will provide guidance and training to EmployIndy’s subrecipients and contractors covering the proper process for submitting supporting documentation with invoices or accrued expenditure reports. These documentation requirements will ensure that supporting information directly and clearly ties back to invoices and/or accrued expense reports. EmployIndy’s Executive Vice President for Finance and Operations will work with other members of the Executive Team and other senior leaders to hold all staff accountable for following this process. Responsible Party and Timeline for Completion: Corrective Activity Responsible Party Timeline for Completion Develop training for the timely submission and proper submission, review, and approval of accrued expenditure reports and invoices, and appropriate documentation requirements Controller and Associate Director of Grants & Contracts 1st Quarter of Calendar Year 2024 Train internal EmployIndy staff and external subrecipient and contractor staff on properly submitting, reviewing, and approving accrued expenditure reports and invoices, and including proper documentation supporting expenditures Controller, Associate Director of Grants & Contracts, and EmployIndy Program Leadership By 2nd Quarter of Calendar Year 2024 Hold Financial Operations, Program Leadership, and subrecipient and contractor staff accountable for following established processes Executive Vice President of Finance and Operations Ongoing

Description of Corrective Action Plan: Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As part of the improvement to financial operations, EmployIndy will provide updated training to all staff covering the proper process for submitting, reviewing, approving, and retaining supporting documents for expenditures. The existing procedure includes a multi-step review and approval process for all expenditures, including those in the WIOA and other federal funding clusters. Additionally, EmployIndy’s Financial Operations, Grants & Contracts, and Program Management teams will provide guidance and training to EmployIndy’s subrecipients and contractors covering the proper process for submitting supporting documentation with invoices or accrued expenditure reports. These documentation requirements will ensure that supporting information directly and clearly ties back to invoices and/or accrued expense reports. Responsible Party and Timeline for Completion: Corrective Activity Responsible Party Timeline for Completion Develop training for the timely submission and proper submission, review, and approval of accrued expenditure reports and invoices, and appropriate documentation requirements Controller and Associate Director of Grants & Contracts 1st Quarter of Calendar Year 2024 Train internal EmployIndy staff and external subrecipient and contractor staff on properly submitting, reviewing, and approving accrued expenditure reports and invoices, and including proper documentation supporting expenditures Controller, Associate Director of Grants & Contracts, and EmployIndy Program Leadership By 2nd Quarter of Calendar Year 2024 Hold Financial Operations, Program Leadership, and subrecipient and contractor staff accountable for following established processes Executive Vice President for Finance and Operations Ongoing

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