Corrective Action Plans

2024-015 Program: Medicaid Cluster, Foster Care Title IV-E, Temporary Assistance for Needy Families, Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.778, 93.658, 93.558, 93.566 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Various Compliance Requirements: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.413(c)(1), Direct Costs, state that direct costs are those costs that can be identified specifically with a particular final cost objective, such as a Federal award, or other internally or externally funded activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. Costs incurred for the same purpose in like circumstances must be treated consistently as direct or indirect costs. 2 CFR Section 200.416(b), Cost Allocation Plans and Indirect Cost Proposals, states that individual departments typically charge Federal awards for indirect costs through an indirect cost rate. A separate indirect cost rate proposal for each operating department is usually necessary to claim indirect costs under Federal awards. Indirect costs include (1) the indirect costs originating in each operating department of the State, local government, or Indian Tribe carrying out Federal awards; and (2) the costs of central governmental services distributed through the central service cost allocation plan and not otherwise treated as direct costs. Condition: During our testing of pooled costs claimed through County Expense Claims, we noted that one (1) of forty (40) transactions was not a department cost that should have been included in the pooled cost. This pooled allocation affected the following major programs of SSA: 93.778, 96.658, 93.558, and 93.566. Cause: A journal entry was posted to the SSA Department’s general ledger by another County Department without SSA’s review/approval for allowable activities. The other County department inaccurately posted unallowable costs to the SSA department’s general ledger and SSA did not follow their procedures to ensure allowable costs were properly reported as a cost that can be specifically assigned to activities of the major programs identified in the County’s expense claims. Effect: Unallowable costs were included in the direct cost pool to be further allocated to the federal funded major programs. Questioned Costs: Questioned costs identified amounted to $50,971. The allocation of questioned costs to the major programs tested were as follows: • Medicaid Cluster (93.558) - $16,329 • Foster Care Title IV-E (93.658) - $17,009 • Temporary Assistance for Needy Families (93.778) - $17,633 The allocation to the Refugee and Entrant Assistance State/Replacement Designee Programs (93.566) was of a trivial amount. Context/Sampling: A sample of forty (40) amounting to $10,365,065 out of all costs included in the indirect cost pool of the County expense claims were selected for testing. Repeat Finding from Prior Years: No. Recommendation: We recommend the SSA enhance its procedures to ensure that allocated pooled costs have direct benefit to the department’s various federally funded programs. Management Response and Corrective Action: 1. Person Responsible: Jackqueline Ly, Financial Services Fiscal Administrator 2. Corrective Action Plan: SSA will work with other county agency’s financial team to ensure all transactions affecting SSA's ledger are reviewed and posted correctly. Conduct a monthly reconciliation of cost pool to verify compliance with allowable cost principles and provide more regular trainings for staff involved in cost allocations and expense tracking/reporting. 3. Anticipated Implementation date: April 2025

Corrective Action Plan 2023-001: Management will implement a comprehensive time tracking review process that also extends to reviewing time for employees that choose to work remotely and will ensure that time not allocated to the grant is not included in the costs allocated to the grant. Management will revise the fringe benefit rate that gets charged to the hourly rates to ensure that none of the costs included in the fringe benefits are also direct expenses billed to the grant. The unallowable costs will be redirected to other allowable grant costs in 2024. Anticipated Completion Date: September 2024 Contact Person: Jay Konomos, Pillar Leader

2023-039 Oregon Health Authority Ensure program payroll costs are incurred only for program staff MANAGEMENT RESPONSE: We agree with this recommendation. WIC Leadership is dedicated to reviewing and integrating existing reports into their time review process and will also ensure that staff responsible for employee time approval have been adequately trained on how to use those reports and features in Workday to review time. Questioned costs will be refunded. Anticipated Completion Date: September 30, 2024 Contact person: Tiare Sanna, Public Health Manager

Condition - The Special Education District prepared, and the cognizant agency approved, a grant budget that included $637,216 of salaries for learning loss, summer enrichment and after school programs (run by member districts). The Special Education District claimed grant expenditures for payments to member districts as salaries. Plan - Management will ensure compliance with all aspects of the program in the future. Anticipated Date of Completion - July 1, 2024. Name of Contact Person - Greg Wetheim, Director. Management Response - Management does not agree with this finding. Management reached out to the cognizant agency which provided the following response - "The ESSER III Cooperative grant was state set-aside funds that were originally awarded to ISBE. ISBE determined that to meet the stipulations of Learning Loss-Summer Enrichment-After School Program reservations, the most efficient way to reach the maximum number of students would be through the cooperatives providing for their member districts. Henry-Stark County Special Education District met those requirements and fulfilled their financial obligations by providing evidence-based activities through their member districts"

Upon learning of the possibility of frauduelent activity, the University began an internal audit review and all activity on the grant was stopped. Throughout the process, the University coordinated with the Ohio Department of Development. The internal audit procedures led to the determination that $209,101 was incorrectly reported by the program advisor and was not detected by the program director. These funds were returned to the Ohio Department of Development on October 11, 2023. The program has been termianted and program income returned. The individuals involved with this program are no longer employees of the University. The University is in the process of seeking reimbursement from the former employee. An internal controls questionnaire was prepared and reviewed for the other Small Business Development Center (SBDC) program noting no areas of concern. The FY24 internal audit plan will include additional review of the remaining SBDC program as well as review of controls within the department which previously managed the program noted in the finding. In addition, training related to roles and responsibilities for supervisors/approvers will be provided in FY24 to emphasize the guidance provided in the grants manual. Contact person responsible for the corrective action: Mark Polatajko, Senior Vice President for Finance and Administration.

Finding: 2022-001 Material Weakness in Internal Control over Financial Reporting and Compliance Personnel Responsible for Corrective Action: Kerry Romero, Director of Accounting Anticipated Completion Date: December 31, 2023 Condition: During our testing, we noted reimbursement requests were prepared using grant budgets rather than direct costs incurred. Management was unable to determine direct costs related to general and payroll disbursements. As a result, proper revenue recognition could not be determined for financial reporting purposes. Corrective Action Plan: The Organization will use the jobs and classes functions within their accounting software to track expenses related to grants. The Organization hired a Grant Coordinator to oversee the review, tracking, and reporting for all grants. The Organization will train and work with all applicable staff to create timesheets for grants requiring such documentation. The Organization will prepare a Schedule of Expenditures of Federal Awards (SEFA) which will be used in conjunction with the accounting software to track grant costs.

FINDING: DYER COUNTY SCHOOL DEPARTMENT HAD DEFICIENCIES IN THE USE OF EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASED (ELC) GRANT FUNDS, WHICH RESULTED IN QUESTIONED COSTS Response and Corrective Action Plan Prepared by: Cheryl Mathis, Director of Schools & Jeremy Gatlin, School Board Chairman Person Responsible for Implementing the Corrective Action: Cheryl Mathis, Director of Schools & Jeremy Gatlin, School Board Chairman Anticipated Completion Date of Corrective Action: October 11, 2022 ? Repeat Finding: No Reason Corrective Action was Not Taken in the Prior Year: NIA Planned Corrective Action: The school system will strengthen its internal controls by requiring that any future bonus paid to any member of the administrative staff be approved by the school board before the funds are disbursed to ensure that duties are adequately segregated. /l

Management understands that CFR 200.413(a) states “Direct costs are those costs that can be identified specifically with a particular final cost objective, such as a Federal award, or other internally or externally funded activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. The County is currently working toward stronger internal controls, education of staff, and a more intense review process. It is expected that these changes will take time. The new Grants Committee is meeting monthly to keep grant management in the forefront of all those concerned.

Management understands that CFR 200.413(a) states “Direct costs are those costs that can be identified specifically with a particular final cost objective, such as a Federal award, or other internally or externally funded activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. The County is currently working toward stronger internal controls, education of staff, and a more intense review process. It is expected that these changes will take time. The new Grants Committee is meeting monthly to keep grant management in the forefront of all those concerned.

Management and accounting personnel will create procedures to ensure that direct cost is charged at the actual amounts incurred and will develop a payroll cost allocation and allocable direct cost allocation methodology that ensures costs are charged in compliance with the applicable federal costs principles.