Corrective Action Plans

Program: AL 84.010 ? Title I Grants to Local Educational Agencies ? Allowability and Subrecipient Monitoring Corrective Action Plan: The Department will contact the two subrecipients noted to provide one-on-one technical assistance and will also provide additional technical assistance regarding proper time and effort documentation to all subrecipients. Additionally, time and effort guidance is available to all subrecipients on the Department?s website, will be discussed at upcoming subrecipient training opportunities and supported by a dedicated Grants Management Training Specialist. The Department will ensure the identified written deficiencies noted in the subrecipient fiscal monitoring exit letter clearly identifies a finding vs. technical assistance needed; whereas a finding is supported by follow-up in accordance with federal UGG regulations and technical assistance provides knowledge of the Department?s training and resources available. Contact: Jen Utemark, Budget and Grants Management Anticipated Completion Date: December 31, 2023

FINDING 2022-001 Contact Person Responsible for Corrective Action: Adam C. Minth, Assistant Superintendent Contact Phone Number: 219-374-3504 Views of Responsible Official: The school corporation concurs with the finding and will be implementing corrective procedures by the end of this fiscal year. Description of Corrective Action Plan: The Corporation Treasurer and the Assistant Superintendent of Business and Operations are going to perform an analysis on the identified employee who is currently splitting her duties between the Child Nutrition Cluster and other non-federal duties. The analysis will be used to determine what percentage of her workload is directly related to the Child Nutrition Cluster, and what percentage is directly related to non-federal duties. Once the analysis has been completed, the Assistant Superintendent of Business and Operations will direct the Payroll Specialist in regard to what percentage of her pay should go to the Child Nutrition Cluster, and what percentage should go to the Operations Fund. Anticipated Completion Date: 4/30/2023

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: Our internal control process is properly designed to approve and calculate the payroll expenses and allocation of time to the program, but we did not maintain support for a true up for actual time spent on the program compared to the budget. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: The program manager will review and approve the level of effort contributed to the program by the employees. Formal documentation providing the support for a true up of actual time spent on the program compared to the budget will be maintained. Anticipated Completion Date: December 2023

Views of Responsible Officials: As of March 2023, we have implemented timesheet and work tracking for all employees and contractors receiving compensation from the Foundation. The timesheets have been enhanced to show the task completed. Each timesheet is reviewed, signed and dated by the Executive Director.

Nemours will create a standard operating procedure (SOP) that outlines a centralized process for effort allocation review and editing. The SOP will incorporate procedures to ensure accuracy and validation of all correcting entries. Meetings with each Nemours principal investigator (PI) will occur at least quarterly to review study financial information. An effort certification report will be reviewed by the PI for accuracy and sign off. Nemours policy 11.1.4, Cost Transfers for Funded Activities, will be reviewed and updated. Corrective action will be complete by October 31, 2023.

Views of Responsible Officials: We have streamlined and consolidated the payroll allocation file so that such manual errors will not occur in the future. We will also institute a monthly review process of employee timesheets, and the Executive Director will review and approve timesheets on a quarterly basis.

Audit Finding Reference: 2022-001 Improve Time and Effort Documentation Planned Corrective Action: We understand the importance and requirement regarding this finding. Semi-Annual certification of all staff funded fully out of grants will be completed. Monthly Time and Effort certifications will be completed for all staff funded out of multiple accounts, grant or local. Stipend and Payment for additional work forms will be completed for all staff supporting grant funded activities outside of contractual time. These forms will be re- viewed and maintained by Grant administrators. The district will use forms created and recommended for use by Massachusetts Department of Elementary and Secondary Education. Sample forms are attached. Name of Contact Person and Completion Date: Laureen Cipolla, Accountability and Student Achievement, laureen.cipolla@leominsterschools.org 978-537-7700 x l345 Anticipated date of completion - 6/30/23

In order to ensure City personnel time is allocated accurately and for allowable time charged to the CDBG program the City will continue to utilize employee-completed timesheets which match City pay periods. Each timesheet will be reviewed by the employee?s supervisor within about a week of the completion of any pay period. Since there are already policies and procedures established for time keeping for the CDBG program, the Department of Finance and Management will issue a memo for City personnel supervising CDBG funded staff outlining the time keeping procedures to be followed.

FINDING 2022-001 Contact Person Responsible for Corrective Action: Patricia L. Clark, Superintendent Corrective Action: The Milford School Department will prepare and disseminate to all employees wage agreements with documented pay rates. Anticipated Completion Date: October 15, 2023

FINDING 2022-005 Contact Person Responsible for Corrective Action: Mary K. Kaczka, Assistant Director, Community Development Contact Phone Number: 574-322-4472 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Program Income ? Use Management has taken or will take the following steps related to the weaknesses identified in payroll and vendor payments: Payroll: Employee time and effort logs were implemented as part of our corrective action plan for finding 2021-003. Due to the timing of the previous finding Management was unable to fully implement the action plan for the 2022 audit year. Time and effort logs are required to be completed by staff whose salaries and wages are paid from more than one Federal award as defined by 2 CFR 200.430(i)(1)(vii). Time and effort logs include allocation of time by program activity and general ledger account number. The time and effort log is acknowledged by the employee and the supervisor as part of the bi-weekly payroll process. Vendor: Late fees and taxes: Management will review existing claims process with staff and strengthen as necessary. Management will communicate with staff involved with the payment of claims that the payment of late fees or taxes the unit is exempt from are ineligible uses of federal funds. Program Income: Determining or Assessing and Recording: Management will address the program income weaknesses as follows: CDBG staff meets with city controller staff monthly and will expand its existing reconciliation to include program income receipted by the city and recorded in IDIS. Anticipated Completion Date: August 31, 2023

2022-003. Allowable Costs/Costs Principles United States Department of Education, passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States ALN: 84.027A Special Education Grants to States: IDEA 611 ARP Allocations ALN: 84.027X Special Education Preschool Grants ALN: 84.173A Special Education Preschool Grants: IDEA 619 ARP Allocations ALN: 84.173X Education Stabilization Fund (ESF) COVID-19: Governor?s Emergency Education Relief (GEER) Fund ALN: 84.425C COVID-19: Elementary and Secondary School Emergency Relief (ESSER) Fund ALN: 84.425D COVID-19: American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) Fund ALN: 84.425U Condition: Subpart E, 2 CFR ?200.430 of the Uniform Guidance requires that charges to ?federal awards for salaries and wages must be based on records that accurately reflect the work performed.? The documentation should support the distribution of the employee?s compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PARs) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District failed to prepare periodic certification equivalents correctly, to comply with Subpart E, 2 CFR ?200.430. - 13 - Planned Corrective Action: The Deputy Treasurer, Treasurer, and Payroll Supervisor will develop procedures to ensure that the Payroll Office obtains the necessary documentation to certify that salaries and wages were charged to the appropriate grants. Responsible Contact Person: Dr. Rodney Asse - Assistant Superintendent for Business Riverhead Central School District 814 Harrison Avenue - Riverhead, New York, 11901 Anticipated Completion Date: June 30, 2023

Reference Number: 2022-027 Prior Year Finding: 2021-025 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Award Number and Year: B08TI083060 (10/1/2019 ? 9/30/2021), B08TI083488 (10/1/2020 ? 9/30/2022) Compliance Requirement: Allowable Cost/Cost Principles ? Time and Effort Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Division should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division will reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Division will not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

Reference Number: 2022-015 Prior Year Finding: No Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number and Year: 20210DETANF (10/1/2019 ? 9/30/2025), 2222DETANF (10/1/2021 ? 9/30/2026) Compliance Requirement: Allowable Cost/Cost Principles ? Time and Effort Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Division should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Social Services (DSS) will review and strengthen its internal controls in regard to time and effort reporting to ensure it can substantiate all reimbursements from federal programs. The following specific actions will be taken to improve the current process. ? Reconcile actual costs to budgeted distributions ? Conduct semi-annual reconciliations of Semi-Annual Certification forms and quarterly reconciliations of T&E forms with budgeted distributions. ? Reconcile Personnel Summary with Earning Distribution Page. ? Implement internal controls for Time and Effort Reporting. ? Confirm that T&E information submitted is accurate and reconciled. ? Provide training for T&E certification. Name(s) of the contact person(s) responsible for corrective action: Victor Ting ? DSS Chief of Administration Joanne Sunga ? DSS Social Service Chief Administrator Planned completion date for corrective action plan: September 30, 2023

Reference Number: 2022-012 Prior Year Finding: 2021-010 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Public Health Federal Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Year: NU50CK000497 (8/1/2019 ? 7/31/2024) Compliance Requirement: Allowable Cost/Cost Principles ? Time and Effort Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The Division should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To strengthen its process, the Division of Public Health?s Laboratory (DPHL) will revise its Standard Operating Procedure (SOP) to add First State Financials (FSF) payroll reconciliation as the primary method of time tracking validation. DPHL had been using historic Division organizational charts to manually reconcile monthly payroll charges, which was inefficient. Having access to the FSF payroll records for the entire period allows us to search for staff charged improperly and resolve issues quickly. Name(s) of the contact person(s) responsible for corrective action: Wes Holleger, Laboratory Deputy Director, Division of Public Health Planned completion date for corrective action plan: June 30, 2023.

Identifying Number: 2022-008 Finding: Unallowable cost ? salary certification and personnel activity reports Corrective Actions Taken or Planned: UCAN agrees with this finding and believes the turnover in personnel affected this area as there was a misunderstanding on what was required. Employees in leadership positions have been trained on what is required and are ensuring that all staff certifications are being gathered monthly. This is a repeat finding, with the original corrective action plan to be completed before December 31, 2022. We do believe that corrective actions that have been taken have resolved this issue. Contact person is Kimberly Parish, Chief Financial Officer and she can be reached at kim.parish@ucanchicago.org.

Management will review time and effort documentation requirements with applicable employees.

U.S. DEPARTMENT OF HOMELAND SECURITY 2022-002 COVID-19 - Disaster Grants ? Public Assistance (Presidentially Declared Disasters)- ALN No. 97.036 Recommendation: We recommend the Town enhance procedures and controls to ensure that payroll costs charged to the grant are adequately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the auditor?s findings. Management will enhance procedures and controls to ensure that payroll costs charged to the grant are adequately documented. Name(s) of the contact person(s) responsible for corrective action: Sue Nickerson, Town Accountant. Planned completion date for corrective action plan: Immediately.

FINDING 2022-004 Subject: Child Nutrition Cluster ? Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, After School Snack Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY2021, FY2022 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with the requirements related to the grant agreement and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements. Context: The School Corporation had not designed or implemented adequate internal controls to ensure that payroll disbursements were only for food service-related services. Payroll disbursements comprise approximately 45% of the program costs charged to the Child Nutrition Cluster. One employee was responsible for processing payroll. Payroll reports were submitted to the School Board and Treasurer for review and approval; however, the reports only provided a total gross amount paid from each fund. The reports did not list the employees who were paid from the fund. In March 2021, the Treasurer implemented a review of the payroll distribution report, which is broken out by fund and individual employee. The lack of controls related to payroll disbursements was isolated to the 2020-21 year. Additionally, payroll disbursements for custodial employees were allocated to the Child Nutrition Cluster based on a percentage of the custodial employees? salaries. However, there were no time and effort logs or other documentation maintained to support the percentage of the custodial salaries allocated to the Child Nutrition Cluster. The custodial salaries make up approximately 3% of the total payroll disbursements charged to the Child Nutrition Cluster. This was an issue throughout the audit period. Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Description of Corrective Action Plan: The NJ-SP School Corporation will implement internal controls to ensure compliance with the activities allowed or unallowed and allowable costs/cost principles compliance requirements. This will consist of maintaining documentation to support that payroll disbursements are only for food service operating costs by having supporting timesheets and timecards or time and effort reports for all employees paid from the School lunch fund. These controls will be implemented by July 1, 2023. Responsible Party and Timeline for Completion: Dalton C. Tunis ? Corporation Business Manager/Treasurer Anticipated Completion Date: July 1, 2023

Finding 2022-001: Education Stabilization Fund??Governor?s Emergency Education Relief (GEER) and Elementary and Secondary School Emergency Relief (ESSER) Fund Semi-Annual Certification Procedures?Continued Pass-through entity: Michigan Department of Education (MDE) Assistance Listing Number(s): 84.425C and 84.425D Award Numbers: COVID-19 211202-2122, COVID-19 213712-2021, COVID-19 213722-2122 and COVID-19 213742-2122 Award Year End: September 30, 2023 Recommendation: The School District should provide training to educate all employees working in federal programs of the requirements for documenting personnel expenses under Uniform Grant Guidance, and the School District should require proper time-and-effort documentation to be timely prepared and certified by the appropriate program supervisor. Action taken: The School District will implement controls to ensure the appropriate time-and-effort documentation is completed timely and approved by the appropriate program supervisor by adding the topic to management meeting agendas and utilizing Outlook calendar events. Responsible Person and Anticipated Completion Date: Superintendent, December 2022. If the Michigan Department of Education has questions regarding this plan, please call Jim Nielsen at (231) 760-1309.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Cortney Parrish, Corporation Treasurer Contact Phone Number: 765-240-2346 Views of Responsible Official: We agree with the finding Description of Corrective Action Plan: As of fiscal year 2022, the School Corporation no longer pays teachers or aides from the School Lunch Fund, with the exception of one teacher being paid from the School Lunch Fund until December of 2022. As of January 1, 2023, only cafeteria employees are paid from the School Lunch Fund. Anticipated Completion Date: Completed

FINDING 2022-009 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over Activities Allowed or Unallowed & Allowable Costs/Cost Principles. After this review, we will implement a system to ensure that all costs are allowable for the program. Additional steps will be completed to ensure that Time and Effort documents are completed and maintained for audit. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

FINDING 2022-008 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Activities Allowed or Unallowed and the Allowable Costs/Cost Principles. After this review, we will implement a system to ensure that all costs are allowable for the program. Additional steps will be completed to ensure that the Time and Effort documents are completed and maintained for audit. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

FINDING 2022-007 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over the Activities Allowed or Unallowed & Allowable Costs/Cost Principles. After this review, we will implement a system to ensure that all costs are allowable for the program. Additional steps will be completed to ensure that the Time and Effort documents are completed and maintained for audit. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

Tacoma Arts Live Response to Single Audit Findings: Tacoma Arts Live management acknowledges that a union worker?s pay was not calculated in accordance with the union contract guaranteeing a 4-hour minimum on the March 20, 2020 payroll. This resulted an underpayment of $97.68. This payroll occurred during the first week of a global pandemic that caused quarantine and all workers to move from working in the office to working in a remote environment. The underpayment was immediately paid upon notification of the mistake. We have received no complaints from the employee. On the March 20th, 2020 payroll, an employee received a disbursement from a tip pool derived from multiple events in the amount of $61.00. This compensation was not removed from the SVOG tracking spreadsheet. Therefore, it was erroneously allocated to payroll costs for the SVOG award. Overall, qualified SVOG spending by Tacoma Arts Live exceeded that which was submitted as proof of spending for our award. Management believes that such over-allocating would allow any small errors in our reports. We regret these two errors and have corrected accounting procedures to control for such items in the future, as noted below. Tacoma Arts Live Corrective Action Plan for Single Audit Finding: Management has implemented an additional internal review process of all over-hire payroll reports. Additionally, management will not balance minor errors by including an excess of legitimate costs when reporting on federal awards.

Finding 2022-003 Federal Agency Name: Department of Justice Program Name: Crime Victim Assistance FFAL #16.575 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Our testing over payroll expenditures charged to federal program identified nine instances in which percentage of VOCA hours worked per employee timesheet differed from the percentage of VOCA hours charged to the federal program. Responsible Individuals: Becky Simmons, President and CEO, Donna Nugteren, Director of Finance, Rachel Schartz, Director of Grants Management Corrective Action Plan: State payroll is submitted monthly in the grant drawdown process. The state reviews all payroll and processes for calculating hours. They have provided Call to Freedom with their calculator to assist in the recording of employees who are partially covered under the state grant. All state drawdowns are reviewed by the state prior to payment. The new grant begins 07.01.23. Call to Freedom has obtained the requirements from the state in their Grantee Guidelines document. The Director of Grants Management is a new addition to Call to Freedom and will assist in the review of the process. Call to Freedom will verify accuracy of hours recorded. The percentages are determined by the number of hours each employee records in the grant for the monthly drawdown. Call to Freedom will audit monthly and submit to the state for their review and approval. Anticipated Completion Date: July 2023