Corrective Action Plans

Finding 2022-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Through testing of operational expenditures of the College, it was determined; o Payroll expenditures charged to the award were not for costs newly associated with the coronavirus, a requirement communicated within the supplemental guidance in the Higher Education Emergency Relief Fund III Frequently Asked Questions published May 11, 2021 and updated May 24, 2021. Through testing of disbursements to students, it was determined; o No support could not be provided to substantiate a secondary level of review was completed prior to disbursement of funds. o 26 instances identified in which the College directly controlled how student?s use their emergency financial aid grant. o 8 instances identified in which college discharged outstanding balance on student account for costs incurred prior to March 13, 2020. o 2 instances identified in which the College charged coronavirus vaccine incentive payments under the student portion of HEERF award. Responsible Individuals: Dr. Lane Azure, President Corrective Action Plan: o In response to the payroll finding, this was funded through MSI (no Student or Institutional funds were used for payroll). SWC president attended weekly meetings with American Indian Higher Education Consortium (AIHEC) who assisted and advocated for these HEERF monies for all Tribal Colleges and Universities (TCU). Handouts (attached) of slides were given to each institution and Payroll was an allowable cost with the exception of the President. The college president believed in order to allow the college to stay open and not lose students and staff, subsidies had to be included in payroll. There were no predictions on how long this world-wide pandemic was going to last or how much funds the government was going to give to IHE. SWC is a small tribal college where hiring and maintaining qualified personnel has been difficult long before the pandemic and now even more so. SWC could not afford to hire new staff even if it was feasible to find someone to fill new positions. Therefore, SWC used HEERF to make payroll on many employees whose job duties changed so they could assist the college in staying open and transition to a completely different method of delivering education to SWC students. SWC president was told by the Department of Education and AIHEC that these funds had to be exhausted in a limited amount of time. In addition, there was a limited number of items that the funds could be spent on, but it was changing every day to be more liberal. In March 2020, SWC had to begin offering courses via distance delivery which was a completely new method for this college. In summer 2020, the college did not offer classes and in fall 2020 SWC had to begin offering a hybrid method of delivery. Every single employee of this college had to do their day to day duties differently in order to support the new delivery method for education ranging from contact tracing, hyflex delivery, social distancing, hygiene, masking up, staff meetings, parking, teaching, and etc. The range of employees went from admissions, student services, academic staff, faculty, and the business office. All employees were coming in at different shifts, and/or working remotely, while social distancing. o The College will ensure documented secondary level of review and approval is retained. o For grant payments funded by institutional portion, Grant payments were applied to student accounts and if no outstanding balance, a check was given to the student. For grants funded by MSI, a formula was used to distribute $125 per credit and an allowance for books and fees. The COARS was a financial aid grant to the student who applied for the relief. o Any debt relief provided for students was for those students who could not attend the current academic year because of a prior balance. In order to attend college during the pandemic, MSI funds were used to discharge the student?s balance at the discretion of the student. o The checks for these instances were given directly to the student to defray costs of going to get the vaccine, for transportation, for cost of the office visit, or whatever it may have been they needed in order to get the vaccine. It was emergency aid to the student. Anticipated Completion Date: July 1, 2022

FY22 Audit Corrective Action Plan: 2022-001 - Allowable Cost/Cost Principal Condition: During audit procedures, it was identified that the Unit did not complete the semi-annual time certifications/periodic time certifications for six employees. Cause: The CSD does not have the necessary internal controls over compliance. Effect: Expenses may not be properly allocated to the grant; this could result in unallowable expenses being charged and subsequently improperly reimbursed by federal funds Recommendation: It is recommended that the Unit implement internal control processes and procedures to ensure that time and effort records for employees working are properly documented in accordance with the grant requirements. FY22 Process: The Five Town CSD had regularly had each employee paid with federal money sign a semi-annual certification and that certification is maintained in the employee?s personnel file under Contracts. The CSD believes that these certifications had been pulled from the files by the prior business manager in an effort to compile compliance paperwork to the Maine DOE for reimbursement purposes. New Process: In addition to our practice of requiring compliance from the employee or supervisor with direct knowledge of the employee?s time and effort, we are preserving a digital copy in our federal funds cash management folders as well at attaching the document to the employee?s digital record so they are preserved and available for federal grant and audit compliance. Time and Effort records will be reconciled semi-annually with the general ledger documentation of grant funded salary expenditures. Responsibility: The Business Manager, Peter Orne, and Human Resources Director, Monica Gallagher, are responsible for the execution of the plan and subsequent reconciliation. Completion Date: This is an ongoing process and semi-annual certification for July 2022 to December 2022 has been reconciled.

Finding Number 2022-001 Planned Corrective Action - Significant Deficiency ? Internal Controls Over Payroll (Documentation of review of timesheets by an appropriate level of supervisor was not consistent) This finding was originally communicated to AIM after last year?s audit. AIM has included a policy in both its Financial Policies and Procedures and its Employee Manual that requires that timesheets be submitted to and approved by the employee?s supervisor. Compliance has been consistent since mid-October 2021. Anticipated Completion Date - October 15, 2021, Responsible Contact Person - Virginia Moss, CPA, Chief Financial Officer

Response to Finding #2022-002: The Business Office, in coordination with the Human Resources Department, is developing a process to ensure timely reviews and approvals of employee time and effort charged to federal programs is documented on a periodic basis. The corrective action is expected to be implemented by June 30, 2023.

FY 2022 Corrective Action Plan Audit Firm: RSM US LLP 30 South Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 07/01/2021 ? 06/30/2022 Contract Number: FCSAK05984 Award Year: 2021 ? 2022 Comments on Findings and Recommendations: Finding 2022-001?Budget Based Salary Allocation (Compliance and Control Finding)? The Jewish Federation of Metropolitan Chicago (the Federation) allocated staff salaries to the federal program based on budget estimates, which alone does not qualify as support for charges to federal awards. The Federation allocated one employees? salary to the program based on a budgeted rate. All other employees have 100% of their salaries allocated to the program. 2 CFR 200.430(i) Standards for Documentation of Personnel Expenses (1) Charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to federal awards, but may be used for interim accounting purposes, provided that the non-federal entity's system of internal controls includes processes to review after-the-fact interim charges made to a federal award based on budget estimates. All necessary adjustment must be made such that the final amount charged to the federal award is accurate, allowable, and properly allocated. Action Taken?As the Federation does not have processes and controls in place for federal program time tracking, the Federation will only allocate staff to the program that spend 100% of their time on the program starting July 1, 2022. The required corrective action for Finding 2022-001 for the period 07/01/2021 ? 06/30/2022 was completed on July 1, 2022. The person responsible for completion of the corrective action plan was James Pinkston, Vice President, Accounting. James Pinkston Date Vice President, Accounting Jewish Federation of Metropolitan Chicago 30 South Wells Street, Chicago, IL 60606 Email: jamespinkston@juf.org

SAU 58 had a big transition our office with the replacement of all three of our accounting positions; Business Manager, Payroll/HR and Accounts Payable & Grants. The Accounts Payable position was then vacated for a second time and we found a new replacement in Jan 2022. During this transition period the Time and Effort for two positions that were grant funded, was overlooked. We did provide documentation of payroll from Payroll/HR but did not get the signature of the teacher or other staff member on the Certification form. Typically, we would have been able to rectify the omission but the employees had both left our district at the end of the school year. The Business manager is ultimately responsible for the implementing of the process and internal controls and will follow up with the Accounts Payable clerk to be sure each month all documentation is on file. Since the new AP person came on, she has implemented a spreadsheet to track each employee paid by Federal Funding. This way we know who has submitted their certification, and at what point we are at during the year. We will be looking at electronic documents in the future for easier tracking and getting signatures on certification documents but as of now the spreadsheet has made this process much easier to track and be sure we do not miss documents. If a big transition happens again the Accounts Payable Clerk will be responsible for all grant compliance paper work. The Business Manager will oversee this process. The above processes and procedures have already been implemented and the Business Manager will follow up monthly with the Accounts Payable clerk. Name of Contact Person and Completion Date: Name 1 Heather McMann Name 2 Tiffany Griffin Anticipated Completion Date ? Already implemented.

Finding 2022-007 Personnel Responsible for Corrective Action: Assistant Comptroller ? Brian Huggins Anticipated Completion Date: June 2023 Corrective Action Plan: The University's current process is to collect and retain procurement documents for no less than five years. The institution will work to strengthen the current process in place relevant to securing adequate documentation. Supporting documentation was provided for data selection relating to the upgrades to the HVAC, ventilation, and the spacing of the academic facilities which were all completed in accordance with Covid guidelines. The University is working with our third-party payroll provider to automate time and effort reporting.. We are currently using paper forms for reporting until we can implement Time & Effort through ADP. The Director of Title III & Finance Compliance officer to further discuss time and effort.

Finding 2022-003 Personnel Responsible for Corrective Action: Director of Title III and Compliance ? Dr. Neidra Butler Anticipated Completion Date: July 2022 Corrective Action Plan: The University is working with our third-party payroll provider to automate time and effort reporting.. We are currently using paper forms for reporting until we can implement Time & Effort through ADP. The Director of Title III & Finance Compliance officer to further discuss time and effort.

Finding 2022-003 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425E P425E200919- 20B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Eide Bailly LLP found that the University over-awarded Higher Education Emergency Relief Fund (HEERF) funding to one student based on its determination over eligibility of the student portion of HEERF funding, which is awarded based on (1) expected family contribution and (2) enrollment status. The student was awarded based on fulltime enrollment; however, the student's enrollment status was part-time. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant; Karrie Morgan, Director of Financial Aid; Anna Heckenliable, Registrar Corrective Action Plan: Responsible Individuals above will review credit hour reports pulled from the system for accuracy to ensure no hours are duplicated. Anticipated Completion Date: Management expects this finding to be resolved by January 31, 2023.

2022-002 Activities Allowed or Unallowed, Allowable Costs/Cost Principles Medical Assistance Program ? CFDA No. 93.778 ? Award Period: July 1, 2021 through June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance Response: Adult Care Management, Inc. (ACMI) agrees with the finding of Taylor Roth & Company, PLLC, in the fiscal year 2022 Single Audit (SEFA) that the established internal controls over payroll cost allocation did not operate as intended to ensure appropriate allocation of payroll costs across all programs in the five (5) of the twenty-four sampled payroll periods for one (1) individual. Action: Effective March 10, 2023, the internal control practices of ACMI will be strengthened to support a review system able to prevent and/or detect and correct errors in a timely manner to ensure payroll costs are accurate, allowable, and properly allocated. Specifically, management?s monthly review of all cost allocations will include a review of the data entry hours from payroll timesheets into the payroll allocation spreadsheet of no less than 10% of total reporting employees, with a priority focus on employees reporting time to more than one program / cost center.

2022-001 ? Employee Time and Effort Documentation (Significant Deficiency) Federal Program Information: Funding Agency: U.S. Department of Education Title: Teacher & School Leader Incentive Program Assistance Listing: 84.374 A Passthrough: N/A Award Year: 2022 Condition: The Foundation does not have a system of internal control to accurately track personnel costs when the individual works on more than one program. The Foundation makes a good-faith effort to budget an individual?s time based on their best estimate of the distribution of the employee?s time over the various programs. However, the Foundation?s employees were not required to track their time on a daily basis and identify which program was worked on during that day. The Foundation did not require those employees who are assigned to multiple cost programs to track and certify their time. The Foundation did not ?true-up? actual time versus budgeted time for the various programs during the year. Auditor?s Recommendation: The Foundation should implement internal control policies and procedures which require employees who work under two or more programs to track their time in a method that allows for proper allocation of expenses between those programs. Additionally, the Foundation should implement a process for employees to certify that their time is properly tracked and allocated. Finally, the Foundation should implement a time-frame to adjust budgeted salaries to actual salaries based upon the tracking performed by employees. Responsible official?s view: Specific corrective action plan for finding: Dr. Linda Coy in conjunction with James Coy, CFO and Patty Eaton, Business Manager have developed a revised process of collecting T & E data from employees affected by this action. Each affected employee will collectdaily activities tied to the percentage of time allocated to their respective positions and submit on a monthly basis to the business office. The business office will calculate the time spent on each project and provide that information back to the employee for adjustment during the following month. The documentation, for each employee that is part of this process will be available to the auditors during the next audit cycle. The HR department will maintain these files for inspection. Timeline for completion of corrective action plan: After consultation with the auditor, it was decided that the effective date for implementation is September 1, 2023. Employee position(s) responsible for meeting the timeline: Dr. Linda Coy, Three Rivers Education Foundation Director & James L. Coy CFO

2022-003 ? Allowable Costs/Activities Allowed or Unallowed: Fringe Benefits and Shared Costs Name of Responsible Individual(s): Pamela Aguilera, Chief Financial Officer Corrective Action: During the initial year of receiving our first direct federal grant, Safe & Sound calculated fringe benefits based on a percentage of the salaries allocated to the grant. Salaries were calculated based on time and effort. Safe & Sound has reviewed the current practices related to allocating fringe benefits and shared costs. Safe & Sound?s Finance team reviewed and verified that we have the adequate fringe benefit and shared costs to meet the costs allocated to this grant. To ensure we have the proper supporting documentation to meet the Uniform Guidance requirements in 2 CFR Sections 200.303 and 200.403, we will implement time and effort documentation for benefit and shared cost allocations on a monthly basis and will review for any necessary budget to actual adjustments. Date Completed: 8/31/2023

2022-004 Federal Agency: U.S. Department of Education Pass Thru Entity: Oklahoma State Department of Education Program: COVID-19 Education Stabilization Fund Assistance Listing: COVID-19- 84.425D & 84.425U Grant Period: Year ending June 30, 2022 Recommendation: The Auditor recommended that The District needs to have time and effort documentation maintained. The District needs to develop procedures to maintain documentation supporting work performed. Action Taken: District was unaware of the time and effort requirement for this program. New Federal Program director is monitoring this time and effort. FY23 the time and effort documentation has been kept for this program. Anticipated Completion Date: May 2023 Responsible Official: Superintendent

Please allow this correspondence to serve as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to the audit findings. During the FY2022 Single Audit, six audit findings were identified by Washington, Pittman & McKeever, LLC. CCH and CCDPH will address the recommendations of the auditors by taking the following Corrective Action Plans (CAP) outlined below: Finding 2022-004: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from Program Leads and the Accounts Payable unit not following the established requirements for properly supporting invoices for services provided. The invoices that were attached in EBS Oracle were insufficient as required by the established County Policy. Correction Action: The CCH Director of Grants Accounting will be responsible for training the Program Leads and Account Payable (AP) unit to ensure proper supporting documents are attached to each invoice as required by the established County Policy. In the event the AP unit determines more supporting documentation is needed, then the Program Director/Lead will assist in obtaining proper supporting documents from partnered subrecipients and/or vendors. Supporting documents may include additional timesheets, payroll registers, T&E justification, etc. Issues will be flagged (based on assessed risk) by applying requirements identified in the CCH Subrecipient Monitoring Policy. Anticipated completion of the corrective action will be December 31, 2023.

Finding #2022-007: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from the Program Leads and Accounts Payable unit not following the established requirements for properly supporting invoices for services provided. The invoices that were attached in EBS Oracle were insufficient as required by County Policy. Correction Action: The CCH Director of Grant Accounting will be responsible for training the Program Leads and Account Payable (AP) staff to ensure proper supporting documents are attached to each invoice as required by County Policy. In the event the AP unit determines more supporting documentation is needed, then the Program Director/Lead will assist in obtaining proper supporting documents from partnered subrecipients and/or vendors. Supporting documents may include additional timesheets, payroll registers, T&E justification, etc. Issues will be flagged (based on assessed risk) by applying requirements identified in the CCH Subrecipient Monitoring Policy. Anticipated completion of the corrective action will be December 31, 2023.

Management agrees with the finding. The noted PI circumvented existing internal controls, all of which performed as designed to ensure financial compliance and grants stewardship. Management recognizes the opportunity to ensure that PIs are aware of the University?s grant accounting policies and practices as well as federal policies through formal trainings. Research Financial Services, and the Office for Research will work closely with the Chancellor led units to create and enforce trainings for our university faculty and researchers. Management will also investigate opportunities to reduce opportunities to circumvent controls.

The following are the School District?s response to the suggested recommendations made in the management letter received from the School District?s auditors, PKF O?Connor Davies: Finding 2022-001: Other Matters ? Personnel Activity Reports (PARs) Condition For 4 out of 4 employees selected, no Personnel Activity Reports (PARs) were able to be provided documenting the allocation of the work performed on each grant. Corrective Action Planned The district will maintain the required PAR reports for each grant funded employee. If an employee is retroactively charged to a federal fund, we will obtain a signed PAR form from that employee at that time. Anticipated Completion Date November 21, 2022. The PAR forms have been completed and any additional PAR forms will be completed in accordance with Federal requirements. Individual Responsible for Corrective Action Plan Angelo Rubbo, Assistant Superintendent of Business, Finance, and Facilities

CSC?s management concurs with the finding. See Section IV- Current Year Corrective Action Plan.2022-002 Allowable Costs/ Cost Principles Name of Contact Person: Brenda Chandler and Johnny Mammen Corrective Actions: CSC has implemented a policy as of July 10, 2023, that ensures that personnel are hired after the positive background compliances confirmations are obtained along with the modification of internal controls to ensure CSC?s compliance with Federal statutes, regulations, and the terms and conditions of the federal award as stated in the grant requirements. The Human Resources Director will be responsible for implementing and monitoring this policy. Due to the new personnel in finance effective July 17, 2023, CSC will be able to ensure that all grants? receipts are supported by appropriate documentation for expenses incurred. The Senior Accountant will be supervised by the Director of Finance who will be responsible for the implementation of the corrective action. Proposed Completion Date: July 10, 2023 and July 17, 2023 Telephone Number: 202-517-6737

Oversight Agency: U.S. Department of Health and Human Services Turning Point Behavioral Health Care Center respectfully submits the following corrective action plans for the year ended June 30, 2022. Auditor: Dugan & Lopatka, CPA?s 4320 Winfield Road Suite 450 Warrenville, IL 60555 Audit Period: For the year ended June 30, 2022 The finding from the schedule of finding and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings ? Federal Award Programs Audit 2022-001 Auditor?s Recommendation: We recommend Turning Point Behavioral Health Care Center remind its employees that the personnel activity reports are required to be completed. Action Taken: We agree with the finding, and we will be implementing additional staff training for the Personal Activity Reports to be completed by February 24, 2023. In addition to staff training, we have also created a new process to review all Personal Activity Reports. This process will be completed monthly by payroll staff to ensure all personal activity reports are completed accurately. If the funding agency has questions regarding this plan, please call me at 847-933-0051 ext. 417.

Finding Number: 2022-003 Program Name/Assistance Listing Title: Indian School Equalization Program, Administrative Costs Grant for Indian Schools, Twenty-First Century Community Learning Centers Assistance Listing Number: 15.042, 15.046, 84.287 Contact Person: Irene Casias, Human Resources Anticipated Completion Date: March 31, 2023 Planned Corrective Action: The need for improved record keeping and scheduling of such action has been stressed to the new person responsible for such actions. The individual is aware and will strive to make sure that the School is in compliance with the requirements.

Finding 2022-002 Contact Person: Lily Rakness Parra, County Clerk Corrective Action Planned: Washakie County agrees with the finding of 2022-002. A Sams.gov account has been activated in order to verify that entities that are being utilized for County business are not excluded from or are ineligible for participation in Federal programs or activities. Also, the County is currently drafting a Procurement Policy for Washakie County to utilize for the use of Federal funding as well as in an everyday manor of purchasing and maintenance of county facilities in order to satisfy above finding.

Staff has initiated a process whereby ? for employees not using eSuites ? manual review and approval of bi-weekly hours is conducted by supervisors in the appropriate department (i.e., Transit, Police, etc.). Management believes this additional review and approval level will provide the necessary back-up to improve internal control over timecards/timekeeping. Responsible Person: Kevin Saycocie Expected Implementation Date: 07/01/2023

Corrective Action Plan The Troy City Board of Education (the Board) respectfully submits the following corrective action plan for the year ended September 30, 2022. Carr, Riggs & Ingram, LLC 1117 Boll Weevil Circle Enterprise, AL 36330 The finding from the September 30, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistent with the number assigned in the schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT No such findings in the current year. FINDINGS ? FEDERAL AWARDS PROGRAM AUDITS Item 2022-001 Activities Allowed/Allowable Costs & Costs Principles (Payroll) Recommendation: 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? We recommend a more detailed and frequent review of the payroll register used to prepare the time and effort certifications should be performed and documented Action Taken: All late hires will be manually added to the review list as needed during the fiscal year for review. Tricia Norman, CSFO, will be responsible for the corrective action plan and anticipates completion of corrective action will be taken before 9/30/2023.

Corrective Action Plan: The Agency of Administration Financial Services Division recognizes the need for a refresher training for all staff on existing procedures to minimize keystroke errors in the future. This training will be completed by May 31, 2023. An additional process will be added to the existing procedures. On a quarterly basis, the General Ledger will be reviewed by program staff to check for reasonableness and the review will be confirmed by a Supervisor. Scheduled Completion Date of Corrective Action Plan: Expected: May 31, 2023: Training for FSD Staff on existing procedures Expected: June 30, 2023: Procedure for General Ledger Review implemented Contacts for Corrective Action Plan: Doug Farnham Deputy Secretary, Agency of Administration Douglas.Farnham@vermont.gov (802) 585-8119 Holly S. Anderson Chief Financial Officer, Agency of Administration ? Financial Services Division Holly.S.Anderson@vermont.gov (802) 505-1177

Finding 2022-102 ? Improve Controls over Allowable Costs (Material Weakness) FAL Numbers: 15.042 Program Titles: Indian School Equalization COVID-19 Indian School Equalization Condition and Context: During 2022, the School provided stipends to employees for recruiting and retention. These stipends ranged from $1,800 to $16,700 per employee. The recruiting and retention stipends had no supporting documentation justifying the amount paid. Recommendation: The auditors recommended that the School establish a written policy on the stipends for recruiting and retention that is reasonable and comparable to other similar organizations in the area. Contact Name: Renee Ramirez, Business Manager Corrective Action Planned: HBCS will develop, in conjunction with the Governing School Board, a recruitment and retention policy that is reasonable and comparable to other schools on Hopi. Anticipated Completion Date: June 30, 2023