Corrective Action Plans

Management concurs with the finding and will implement a proper expenditure reporting process, reconciled monthly, to avoid recurrence during future audits.

The City will review the process for identifying federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards. This will include inquiries of the Engineer’s Office.

Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee's financial statement. It is the responsibility of the auditee's management to design and implement internal controls that provide reasonable assurance over the completeness and accuracy of the SEFA. The SEFA is the basis for the auditor's identification of major programs. Condition: The City's initial SEFA provided for the audit was incomplete and contained inaccurate program expenditure amounts. In particular, there were multiple federal programs that were not identified, or had inaccurate amounts reported, on the initial SEFA for the year under audit: ALN 16.554 National Criminal History Improvement Program (NCHIP) ALN 20.600 State and Community Highway Safety ALN 66.458 Capitalization Grants for Clean Water State Revolving Funds ALN 93.568 Low-Income Home Energy Assistance ALN 97.044 Assistance to Firefighters Grant ALN 97.067 Homeland Security Grant Program Cause: The City does not have a method to accurately track the related expenditures for reporting. Effect or Potential Effect: A Uniform Guidance compliance audit is based on the premise that management must comply with federal statutes, regulations and the terms and conditions of the federal awards it received. Without identifying the funds as federal, the auditee may not have complied with those requirements. In addition, there is increased risk regarding the accurate reporting of grant expenditures and noncompliance with policies and procedures surrounding the recording of federal awards. Questioned Costs: None Context: The City was aware of the requirement to prepare a SEFA prior to the audit; however, they were not able to accumulate the appropriate records to correctly identify the source of funding for all ongoing projects. In addition, management was unable to accurately determine the amounts to be reported on the SEFA in accordance with 2 CFR §200.502. The adjustments to the SEFA amounted to an increase in Total Federal Expenditures reported of $892,160. Repeat Finding: This is a repeat finding; it was previously finding 2021-006 and 2021-007. Recommendation: We recommend the City develop and implement procedures to ensure that information related to all federal awards is accumulated to assist in the preparation of the SEFA. In addition, we recommend management of the City verify the completeness and accuracy of the amounts reported on the SEFA. Response: The City agrees with the finding, and will develop a method for accurately tracking federal expenditures. Anticipated Completed Date: June 30, 2025 Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance City of Cortland, 25 Court Street, Cortland, NY 13045 (607) 758-8373

Management’s Planned Corrective Action: Disagree: We have established a cost center or “Department” for each federal program that clearly identifies federal expenditures. Our funders request monthly copies of receipts and payment issued to verify expenses. Responsible Party: Beaulieu Accountancy Corporation, Accountant Completion Date: 9/25/2024

Finding no.: 2022-003 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The SEFA was assigned to be prepared internally, but unfortunately was not submitted due to staff turnover during the course of the audit. This oversight will be corrected by improving procedures around internal task assign-ments when employee turnover is experienced in the Fiscal department during the course of the audit. Anticipated completion date: December 2023

Consortium’s Fiscal Agent will ensure that supporting documentation will be maintained for all expenditures to ensure that each expenditure charged to the program is for an allowable activity/cost. In addition, Fiscal Agent will complete corrective action for 2022-005 & 2022-006

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

Finding Number: 2022-003 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: The federal funding was not received until fiscal year 2023 while some expenditures were incurred in fiscal year 2022. The timing of events contributed to the oversight on the 2022 SEFA. WakeMed has reeducated staff on the preparation of the SEFA in order to prevent this error from reoccurring.Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

Action Taken: Management is in the process of instituting additional procedures to ensure all awards are assessed not only to identify whether sources of funds are Federal, requiring inclusion on the SEFA, but also to identify continuing compliance period when applicable. Management has also conducted internal training relative to applicable 2 CFR 200 regulations and requirements and will continue to provide periodic staff training to ensure continued compliance. Anticipated Completion Date: Management estimates that additional processes will be in place by December 31, 2024.

The Township Fiscal Officer will prepare the SEFA or contract with a CPA firm to have the SEFA prepared going forward.

Management accepts this finding. A detailed set of procedures was documented immediately after the discovery of this error in preparing the Schedule. Included in these procedures, a query is run of research projects. This query is sent to Sponsored Research Services (SRS) to review to verify the reporting status and AL numbers, and other items are correct and complete. Once SRS has verified the data in the query is complete and accurate, then the Controller’s office will proceed with preparing the Schedule as well as reconciling it to the Statement of Activities (SOA) In the procedures, we have added that SRS and the Controller, and/or Chief Financial Officer review the Schedule prior to initiation of the audit review process.

Internal communication processes for direct pay projects were used in conjunction with ODOT reports to capture these offsetting revenues and expenditures as well as the additions to capital assets in 2023.

Federal Award Finding and Questioned Costs Finding Reference: 2022-004 – Other finding – SEFA Preparation Federal Program Information Federal Agencies: United States Department of Homeland Security Awards: Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) Award Periods: January 20, 2020 – May 11, 2023 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation The System should update its policies and procedures and internal controls, specifically the process to accumulate and report FEMA expenditures of federal awards to be in accordance with the FEMA Schedule requirements outlined above. View of responsible officials The System agrees with the comment and has developed a plan to correct the finding. Corrective Action Planned The System has trained all applicable staff on the appropriate interpretation of FEMA Public Assistance Grant Program guidance for reporting Assistance Listing 97.036 expenditures in the SEFA. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Planned completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2024

The School District will review the Uniform Guidance requirements and ensure all expenditures are accurately reported on the School District’s federal schedule.

The District has hired a consultant, a CPA firm with experience in Uniform Guidance reporting, to ensure the District is in compliance with Uniform Guidance compliance requirements.

AUDIT FINDINGS 2022-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, review controls over the accuracy and completeness of the Schedule were not designed to operate at an appropriate level of precision for the discretely presented component unit. As a result, $1,795,854 of FEMA expenditures was inadvertently omitted from the December 31, 2022 Schedule. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Implement a control of management review at an appropriate level of precision for the discretely presented component unit in order to ensure the accuracy and completeness of the Schedule. Anticipated Completion Date: September 2023 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2022-001.

Fremont County was assessed a Federal Awards Finding for the 2022 Audit year by Certified Public Accountants, Logan and Associates, LLC, for Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.512(a) and 200.510(b) . The regulation requires the County to determine the amount of Federal awards expenditures during the year and to properly report these expenditures in the schedule of expenditures of federal awards. After the assessment Fremont County has identified areas of improvement including internal controls. Staff members will implement monthly controls to be in compliance with the Federal Award requirement moving forward with the grant administrator. Staff members will also be encouraged to take annual Federal Award courses provided by Colorado Government Finance Officers Association or other similar entities. Fremont County will continue to enhance and streamline training for new and existing personnel, in the finance department, and implement new preventive controls. Fremont County believes these steps will improve timely and accurate submission for the Federal Awards.

Views of Responsible Officials QHS agrees with the finding and accepts the recommendation.

Condition: The City did not have sufficient controls in place to ensure that the schedule of expenditures of federal awards was prepared correctly. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended at the City. A grant committee has been established with key personnel in the City that works with grants and monitoring spreadsheets have been developed to track pending grant applications and awarded grant activity. These tools will be further enhanced with key due dates to ensure that grants are applied for by the required deadlines and requests for reimbursement are completed in a timely manner. In addition, the City will research grant management software options to further enhance grant monitoring. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: March 31, 2025

All future federal expenditures will be reconciled to the disbursement ledger.

CORRECTIVE ACTION PLAN: DEVELOP AND IMPLEMENT PROCEDURES TO MAINTAIN ADEQUATE ACCOUNTING RECORDS THAT ACCURATELY TRACK EXPENDITURES BY INDIVIDUAL FEDERAL PROGRAMS, ENSURING COMPLIANCE WITH REPORTING REQUIREMENTS AND TRANSPARANCY IN FUND UTILIZATION. 1. IMMEDIATE ASSESSMENT: CONDUCT A COMPREHENSIVE ASSESSMENT OF CURRENT ACCOUNTING PRACTICES AND RECORDS TO IDENTIFY DEFICIENCIES IN TRACKING EXPENDITURES BY FEDERAL PROGRAMS. DETERMINE THE SCOPE AND EXTENT OF INACCURACIES OR GAPS IN DOCUMENTATION. 2. ENGAGE ACCOUNTING EXPERTISE: ENGAGE A THIRD-PARTY CPA FIRM EXPERIENCED IN GOVERNMENTAL ACCOUNTING AND FEDERAL GRANT COMPLIANCE TO ASSIST IN RESOLVING THE ISSUE. 3. REVIEW FEDERAL PROGRAM REQUIREMENTS: REVIEW THE REQUIREMENTS OF EACH FEDERAL PROGRAM UNDER WHICH FUNDS ARE RECEIVED. IDENTIFY SPECIFIC REPORTING AND EXPENDITURE TRACKING REQUIREMENTS MANDATED BY EACH PROGRAM. 4. DEVELOP CHART OF ACCOUNTS: DEVELOP OR REVISE A DETAILED CHART OF ACCOUNTS THAT CLEARLY DISTINGUISHES EXPENDITURES BY EACH FEDERAL PROGRAM. ASSIGN UNIQUE CODES OR IDENTIFIERS TO TRANSACTIONS ASSOCIATED WITH EACH PROGRAM. 5. IMPLEMENT SEGREGATION OF EXPENDITURES: IMPLEMENT PROCEDURES TO SEGREGATE EXPENDITURES BY FEDERAL PROGRAM AT THE TIME OF RECORDING. ENSURE ALL TRANSACTIONS ARE ALLOCATED ACCURATELY TO THE APPROPRIATE PROGRAM BASED ON THE CHART OF ACCOUNTS. 6. DOCUMENT EXPENDITURE ALLOCATION: DOCUMENT THE ALLOCATION OF EXPENDITURES TO SPECIFIC FEDERAL PROGRAMS CLEARLY AND COMPREHENSIVELY. MAINTAIN SUPPORITNG DOCUMENTATION SUCH AS INVOICES, RECEIPTS, AND PAYROLL RECORDS THAT SUBSTANTIATE THE ALLOCATION. 7. TRAINING AND CAPACITY BUILDING: CONDUCT TRAINING SESSIONS FOR ACCOUNTING STAFF INVOLVED IN RECORDING AND REPORTING EXPENDITURES. TRAIN THEM ON THE NEW PROCEDURES, CHART OF ACCOUNTS, AND THE IMPORTANCE OF ACCURATELY TRACKING EXPENDITURES BY FEDERAL PROGRAM. 8. REGULAR RECONCILIATION AND REPORTING: IMPLEMENT A PROCESS FOR REGULAR RECONCILIATION OF EXPENDITURES WITH FEDERAL PROGRAM REQUIREMENTS. ENSURE RECONCILIATION IS PERFOMRED MONTHLY OR QUARTERLY TO IDENTIFY DISCREPANCIES PROMPTLY. 9. INTERNAL CONTROLS AND MONITORING: STREGTHEN INTERNAL CONTROLS TO PREVENT FUTURE INACCURACIES IN EXPENDITURE TRACKING. ASSIGN RESPONSIBILITY FOR OVERSIGHT AND MONITORING OF COMPLIANCE WITH THE NEW PROCEDURES. - TIMELINE FOR IMPLEMENTATION: ONGOING: MAINTAIN VIGILANCE OVER COMPLIANCE AND ADJUST AS NEEDED. - CONCLUSION: BY IMPLEMENTING THIS CORRECTIVE ACTION PLAN, WE AIM TO ESTABLISH ROBUST ACCOUNTING PRACTICES THAT ACCURATELY TRACK EXPENDITURES BY INDIVIDUAL FEDERAL PROGRAMS. THIS WILL ENSURE COMPLIANCE WITH REPORTING REQUIREMENTS, ENHANCE TRANSPARENCY IN FUND UTILIZATION, AND MITIGATE RISKS ASSOCIATED WITH INACCURATE FINANCIAL REPORTING. THIS PLAN OUTLINES OUR COMMITMENT TO ADDRESSING THE CURRENT DEFICIENCIES AND ESTABLISHING A SUSTAINABLE FRAMEWORK FOR FUTURE OPERATIONS. - RESPONSIBLE PARTY: KIMBERLEY CHAFFIN, EXECUTIVE DIRECTOR- DATE OF IMPLEMENTATION: OCTOBER 1, 2023.

2022-001 WIOA Cluster ? Assistance Listing No. 17.258/.259/.278COVID-19-Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027Aging Cluster ? Assistance Listing No. 93.044/.045/.053Recommendation: We recommend that the County improve its SEFA compilation process to ensure that program expenditures reported on the County?s SEFA are complete and accurate. Procedures and controls should include a process to identify programs that are new to the County and ensure they are properly reported on the SEFA.We further recommend that County?s Office of Budget and Finance (OBF) work with the County?s agencies and departments to review and update their SEFA review and confirmation procedures to ensure that expenditure information they submit to OBF is accurate, that it includes all programs expended, and ties to detail expenditure transactions in the County?s accounting system. They should also review and enhance procedures and controls to ensure that subrecipient payments are accurately reported.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: On July 1, 2022, Baltimore County deployed Workday Financials, as a replacement for the legacy ERP system, known as CGI Advantage. The Workday system is configured in a way that silos all Federal grants or portions of grants into one fund for reporting purposes. This new configuration captures all award information including CFDA number, Grantor, and Federal/State Grant Number is captured. Additionally, all subrecipients are managed through a Supplier Contract and are categorized as such. This system implementation will ensure accurate and efficient reporting as it related to the SEFA compilation and Subrecipient reporting.Furthermore, DEWD will provide OBF the reports and cost pools to support grant draws on a quarterly basis to assist OBF in the preparation of the Schedule of Expenditures of Federal Awards. DEWD will prepare grant closeout expenditure adjustments (journal entries) on a timely basis. DEWD reviews expenditures to ensure grant eligibility and proper posting to the correct grant. On a quarterly basis, DEWD performs a reconciliation of grant expenditures during preparation of the grant draw reports. OBF will not certify any quarterly cash draws that do not tie back into the general ledger.Name(s) of the contact person(s) responsible for corrective action: Robert Preston, Leonard Howie, Angelique Pefinis-Newport, Terry HickeyPlanned completion date for corrective action plan: 8/1/2023

Finding 2022-006The Corporation management agreed with the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls. The below wording was added to the SEFA Preparation Memo, which is used to prepare the SEFA each year.a. Grants listed on the prior year are reviewed to determine if the grant is still active or if the grant has closed out.i. For grants that have closed the ending dates of the grant are verified, and current year activity is reviewed to ensure that all activity for that grant has been properly accounted for.Responsible Personnel include Harley McCoige, Controller and Cortney Couture, Director of Accounting.

The UWGC Senior Director of Finance will prepare the SEFA in accordance with an accrual basis of accounting to be consistent with the presentation of the financial statements. The UWGC Chief Financial Officer will perform a second review to ensure that Federal funds are reported in the correct time period and an accrual basis of accounting is utilized for the accurate completion of the Schedule of Federal Awards prior to being presented for audit.

Finding Number 2022-204: $196,247,971 was not properly identified as covid-19 funds on the statewide Schedule of Expenditures of Federal Awards (SEFA).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, and Children10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program64.005- Grants to States for Construction of State Home Facilities84.181 - Special Education - Grants for Infants and Families84.425R - Education Stabilization Fund - Emergency Assistance for Non-Public Schools93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises93.497 - Family Violence Prevention and Services/ Sexual Assault/Rape Crisis Services and Supports93.590 - Community-Based Child Abuse Prevention Grants93.958- Block Grants for Community Mental Health Services93.977 - Sexually Transmitted Diseases (STD) Prevention and Control Grants97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters)Related to Prior Finding: N/AAgency?s view: The Office agrees with this finding.Corrective Action: Since the State began receiving COVID-19 funding, we diligently provided training and resources to the agencies regarding the funding and how it should be reported on the SEFA closing package. This includes a discussion in our annual closing package training, online resources regarding COVID-19 funds, an FAQ document, and being available to discuss questions and concerns. In addition to the steps we are currently taking, we will reiterate the importance of designating COVID-19 related expenditures on the SEFA closing package during our annual closing package training. We will review STARS activity in the COVID-19 related funds and compare to the agency submitted closing packages for reasonableness. Recognizing that not all agencies utilize these specific funds, we will also review COVID-19 related expenditures on an external online source that reports federal grant expenditures. We will then use this information to compare to what is reported on agency closing packages for reasonableness.Anticipated Corrective Action Date: Errors identified were corrected prior to issuance of the Single Audit report. We will work with agencies to ensure all COVID-19 funds are identified for FY23 reporting.Responsible for Corrective Action: Ethan Draves, Reporting and Review Bureau ChiefEdraves@sco.idaho.gov 208-334-3100