Corrective Action Plans

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

Office of the State ControllerFinding Number 2022-203: Errors in the elimination process between state agencies resulted in misstatements to the Schedule of Expenditures of Federal Awards (SEFA) totaling $14,656,928 for direct awards and $14,278,362 for expenditures provided to subrecipients.Federal Programs:21.027 - State and Local Fiscal Recovery Fund84.334S - Gaining Early Awareness and Readiness for Undergraduate ProgramsRelated to Prior Finding: N/AAgency?s view: The Office agrees with this finding.Corrective Action: We will improve our elimination and reporting process by adding the following steps:? We will add an additional tab to our SEFA Master file to cross check all COVID-19 related funding to ensure agencies are not double reporting expenditures.? We will add additional steps to our SEFA preparation and review checklist outlining specific steps for completing the subrecipient elimination process, and identify higher risk areas that require the most scrutiny.? We will also improve our current elimination tab (awards received from other state agencies) and reconciliation procedures for subrecipients.Anticipated Corrective Action Date: Errors identified were corrected prior to issuance of the Single Audit report. Changes to the subrecipient reporting process will occur for FY23 reporting.Responsible for Corrective Action: Ethan Draves, Reporting and Review Bureau ChiefEdraves@sco.idaho.gov 208-334-3100

Finding Number 2022-207: The amount reported as passed through to subrecipients on the Schedule of Expenditures of Federal Awards (SEFA) closing package was overstated by $331,500.Federal Programs:15.605 - Sport Fish Restoration15.611 - Wildlife Restoration and Basic Hunter EducationRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: The Department will provide additional training and update its procedural documentation to ensure that expenses are thoroughly vetted before they are reported as subrecipient expenditures on the SEFA. Each expenditure identified as a subrecipient expense will be tied back to a specific subaward, further limiting the possibility of non-subaward expenses being reported in the subrecipient portion of the SEFA.Anticipated Corrective Action Date: This corrective action plan will be implemented by the end of August 2023.Responsible for Corrective Action: Michael Pearson, Chief, Bureau of Administrationmichael.pearson@idfg.idaho.gov(208) 287-2800Jon Oswald, Financial Managerjonathan.oswald@idfg.idaho.gov(208) 287-2820

ULMS Corrective Action Plan for FY 21-22 Audit FindingsULMS faced significant challenges with the departure of its longtime CFO two months post fiscal year 2021. In addition, the third-party management company who had been responsible for the Partnership accounting, ceased the relationship abruptly without opportunity to smoothly transition the responsibility in-house to ULMS. Our external auditor does not prepare a Management Letter typically used to communicate with the Board of Directors and Governance issues that may not elevate to a finding. As such, significant findings are reflected in Section III ? Federal Award Findings and Questioned Costs.FY 2021 was the organization?s first single audit reporting requirement. ULMS engaged a third-party CPA to review past audit and current documents needed to commence the FY 2022 audit. However, due to an emergency there was limited independent review of documents prior to being submitted to the auditor due to time constraints. ULMS continues to strengthen its accounting team and has hired a new Controller in July 2023. The new Controller is a licensed CPA with over 30 years accounting experience and over 10 years? experience as an independent auditor for a range of organizations including non-profits. The Controller will collaborate with the CFO to ensure there is accuracy in reporting, especially for major federal programs. Finding #: 2022-002Contact Person: Mansour Camara? Management has determined that the finding as written is misleading. The Schedule of Expenditures of Federal Awards (SEFA) prepared by ULMS initially contained errors. However, all errors were corrected by the time the draft financial statements were presented. There was no financial impact on the organization and the most significant issue on the SEFA schedule was a result of miscommunication with ULMS? funding source including the lack of clear identification of the funding source within the contract.Actions to be taken: ULMS migrated to a new and more sophisticated accounting system. This new system has more reporting and tracking capabilities which will enhance grant tracking and review of activities. These additional tools will aid management in overseeing future endeavors. In addition, ULMS will proactively contact the CFO or contract signer of the funding entity and confirm the source of funding for all grants over $100,000. ULMS will participate in more nonprofit conferences on a regional and national level.

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Please note that the ELC program has been reported in the FY 2022-23 SEFA. Additionally, we will update the procedures to document the SEFA reporting for the ELC program. Estimated Implementation Date: September 2024 Contact: Jennifer Chan, Accounting Administrator II Federal Reporting Unit, Financial Management Division California Department of Public Health

EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (Database). In addition, the onset of the COVID-19 pandemic created additional issues which ultimately impacted the EDD’s ability to submit timely year-end financials. However, the EDD continues to make progress to gain ground in the department’s efforts to follow the State’s deadlines for submitting year-end financials and entering the cash basis expenditures into the Database. During fiscal year 2022-23, the EDD completed a restructuring within the accounting area which realigned workload amongst the units and provided additional resources in critical areas. These changes will have a lasting effect and help the department to be better positioned going forward in processing the accounting workload and ultimately be able to catch up and submit year-end financials and enter the cash basis expenditures into the Database by the State’s deadlines. In addition, the EDD took lessons learned from the financial audits from the prior two fiscal years to update processes and procedures and applied that knowledge going forward. Also, staff continue to participate in various trainings offered by the Department of Finance and the Department of FI$Cal. In addition, staff work with the control agencies when issues arise that would impact our accounting functions. While the EDD has been behind in submitting year-end financials for prior years, the department is making great progress on catching up. The EDD submitted the last of its fiscal year 2021-22 financials in May 2023 and submitted the last of its fiscal year 2022-23 financials in January 2024. The department is now working on identifying the ineligible payment data needed in order to accurately reflect the cash basis expenditures to enter into the Database. The EDD’s goal is to submit fiscal year 2023-24 financials in November 2024. Similar to the 2020-21 financial audit, the EDD will take the knowledge learned during prior audit seasons and continue to engage with the control agencies, and continue to train and develop staff in order to keep progressing towards the department’s goal of becoming timely with the submission of the year-end financials and the entering of the cash basis expenditures into the Database.

During 2022, there was a change in accounting staff which led to difficulty in tracking and preparing the SEFA. Once management became aware of the issues, changes have been made to internal processes to allow for proper SEFA tracking moving forward.

In the future, to ensure that all grant activity is included on the SEFA in the proper year per the UG, Miami University will: Create a new year end folder called “Future Fiscal Year Agreements FYXX” and save any new documents that have a future fiscal year start date in the file. At the beginning of the new fiscal year review the documents that are in the file and if fully executed agreements have been received, create the new grant with the appropriate start date in the current fiscal year. Not set up the grant or fund prior to the grant agreement start date unless pre-award spending is allowed. A “review upcoming fiscal year agreements” reminder will be added to the calendar to ensure that the grant is set up in the correct fiscal year and that expenses are charged in the appropriate fiscal year.When the SEFA is prepared each year, check to make sure any new agreements that were in the fiscal year folder are captured on the report if there were expenses for that year. Contact person responsible for corrective action: Linda Manley, Director Grants and Contracts.

Finding 2022-002: Emergency Watershed Protection Program - Reporting Program: AL 10.923 - Emergency Watershed Protection Program - Reporting Corrective Action Planned: The County will ensure County personnel obtain training to ensure there is a proper understanding of the Federal reporting requirements and preparation of the Schedule of Federal Awards. Anticipated Completion Date: Ongoing Responsible Party: Dixon County Board of Supervisors: Don Andersen, Deric Anderson, Roger Peterson, Neil Blohm, Lisa Lunz, Terry Nicholson, and Steve Hassler

2022-001 Preparation of and Internal controls over Schedule of Expenditures of Federal Awards Preparation (Material Weakness) Federal Agency: U.S. Department of Education Program Names: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555 and 10.559 Award Period: June 30, 2022 Recommendation: The Board of Education and management should review the financial reporting process. Once this review is complete, the District should then perform a risk assessment to determine the best way to implement appropriate internal controls over financial reporting to ensure that the District prepares the schedule conformity with Uniform Guidance. Action Taken (Unaudited): Management plans to develop proper written policies and procedures for the internal control over compliance to ensure accuracy and completeness in the preparation of the schedule as required by Uniform Guidance during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance. Contact Name – Tim Beying Expected Completion Date - 06/30/2024

2022-002 – Completeness and accuracy of the Schedule of Expenditures of Federal Awards- Significant Deficiency Cluster: Not applicable Federal Granting Agency: Department of Homeland Security and Emergency Services Award Name: COVID-19 – Disaster Grants- Public Assistance (Presidentially Declared Disasters) Pass-Through from New York State Department of Homeland Security and Emergency Services Assistance Listing #: 97.036 Assistance Listing Title: COVID-19 - Disaster Grants- Public Assistance (Presidentially Declared Disasters) Pass-Through from New York State Department of Homeland Security and Emergency Services Award Year: January 1, 2022- December 31, 2022 Management of Maimonides Medical Center did not correctly interpret the rules in regards to the review and approval process by FEMA and New York State Department of Homeland Security and Emergency Services for the requirement to record FEMA funds. Management has consulted with their auditors on the proper timing to recognize and record the revenue. The Medical Center has reviewed the FEMA portal to ensure all FEMA project funds obligated and expended are reported in the proper period. Responsible Individual: Robert Palermo, Executive Vice President Chief Financial Officer