Corrective Action Plans

CAP for Finding: 2022-302 DATE: March 27, 2023 TO: Carolyn Stittleburg, Deputy State Auditor for Financial Audit Legislative Audit Bureau FROM: Barry Kasten, Director Bureau of Fiscal Services Department of Health Services SUBJECT: Corrective Action Plan ? Multiple Grants ? Reporting in the Schedule of Expenditures of Federal Awards Department staff has reviewed the Legislative Audit Bureau?s (LAB) interim audit memo for Finding 2022-302: Multiple Grants - Reporting in the Schedule of Expenditures of Federal Awards. This is the department?s Corrective Action Plan. ? Recommendation (2022-302): Multiple Grants ? Reporting in the Schedule of Expenditures of Federal Awards We recommend the Wisconsin Department of Health Services further evaluate federal grant expenditures reported in the STAR General Ledger as it prepares its schedule of expenditures of federal awards and ensure it is: ? adjusting expenditures for prior-year transfers of expenditures in the current year. Wisconsin Department of Health Services Planned Corrective Action: DHS adjusted the expenditures for prior-year transfers of expenditures as recommended by LAB though DHS believes that there is no clearly defined direct authoritative guidance provided by OMB mandating a uniform method for reporting a transfer of prior year grant expenditures. Because of this, DHS believes it is prudent to seek confirmation of this treatment from the federal government going forward. LAB, in describing the effect, indicates that ?the State under-reported expenditures for the ELC grant by $55.9 million.? These expenditures were previously reported in prior fiscal years. Upon approval of the State?s FEMA project workbook, and in accordance with the compliance supplement, these previously reported expenditures were reported in FY 2021-22 under the Disaster Grants?Public Assistance (Presidentially Declared Disasters) (Assistance Listing number 97.036) grant. Without a matching reduction in expenditures to the ELC grant by $55.9 million, DHS is concerned that the lifetime expenditures on the SEFA schedule for these grant programs are going to reflect more expenditures than federal funding received. Additionally, because there is not direct authoritative guidance currently provided by OMB mandating a uniform method for reporting a transfer of prior year grant expenditures, DHS will work with DOA to seek clarification from the Federal Government on the proper treatment and reporting of transfers of prior year expenditures on the SEFA. Anticipated Completion Date: November 1, 2023 We recommend the Wisconsin Department of Health Services further evaluate federal grant expenditures reported in the STAR General Ledger as it prepares its schedule of expenditures of federal awards and ensure it is: ? properly identifying applicable COVID-19 expenditures; ? reporting all federal expenditures for each federal grant program, regardless of whether the agency has received reimbursement from the pass-through entity; and ? removing repayments of prior-year overpayments of expenditures from current-year expenditures. Wisconsin Department of Health Services Planned Corrective Action: DHS will ensure that it reviews the instructions that are received from DOA and present the proper amounts in the SEFA. This will include a review of adjustments made to grants open in prior state fiscal years and verification that they have not already been reported on the SEFA in a prior year, such as the WIC adjustment identified. Anticipated Completion Date: November 1, 2023 Person responsible for corrective action: Barry Kasten, Director Bureau of Fiscal Services, Division of Enterprise Services barry.kasten@dhs.wisconsin.gov

See Corrective Action Plan for chart/table

Finding Number: 2022-004 Condition: The schedule of expenditures of federal awards (SEFA) was not complete and accurate. Planned Corrective Action: Additional training for those individuals responsible for grant accounting has and will continue to be conducted, in addition to creating additional policies and procedures in FY23. Contact person responsible for corrective action: Kristen St. Peter Anticipated Completion Date: June 2023 Management Response: Management concurs with the finding and additional training for those individuals responsible for grant accounting has and will continue to be conducted as well as incorporating additional levels of review to ensure the SEFA is completed accurately and timely.

Finding Number: 2022-003 Condition: The College reported $593,703 of expenditures on the SEFA for disbursements to students that occurred prior to July 1, 2021. This treatment is not in accordance with the accrual basis of accounting following generally accepted accounting principles (GAAP), which is the basis of accounting for the College's SEFA. Planned Corrective Action: The College will review its practices for SEFA reporting and in the future follow U.S. GAAP and the uniform guidance. Contact person responsible for corrective action: Tom Reynolds, Associate Vice President of Business Services and Deputy Treasurer Lakeland Community College Anticipated Completion Date: As soon as possible moving forward starting 12/19/2022

Lincoln Marti Charter Schools has taken immediate corrective action to ensure that all federal expenditures are reflected correctly in the Schedule of Expenditures of Federal Awards. Policies and procedures on grants and contract funding were reevaluated and the staff responsible for preparation of the schedule have received additional instruction on how to accurately prepare and finalize the schedule. Additionally, there will be segregation of duties between the preparer and reviewer of the Schedule of Expenditures of Federal Awards.

Finding Number: 2022-002 Condition: The SEFA was not accurate. Planned Corrective Action: Management has accepted the finding. Moving forward, internal conrols will be strengthened with regard to review and recording of revenue and expense recognition. Specifically, as it relates to this instance, review of documentation from the U.S. Department of Education (DOE) as it relates to HEERF grant funding will be more closely reviewed for understanding to include verification of understanding, guidelines and procedures from the DOE and other pertinent agencies for grant funding. Contact person responsible for corrective action: Deborah McKenzie, Director of Grants & Chief Financial Officer Anticipated Competion Date: November 30, 2022

Federal Schedule Audit Comment: County Response Emergency Rental Assistance Program Timely Reporting: The County made every attempt through communications with the Treasury to upload annual reports for ERA 1, without being able to do so by the due date. The County did submit the documents manually by e-mail through dumps of the system. County staff worked with the US Treasury to address these issues. A resolution to the problem did not occur until second quarter of 2023. The Final report for ERA 1 has been submitted through the portal. Cumulative Expenditure/ Obligation Amounts: There was some misinterpretation on the part of County staff on whether the cumulative amounts to be reported was for the quarter or cumulatively for the grant program. It is to be noted that amounts in the County system were properly recorded and no exceptions were noted in the actual expenses/ obligations being for a valid grant purposes. Corrected on Final Report for ERA 1. State/ Local Federal Relief Funds Program Cumulative Expenditures/ Obligations Incorrectly Reported: There was some misinterpretation on the part of County staff on reporting the election of the $10,000,000.00 Revenue Replacement Funds for the SLFRF. It was thought that you could only show the $10,000,000.00 as obligated and expended once the election was made. This resulted in a net overstatement of obligations for any revenue replacements funds that were not yet obligated by resolution by the Board of Mahoning County Commissioners. The County tracked the individual projects by notes in the Treasury system to note the actual obligations. The County?s financial system tracks grants by fund, department and project codes. The funds in the County?s financial system were and are correctly obligated and tracked. The County will make the necessary corrections to the 2023 second quarter report to make sure the report agrees with the County?s financial system. It is to be noted that no exceptions were noted in funds being used for the stated purposes of the grant. Senior management will provide additional oversight to the reports prior to submitting to the US Treasury.

Finding 2022-002: Program: Various, including AL 97.036 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters); AL 10.923 Emergency Watershed Protection Program; and AL 93.563 ? Child Support Enforcement ? Reporting. Corrective Action Planned: The County will develop a Schedule of Expenditures of Federal Awards (SEFA) chart and designate the County Clerk to coordinate the collection of information from individual county offices on Federal awards expenditures. Anticipated Completion Date: March 30, 2023 Responsible Party: Carl Grotelueschen, County Board Chair

2022-002 Internal Control over Compliance and Compliance with Reporting (Preparation of Schedule of Expenditures of Federal Awards) Auditor Recommendation: We recommend management attend Federal award trainings and information to ensure the documented policies and procedures can be performed as described. This will ensure the Federal funds are reported accurately on the SEFA and that programs are reported under the correct assistance listing number. Corrective Action: The year ended August 31, 2022 was the first year in which the Center expended federal awards in excess of the limit that requires a Single Audit. Since receiving the EIDL loan, the Center maintained detailed tracking and documentation of all disbursements associated with the loan and understood such expenditures exceeded the $750,000 threshold for a Singe Audit during the fiscal year ended August 31, 2022. With the clarification of the specific rules surrounding the disclosure of EIDL loans on the SEFA, management will continue to review Federal Award guidance and requirements to ensure compliance with current and future federal awards. Name of Responsible Contacts: Larry Goodpaster, Director of Finance & Operations, and Kelly Martin, Accounting Manager Projected Implementation Date: May 1, 2023 and ongoing

Finding 2022-003 Federal Transit Cluster - SEFA Management?s or Department?s Response: Management agrees. Views of Responsible Officials and Corrective Action: SCRRA will document the process to review the SEFA from prior year. Compare the SEFA to the final Single Audit Report to ensure the ending balances tie back to the Single Audit Report, before starting the current year?s SEFA. Name of Responsible Person: Thelma Bloes Implementation Date: June 30, 2023

Corrective Action Plan For the Year Ended December 31, 2022 Finding: 2022?001 Inaccurate SEFA reporting Responsible Official: Michelle Maddox, CFO Corrective Action Plan: Management will implement additional controls to ensure the completeness and accuracy of amounts reported for expenditures of the Federal Transit Administration grants in the schedule of federal awards. These additional controls include the annual review of new implementation guides. Anticipated Completion Date: December 31, 2023

Finding Number: 2022-005 Condition: The SEFA required adjustments related to expenditures that were both improperly included and excluded, resulting in revisions to correct the SEFA. Planned Corrective Action: Proper accrual accounting will be followed with regard to reporting SEFA expenditures, with period recognition more closely monitored. Contact person responsible for corrective action: Matt Zeilstra ? Financial Controller Anticipated Completion Date: 07/27/2023

Finding Number: 2022-007 Condition: For SEFA reporting, expenditures were overstated for one program and understated for another. In addition, an ALN listed for expenditures was inaccurate. Planned Corrective Action: Grant documents will be reviewed upon receipt to determine the proper ALN and the federal portion of funding. All existing grants will also be reviewed. The ALN listed in each grant document will be used when completing the SEFA. A second staff member will verify the accuracy of the SEFA prior to submission. All ALN numbers will be reviewed upon receipt and verified with state analysts when applicable. The organization will ensure that the funding sources are verified to the most appropriate level at the state level to verify funds and funding sources. Contact person responsible for corrective action: Kelly Scott, Deputy CEO Anticipated Completion Date: 4/30/2023

Emergency Connectivity Fund Program ? Assistance Listing No. 32.009 Recommendation: We recommend that the district improve the review process over tracking and reporting reimbursements of federal expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: As the subject matter experts, the district grants accounting department will work with other district departments to ensure eligibility rules and requirements are fully met when seeking reimbursement for expenditures. Grants team members will further work to support departments who play an active role in obtaining and monitoring federal grants to seek reimbursement within a timely manner, and when possible, seeking such reimbursement by the close of the fiscal year or immediately thereafter. Specific guidance will be communicated with other department management and future updates to the district Financial Services Guide will include updated guidance for all departments to reference. The Grants Manager will be responsible for monitoring all correspondence with grant-making entities to ensure timely response to potentially disputed submissions. Name(s) of the contact person(s) responsible for corrective action: Andy Flinn, Grants Manager Planned completion date for corrective action plan: June 2023

County Judge/Executive?s Response: The fiscal court would like to point out that ARPA funds were properly distributed. During this time there was little guidance on how to manage the reporting. All reporting has been corrected.

Views of Responsible Officials: Connect Our Kids acknowledges the findings of the audit and will take immediate corrective action. Planned Corrective Action: All accounts will be reconciled in a timely manner for the following fiscal year. The federal grant revenue and expenditure cutoff will be maintained for the end of the fiscal year with any adjustments for accrual purposes no later than January 31st of the following year. Responsible Official: Cara Dobbins, CFO Anticipated Completion Date: 9/30/2023

As requested, the New Mexico Coalition to End Homelessness has completed its corrective action plan for the audit findings in the 2022 fiscal year annual audit report. We have reviewed the findings and have made a corrective action plan to address each of the findings with completion dates. 2022-002?PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presented in Schedule of Expenditures of Federal Awards. Award Number and Program Award Year: All presented in Schedule of Expenditures of Federal Awards. Compliance Requirement: Other ? Schedule of Expenditures of Federal Awards preparation Type of Finding: E Questioned Costs: None Statement of Condition While conducting the audit, the following was reviewed; the Coalition?s Federal grants report for the fiscal year and identified the federal grants, Assistance Listing # (AL#) and the amounts of the federal expenditures and all of the other items required to properly present the Schedule of Expenditures of Federal Awards (SEFA). The finance staff of the Coalition confirm the correctness of the SEFA. Despite the confirmation of accuracy, additional federal expenditures and grouping of grant expenditures were identified after several reviews of the SEFA. Criteria 2 CFR 200.510 indicates that the auditee must prepare a schedule of expenditures of Federal awards (SEFA) for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502 Basis for Determining Federal Awards Expended. Per 2 CFR 200.502 the determination of when a Federal award is expended should be based on when the activity related to the Federal award occurs. Generally, the activity pertains to events that require the non-Federal entity to comply with Federal statutes, regulations, and the terms and conditions of Federal awards, such as expenditure/expense transactions associated with awards. In addition, 2 CFR Part 200.303 requires the program establish and maintain effective internal controls over Federal awards that provides reasonable assurance of compliance with Federal statutes, regulations, and the terms and conditions of Federal awards. Effect Without an established process governed by effective internal controls, the Coalition may not prevent or detect material misstatements on its SEFA in a timely manner. In addition, the errors could result in improper selections of major program(s) for the single audit and a substandard single audit. Cause Historically, the Coalition has requested the auditor assist in identifying accruals related to federal grant expenditures as the organization has maintained these records on a cash basis. As the organization has taken more responsibility on maintaining its federal grant expenditures on an accrual basis, an incomplete SEFA has been provided. Recommendation It is recommended the Coalition prepare the Schedule of Expenditures of Federal Awards and submit this to the auditor for testing. The SEFA should include the name of the grant, name of grantor, the AL #, the pass-through number if applicable and a reconciliation of the federal revenues and expenditures to the Coalition?s general ledger. The Coalition staff should perform more detailed reviews of the reports to ensure they properly reflect grant receipts and expenditures. This review should be performed by someone other than the preparer and should include documented evidence of agreeing the reported data to the accounting records. We further recommend training for those individuals involved in the preparation and review of the reports to ensure they are fully aware of the requirements. View of Responsible Officials and Corrective Action Plan: The corrective Action Plan will be carried out in the 2023 Fiscal Year and information will be given to the auditors when requested for the 2023 Audit. The Coalition will ensure that all information needed for the SEFA is kept and entered accurately. When the fiscal year closes out, the Coalition will provide the auditors with a test SEFA to confirm that the information we are collecting throughout the year and are asserting are the correct numbers for our federal grants, is indeed the correct information. Corrective Action Plan Timeline: Completed by October 31, 2023 (Final copy of the SEFA will not be given to the auditors until requested for the 2023 Audit) Designation Of Employee Position Responsible For Meeting Deadline: Executive Director, Monet Silva will oversee this project and work closely with the auditors to make sure that the information saved and shared is correct. Thank you, Monet Silva Executive Director

This finding relates to the preparation of the SEFA for the disclosure of the loan balances under the Company?s Railroad Rehabilitation & Improvement Financing (RRIF) loan. In the initial version of the SEFA, Amtrak did not reduce the audit period loan balance by the FY21 loan repayment. An updated version of the SEFA corrected the balance presented. The presentation on the SEFA of the balance of the RRIF loan has specific federal regulation requirements. Amtrak will review and update its SEFA Preparation Guide to ensure full compliance with 2 CFR Part 200 specifically for presentation of the RRIF loan balance. Amtrak will also consider providing training to key grants management personnel on an annual basis to keep them up to date with federal regulations. The contact for this item is Lucia Butts, AVP Funding and Grants. The Company anticipates that the updated procedures and training will remediate this finding in the fiscal year ending September 30, 2023 and beyond.

Management agrees with this finding and is in the process of developing internal controls to ensure timely and appropriate actions are made on the deficiency noted.

Recommendation: Procedures should be implemented to create a materially accurate schedule of expenditures of federal award financial statement, which should include ascertaining between loan and grant expenditures, and understanding the process for reporting loan balances on the SEFA. Views of Responsible Officials and Planned Corrective Actions: In order to create a materially accurate schedule of expenditures of federal award financial statement, the Authority will establish procedures to ascertain loan and grant expenditures, as well as taking into account the Uniform Guidance requirement for presenting loan balances on the SEFA.

2022-008 Inadequate Schedule of Federal Expenditures Reporting ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CFO prepared the FY 21 SEFA in advance of the 3/31/2022 Single Audit deadline. CFO will prepare the FY 22 SEFA in advance of the 3/31/2023 Single Audit deadline. Name(s) of the contact person(s) responsible for corrective action: Ashley Chancellor, CFO Planned completion date for corrective action plan: 11/1/2022

Finding Number: 2022-004 Condition: The schedule of expenditures of federal awards (SEFA) initially presented for audit was not complete and accurate. Planned Corrective Action: A new report in Workday is being created to ensure all expenditures for federal awards are included. Contact person responsible for corrective action: Laura Randall Anticipated Completion Date: 10/31/2023

Finding 2022-006: Federal Financial Reporting Requirements (Significant Deficiency) Information on the Federal Program: U.S. Department of State ALN 19.040 Criteria or Specific Requirement: Code of Federal Regulations (CFR) Section 200.303(b) requires non-federal entities to establish and maintain effective internal control over federal awards that provide reasonable assurance that the non-federal entity is managing federal awards in compliance with federal statutes, regulations, and terms and conditions of the federal award. CFR Section 200.502(a) states that the determination of when a federal award is expended should be based on when the activity related to the federal award occurs. CFR Section 200.510 states that the auditee must prepare a schedule of expenditures of federal awards for the period covered by the auditee's financial statements which must include the total federal awards expended as determined in accordance with CFR Section 200.502. Condition: The schedule of expenditures of federal awards for the year ended December 31, 2022, did not originally include indirect costs totaling $43,632. Cause: FCE's management prepared the schedule of expenditures of federal awards using only direct costs. However, FCE had applied the 10-percent de minimis indirect cost rate when submitting its financial reports. Effect or Potential Effect: The exclusion of indirect costs caused inaccurate amounts to be reported in the SEFA at the start of the audit. This could have caused an inaccurate major program determination. Recommendation: FCE should implement a process for preparing the SEFA that includes comparing amounts reported in the SEFA to amounts included in financial reports of expenditures that are submitted to federal agencies. Action Taken: FCE acknowledges the importance of proper Federal Financial Reporting. FCE will develop and implement formal accounting policies and procedures to ensure that Federal Financial Requirements are met. These will include the steps to follow for preparation of the SEFA, including comparing amounts reported in the SEFA to amounts included in financial reports of expenditures that are submitted to Federal agencies.

Individuals Responsible for Corrective Action Plan: Jason Penegar, BGCA Vice President ? Controller Shelby Mahoney, Accounting Manager - State Alliances Corrective Action: Management will review grant agreements to confirm whether expenditures from pass-through entities are related to federal or state grants, and appropriately include applicable federal grants in the SEFA. Anticipated Completion Date: December 31, 2023

Corrective Action Plan: The Agency has recognized the need to improve our SEFA compilation process and has begun using a quarterly reconciliation process with all agencies and departments. We are currently reconciling data from VISION to the data submitted to the U.S. Treasury for ARPA-SLFRF Quarterly Reporting. We are using this new quarterly reconciliation process as a starting point to check Subrecipient expenditures against total expenditures, as well as reviewing Grant Accounts and reviewing Class Codes. We are checking all of our programs and looking at Beneficiaries vs. Subrecipients to ensure we are categorizing correctly at the macro level. There will be an enhanced collaboration internal to the Agency between the Department of Finance & Management and the Financial Services Division that will occur after agencies and departments submit their ACFR-9s used in the SEFA consolidation process to provide greater review and oversight. Scheduled Completion Date of Corrective Action Plan: Completed: February, 2023: Quarterly Reconciliation Process (VISION to Treasury) Expected: June, 2023: Subrecipient vs. Beneficiary classification review Expected: September, 2023: Collaboration between DFM and FSD for SEFA preparation