Corrective Action Plans

Preparation of Schedule of Expenditures and Federal Awards Name of Federal Program or Cluster Disaster Grants-Public Assistance (Presidentially Declared Disasters) Disaster Grants through FEMA are managed by rules and processes that are not easily accounted for in traditional accounting systems. Procedures will be strengthened to fully and accurately identify all federal program expenditures and record in the appropriate accounting funds. Procedures will be implemented to prepare documentation necessary to support the information in the financial statements earlier and more accurately, for the information to be completed, available and provided to auditors for the audit. Persons responsible: Wilfred Bourne, C.F.O.; Dennis Bent, Director of Accounting Expected Completion date: December, 2024

1. Upon receipt of all grants, FCFS will confirm with the awarding agency the status of subrecipient versus non-subrecipient to determine inclusion in the Schedule of Expenditures of Federal Awards (SEFA). Person Responsible: Carrie Krepps, Executive Director or Sarah Johnson, Operations Director. Timeline for Completion: All current contracts for FY24 have been reviewed; new contracts will be reviewed upon receipt 2. FCFS will prepare quarterly reports for the board detailing grant spend down for both restricted and nonrestricted funding. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations Director; FCFS Board. Timeline for Completion: To begin April 23, 2024, board meeting 3. Grant invoicing will be prepared by the Fiscal Officer and reviewed by the Operations Director prior to submission. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations. Timeline for Completion: August 2023 4. FCFS will submit to quarterly fiscal review by a 3rd party accounting firm to identify potential weakness in fiscal protocol. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations; Pinion Accounting Services. Timeline for Completion: July 2024 for quarterlies ending June 30, 2024. 5. FCFS will employ a 3rd-party accounting firm to help in audit preparation and closing year-end books, including SEFA preparation before submitting any financial documentation to the auditor. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations; Pinion Accounting Services. Timeline for Completion: Pinion has signed letter of engagement and will begin on yearend closeout assistance July 2024

Finding Number: 2023-004 Condition: The schedule of expenditures of federal awards (SEFA) was inaccurate. Planned Corrective Action: Management would like to point out that this finding is related to finding 2023-001. The accrual of additional grant invoices resulted in parallel updates to our SEFA schedule. Therefore, this finding is a direct result of finding 2023-001. As an aside, our current process for reporting SEFA is manual. We are investing in a new accounting system, in which the SEFA information will not require manual intervention and thus reduce any potential entry errors in the future. Contact person responsible for corrective action: Colette Champine, CFO Anticipated Completion Date: Already completed

Identifying Number: 2023-004 Finding: SEFA Reporting Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls for regular review of the general ledger of their programs and reconcile to the vouchers prior to submission to the granting agency. Anticipated Implementation and Responsible Official: June 30, 2024, Suresh Sharma, Chief Financial Officer

Finding No. 2023-001 Schedule of Expenditures of Federal Awards Personnel Responsible for Corrective Action: Name: Edith Robles Department: Finance Title: Director of Finance Anticipated Completion Date: June 30, 2024 Corrective Action Plan: An adequate system of internal controls will be put in place by the end of fiscal year 2024. To ensure SEFA will include accurate assisting listing numbers and accurate inclusion of all federal programs. Allowable and unallowable costs will be reviewed to ensure accurate federal expenditure reporting. Edith Robles will perform an exhaustive review of all grants to close out the fiscal year in preparation for the audit process. In addition to these, SWOP will work with a consultant to provide necessary training of finance personnel.

The migration to a new general ledger financial reporting system is an isolated incident and given the improved reporting capabilities the change in product provided a positive impact. UWGC experienced turnover for the program manager position that created a learning curve that was addressed but resulted in audit completion delay. UWGC has an experienced manager currently overseeing the program who will follow policies and procedures as prescribed and on a timely basis to allow for prompt reporting submission.

UWGC experienced a staffing turnover during the 2024 fiscal year of the manager responsible for the reporting on the SEFA. The manager tracked financial reports on a cash basis causing a timing difference with not recognizing accounts payable. The finance team accounted for expenses in the appropriate period, therefore the Finance team will crosscheck reports for timing difference prior to submission to governing agency.

Finding Number: 2023-003 Condition: The schedule of expenditures of federal awards (SEFA) was not complete. Planned Corrective Action: The College will ensure that the schedule of federal awards (SEFA is reviewed for completeness. Going forward, the SEFA will be compared with the prior year SEFA and a separate schedule of new awards for the current fiscal period. The results of this comparison will be reviewed by the grants office, the controller’s office and the Vice President’s office. This will increase the level of reviews to a three-tiered process which should address issues of completeness of the SEFA. Contact person responsible for corrective action: Ms. Jackie Brown, Ms. Deborah McKenzie, and Dr. Sharron T. Burnett Anticipated Completion Date: 06/30/2024

The YWCA will implement the following changes in its accounting procedures: The Schedule of Expenditures of Federal Awards (SEFA) will be reviewed for accuracy by either the CFO or CEO after it is produced, to ensure that all federal awards are included, and that the amounts on the schedule are accurate.

Views of Responsible Officials: IW has developed and implemented enhanced procedures for the preparation of the SEFA. These procedures include detailed steps for ensuring that all costs related to Federal awards are fully allocated in the general ledger at the time of transaction and prior to SEFA preparation. This process is designed to prevent any future discrepancies between the SEFA and the general ledger. To further strengthen our internal controls over Federal award management, IW has instituted regular monthly reviews of expenditures charged to Federal awards. This review process includes verifying that expenditures are correctly allocated and supported in the general ledger, thereby ensuring the accuracy and completeness of the SEFA.

MNCASA and MACC will implement a review process for accruals and reversals; this review process will occur at the end of each month and the end of the fiscal year. This process will ensure that the ledger matches the SEFA reporting, accruals, and reversals and is done in a timely manner. MNCASA and MACC staff will also attend a training session on SEFA prepartation to increase our knowledge and ensure proper reporting.

Management response to finding 2023-001: Accuracy of expenditures on the Schedule of Expenditures of Federal Awards and submission of special reports for the Head Start Program Cluster Name: Head Start Federal Awarding Agency: Department of Health and Human Services Award Name: Head Start and Early Head Start, COVID (P.L. 116-260) Award Number: 09CH010228-05-05, 09CH011831-02-03, 09HE000328-01-00 Award Years: 2019-2021, 2021-2022, 2021-2023 Assistance Listing Title: Head Start Assistance Listing Number: 93.600 Pass-through entities: Not applicable As described in finding 2023-001, the University inadvertently charged and drew down budgeted capital expenditures from Head Start awards before actual expenditures were incurred by the University. Additionally, the University charged expenditures to a Head Start award after liquidation extensions had expired. The adjustments required to correct these errors were identified in the subsequent fiscal year, resulting in expenditures on the fiscal year 2023 Schedule of Expenditures of Federal Awards (SEFA) being overstated. The University will take the necessary corrective actions as described below to ensure the accuracy of expenditures reported on the SEFA. Finally, as described in finding 2023-001, the University did not identify and track reports required to be submitted for Head Start awards. The corrective actions described below will ensure all award specific reporting requirements are met. Although the University has limited federal awards that are utilized to fund capital expenditures, the Office of Sponsored Projects Accounting and Facility Planning and Management will perform a full review of the current Head Start capital construction accounting policies and practices to ensure they comply with the Uniform Guidance and the terms and conditions of federal awards before June 30, 2024. Reinforcement of the University’s policies and practices will ensure proper grant accounting, and thus, will prevent SEFA reporting adjustments from having to be made. Faculty leadership responsible for overseeing the Head Start program at the University will fill current vacant financial management positions within the Head Start program as soon as possible (with a three month target), undergo a full review of program requirements with all staff, and modify and develop new internal controls related to this finding. Specifically, before July 2024, Head Start fiscal personnel along with faculty leadership will develop a reporting schedule specific to Head Start awards, provide training and resources to staff involved with reporting, implement internal controls related to the reconciliation and validation of reported data prior to report submission, and strengthen internal controls related to the allocability of expenditures to awards (particularly in situations where liquidation extensions or expenditure carry forwards have been granted). Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu

Corrective Action Plan: The Authority will develop a new procedure to ensure compliance with these reporting requirements. All personnel involved in the administration of these programs for which federal funds are expended should receive adequate training about federal compliance and reporting requirements related to such programs. In addition, an individual should be assigned with the responsibility to monitor compliance with all related federal requirements. These procedures will also include a quarterly reconciliation of amounts reported between the Schedule of Federal Awards with the trial balance. Responsible: Mr. Angel M. Felix Cruz, Finance Office Auxiliary Director Ms. Maria Del R. Ramos Ocasio, Accounting and Finance Manager Status: In process. Expected to be completed on or before December 31, 2024.

--Management Response to Finding 2023-001-- I, Heather Ficht, on behalf of EC Works' leadership acknowledge and take responsibility for the deficiencies in the use of internal procedures to accuracy of information reported on the SEFA. To immediately address this deficiency, effective March 1, 2024, all operations staff will be cross trained on the proper completion and submission of the SEFA; additional procedures will also be put in place to ensure grants and other financial awards are identified as federal or nonfederal at the time of receipt. Upon receipt of any grant agreement, the Chief Operations Officer shall be responsible for identifying and communicating the source of each grant/award with the leadership team. The Finance Director shall ensure accuracy of this information and is then responsible for the timely documenting of the information on the "Grant Schedule". The Finance Director shall also be responsible for working with the Senior Accounting Technician to ensure that the proper accounting codes are assigned to each award, indicating if the award is federal or non-federal. Accounting codes and the information contained on the "Grant Schedule" shall be reviewed by the Chief Operations Officer on an ongoing, and no less than quarterly basis. Lastly, the SEFA and all financial reports prepared by the Finance Director and/or the Senior Accounting Technician shall be reviewed and approved by the Chief Operations Officer for accuracy prior to submission.

Finding Number 2023-208: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller (Office) included multiple errors. Federal Programs: 10.551 - Supplemental Nutrition Assistance Program (SNAP) 10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP) 21.027 - Coronavirus State and Local Fiscal Recovery Funds 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises 93.558 - Temporary Assistance for Needy Families (TANF) 93.568 - Low-Income Home Energy Assistance 93.569 – Adoption Assistance 93.575 - Child Care and Development Block Grant (CCDF 93.658 - Foster Care Title IV-E 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Medical Assistance Program Related to Prior Finding: 2022-211; 2021-206 Agency’s view: The Department agrees with this finding. Corrective Action: Since the implementation of LUMA, the department has been cognizant of the systematic challenges and risks and is acutely attentive to monitoring and review efforts. For example, due to LUMA, finance now has a new chart of accounts structure, meaning previously used reports for compilation of the SEFA are no longer a concern. The department held a required training on March 12-13, 2024, for all employees involved with grant administration where the determination of contractor vs. subrecipient, as well as proper account coding, were reiterated. Finance has efforts underway to strengthen compliance through report building and monthly monitoring of proper coding. The department will be moving forward with the implementation of Grant Management Software in SFY25, which finance believes will provide further assurances of data accuracy. Finance will confirm all expenditures and adjustments are completed before running reports when preparing the SFY24 and future SEFA’s. This confirmation will be documented via an email to the Financial Manager of the Budget section. The email response will be retained with the SEFA preparation file for audit purposes. Anticipated Corrective Action Date: Partial efforts already completed; full completion by June 30, 2025. Responsible for Corrective Action: Staci Phelan, Division Administrator Staci.Phelan@dhw.idaho.gov 208-334-0632 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-207: The Division overstated federal expenditures by incorrectly including $6.6 million expended under the State Small Business Credit Initiative (SSBCI) on the Schedule of Expenditures of Federal Awards (SEFA) closing package. Federal Programs: 21.031 – State Small Business Credit Initiative Related to Prior Finding: N/A Agency’s view: The Division agrees with this finding. Corrective Action: The agency will implement improved training and review for the SEFA closing package prior to submission to ensure appropriate reporting of federal expenditures on the SEFA. The SSBCI funds were included in an abundance of caution to ensure reporting of all federal funds received, as it is rare that federal monies are to be excluded from the SEF A. Moving forward, preparation of the SEFA will include an analysis of all new federal awards to be included to confirm if the amounts are to be included, and a side-by-side comparison of the prospective list to the prior year report to note any differences and investigation of any that exist. Anticipated Corrective Action Date: June 30, 2024 Responsible for Corrective Action: Michael Pearson, State Financial Officer Michael.Pearson@dfm.idaho.gov 208-854-3072

Finding Number 2023-205: The Department understated total federal expenditures on the Schedule of Expenditures of Federal Awards (SEFA) closing package by $24,824,862 and understated amounts passed through to subrecipients by $39,901,202. Federal Programs: 21.027 - Coronavirus State and Local Fiscal Recovery Funds; 66.458 - Clean Water State Revolving Fund; 66.468 - Drinking Water State Revolving Fund; 66.419 - Water Pollution Control State, Interstate, and Tribal Program Support; 66.432 - State Public Water System Supervision; 66.460 - Nonpoint Source Implementation Grants; 66.708 - Pollution Prevention Grants; 66.040 - Diesel Emissions Reduction Act State Grants; 81.214 - Environmental Monitoring/Cleanup, Cultural and Resource Management, Emergency Response Research, Outreach, Technical Analysis Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: 1. Identify Root Causes: With the aid of LSO, we identified errors and are acting on a thorough analysis to pinpoint the root causes of the reporting errors on the Schedule of Expenditures of Federal Awards (SEFA) identified during the recent audit. As noted by the auditors, the errors were due to significant turnover-related knowledge gaps, staff being tasked with unfamiliar processes, lack of written desk manuals and other documentation, and issues with maintaining the internal reporting tool. This identification was completed by Rob Sepich, Chief Financial Officer, and Jeri Ann Fogg, Accounting Supervisor, in tandem with the audit. 2. Implement Training and Guidance: DEQ will provide comprehensive training sessions for staff involved in preparing and reviewing SEFA reports, considering the high turnover rate experienced in the department. We are in the process of developing detailed guidelines and documentation outlining SEFA reporting requirements, including specific instructions on categorizing federal awards, allowable expenditures, and reporting formats, to address any knowledge gaps resulting from turnover. As part of the statewide ERP move to LUMA from STARS, staff will utilize new reporting platforms and tools in LUMA to streamline SEFA reporting processes and mitigate potential errors associated with manual data entry or outdated systems. One significant improvement over our legacy reporting will be the use of front-end splits (FES) in LUMA that will automatically split out the state match from the federal component of our expenditures at the time in which they are spent, which was not as clearly defined under STARS. The new accounting system will be clearer to auditors and staff. Rob Sepich, Chief Financial Officer will create reconciliation reports for the SEFA by June 2024, with SEFA reporting compiled and completed in July 2024. 3. Enhance Internal Controls: Moving forward we will significantly strengthen internal controls and review processes to detect and prevent reporting errors in the future, particularly considering the turnover challenges. We anticipate requiring multiple additional review checkpoints and validation procedures within the new reporting platforms to verify the accuracy and completeness of SEFA data that will be reconciled before submission. We will also assign clear responsibilities and designate individuals responsible for overseeing SEFA reporting activities, ensuring continuity and consistency despite turnover and reduce the amount of unfamiliar work given to staff. This will include a review by Doug McRoberts, Grants Manager, Heather Hodges, Principal Budget Analyst, Rob Sepich, Chief Financial Officer, and Jeri Ann Fogg, Accounting Manager. Lastly, we are in the process of developing improved documentation on the new LUMA processes for our day-to-day operations so that we have up to date and accurate desk manuals should we experience additional turnover. These desk manuals are expected to be completed in June 2024. 4. Conduct Comprehensive Review: As part of the audit, we conducted a comprehensive review of the FY 2023 SEFA reports to identify any additional errors or discrepancies that may have been overlooked, considering the turnover-related knowledge gaps. The department was able to resubmit our SEFA closing package, including the list of sub recipients to the State Controller’s Office and LSO Auditors on March 9th, 2024 due to the efforts of Jeri Ann Fogg, Accounting Manager and Rob Sepich, Chief Financial Officer. 5. Continuous Monitoring and Improvement: We will establish a process for ongoing monitoring and periodic review of SEFA reporting activities, leveraging the capabilities of the new reporting platforms in LUMA to streamline processes and enhance accuracy. This will bring us closer to the work processes that other agencies do through the statewide reporting systems and reduce our dependency on reporting tools developed in-house that are unfamiliar to other state agencies. This should reduce the risk of losing key institutional knowledge during turnover and will make it easier for an employee with experience from another agency to be able to quickly pick up our reporting needs. To foster a culture of continuous improvement and knowledge sharing within the department, we will have additional meetings to encourage collaboration and communication to address SEFA reporting and ensure that we are not missing key input from staff. Anticipated Corrective Action Date: See corrective action above for timeline. Responsible for Corrective Action: Rob Sepich, Chief Financial Officer Rob.Sepich@deq.idaho.gov 208-373-0292

Finding Number 2023-204: The Schedule of Expenditures of Federal Awards (SEFA) closing package understated the Education Stabilization Fund - Governor’s Emergency Education Relief (GEER II) by $1,039,753 and overstated the Education Stabilization Fund – Emergency Assistance to Non-Public Schools (EANS) program by the same amount. Federal Programs: 84.425C – Governor's Emergency Education Relief; 84.425R - Emergency Assistance for Non-Public Schools Related to Prior Finding: 2021-202 Agency’s view: The Board agrees with this finding. Corrective Action: The corrective action is to reclass any GEER II Project transactions in FY 2024 to EANS/GEER II Project. That will ensure there are no GEER II transactions in FY 2024 that would need to be adjusted. This was done on March 21, 2024. Anticipated Corrective Action Date: March 21, 2024 Responsible for Corrective Action: Patrick Coulson, Chief Financial Officer Patrick.coulson@OSBE.idaho.gov 208-332-1563

Finding Number 2023-203: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly report expenditures for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) program. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: After management review the department will improve training and process review of preparation of the SEFA closing package to ensure all amounts are correctly reported. This lack of understanding of the SEFA was due to staff turnover and lack of subject matter experts regarding the SEFA for Fiscal Year 2023. The agency will implement the following to fix this issue: a) Financial Manager (or delegate) expenditure detail report shall include grant fund 344 (ARPA grants), 348 fund (grants), and any additional funds designated by the legislature or agency, for the specific purpose of tracking federal grant funding. b) Once prepared by the Financial Manager (or delegate), review of the SEFA by the Financial Officer for completeness, verifying all required grant federal funds appropriated to the agency are included on the SEFA closing package. c) Financial Manager and Financial Officer meet to review the SEFA for agreement of grant expenditure amounts reported on the SEFA. Anticipated Corrective Action Date: Corrective actions will be implemented for fiscal year 2024 reporting. Responsible for Corrective Action: Cindy, McMackin, Financial Manager CMcmacki@idoc.idaho.gov 208-658-2000

Finding Number 2023-202: Closing package submissions and revisions completed prior to the draft of the Schedule of Expenditures of Federal Awards (SEFA) being submitted for audit were not included in the schedule resulting in misstatements. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund; 93.778 – Medical Assistance Program; 93.767 – Children’s Health Insurance Program Related to Prior Finding: N/A Agency’s view: The Office agrees with this finding. Corrective Action: An agency submitted a revised SEFA template in November 2023. We inadvertently excluded those revisions from the draft of the SEFA provided for audit. To prevent this error from happening again, we will document each agency that submits a revised SEFA template(s) on our SEFA review checklist. This will require the preparer and reviewer(s) to verify and sign off on changes made to the SEFA master file. Anticipated Corrective Action Date: Errors identified were corrected before issuance of the Single Audit report. Corrective actions will be implemented for fiscal year 2024 reporting. Responsible for Corrective Action: Tiffini LeJeune, Reporting and Review Bureau Chief TLeJeune@sco.idaho.gov 208-334-3100

Finding Number 2023-201: The Coronavirus State and Local Fiscal Recover Fund (CSLFRF) was understated by $18 million on the Schedule of Expenditures of Federal Awards (SEFA) closing Package. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Department of Administrations agrees that the SEFA was prepared using procedures similar to prior years, which failed to capture the expenditures related to the CSLFRF as those funds were deposited into a non-federal fund as directed by the legislature in HB752. Corrective Action: Prior to the issuance of this memo, the Department transferred the remaining $6,969,325.15 of CSLFRF funds into a separate reporting program. The Department will process quarterly reconciliations utilizing the quarterly reports from the insurance carrier. These transactions will then be queried each year, similar to other federal funding sources, and reported on the SEFA. Future federal awards will be deposited into a federal funding source or clearly delineated from non-federal funding sources to ensure proper reporting on the SEFA. Anticipated Corrective Action Date: Corrective actions will be implemented for fiscal year 2024 reporting. Responsible for Corrective Action: Bailey Peterson, Chief Financial Officer Bailey.Peterson@adm.idaho.gov 208-332-1815

2023-004 Student Financial Aid Cluster – Schedule of Expenditure of Federal Awards (SEFA) Recommendation: We recommend that the University reevaluate its policies and controls related to the preparation of the SEFA to ensure its complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director will reevaluate the controls and set in place policies and procedures for SEFA completion. Name(s) of the contact person(s) responsible for corrective action: Director of Restricted Funds Accounting, Symone Merritt Planned completion date for corrective action plan: October 2024

REFERENCE: 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation SFA Cluster (Assistance Listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science Finding: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted in an overstatement of the SEFA expenditures reported in the SEFA. Corrective Action Plan: This finding has been corrected. Good Samaritan College of Nursing & Health Science has revised how data will be obtained for the schedule of expenditures of federal awards. Additionally, the G5 report will be provided to National Grant Accounting with the SEFA. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science Completion: February 2024

The Business Service Department will work with CSRS to ensure the FEMA funded projectes are reported correctly on the SEFA. Timeline: Immediately Responsible Person: Naquisha Larks, Grants Accountant

Management has reviewed the recommendations and will review current and implement new procedures and controls to ensure that all post- award notices received from funding agencies are properly incorporated into the Schedule. Additionally, Management will review reconciliation procedures, and implement internal controls around the Schedule reconciliation process back to the consolidated financial statements. The corrective action will be implemented no later than June 30, 2024. The primary designated official is Chief Financial Officer.