Corrective Action Plans

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.

RE: Corrective Action Plan for Single Audit for the Year Ended December 31, 2022 (REF #2022-001) Finding: One federal award expenditure amount was incorrectly reported on the initial Schedule of Expenditures of Federal Awards (SEFA). Total expenditures of $2.1 million reported for the Coronavirus State and Local Fiscal Recovery Fund were increased by $3.4 million to bring the final expenditures total for the cluster to $5.5 million for the year ended December 31, 2022. Cause: Internal controls and review processes were not in place to ensure the accuracy of expenditures reported on the annual SEFA. Recommendation: Management should implement procedures to help ensure that controls are in place that will allow for the accurate preparation of the SEFA. We recommend that the County perform a detailed analysis of expenditures for all significant awards on an annual basis. Corrective Action Plan: Effective immediately, the County will put in additional controls and verify all grants are monitored under additional scrutiny and are reported accurately in quarterly reports and the County’s Annual Comprehensive Financial Report (ACFR). Staff Responsible for Implementation: Matt Davis, County Auditor; Mike Sloan, Senior Associate; Jordan Wilson, Grant Associate Implementation Date: December 31, 2024 Status: In progress

We recommend that management either 1) provide training for its key accounting personnel so that they will be able to prepare SEFA and CYEFR for the County and/or 2) contract with an accountant or firm that has the relevant skills, knowledge and experience to prepare the SEFA and CYEFR. We further recommend that the Board of Commissioners enforce the County’s policy of requiring that all accounting records and related supporting documentation be made available to the County Treasurer so that there is a process in which all of the County’s financial activity pertaining to grants is compiled, reconciled and included in a complete set of grant financial reports utilized to prepare the SEFA and CYEFR for the County.

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.

Finding 2022-003: Reconciliation of Accounts Federal Program: Research and Development Cluster (Education and Human Resources)Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1500529 (9/1/2015 – 8/31/2022), 1640791 (9/15/2016 – 8/31/2022) Condition: The year-end schedules for federal grants receivable, net assets, and for vacation payable were not reconciled and needed to be revised and updated. Views of Responsible Officials and Planned Corrective Actions: The outstanding liability due to NSF of $115,244 will be reimbursed when AAPT files the next drawn down request. Anticipated date of drawn down will be by July 31,2024. The senior accountant will be trained to prepare entries previously prepared by the CFO The senior accountant will reconcile accounts, and provide updated current schedules. The CFO will review and approve the entries and schedules prepared by the Senior accountant. Anticipated Completion Date: 10/15/2024 Responsible Official: Michael Brosnan, CFO

The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditors firm to comply with such 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.

Finding 2022-003: Reconciliation of Accounts Federal Program: Research and Development Cluster: 47.076 Condition: The year-end schedules for federal grants receivable, for net assets, and for vacation payable were not reconciled and needed to be revised and updated. Views of Responsible Officials and Planned Corrective Actions: The outstanding liability due to NSF of $115,244 will be reimbursed when AAPT files the next drawn down request. Anticipated date of drawn down will be by July 31,2024. The senior accountant will be trained to prepare entries previously prepared by the CFO The senior accountant will reconcile accounts, and provide updated current schedules. The CFO will review and approve the entries and schedules prepared by the Senior accountant. Anticipated Completion Date: 08/01/2024 Responsible Official: Michael Brosnan, CFO

Finding: 2022-001 Material Weakness over SEFA Preparation Federal Agency: U.S. Department of State Federal Program: Overseas Refugee Assistance Program for Near East (ALN 19.519) Contact Person: Corey Dillow, Senior Managing Director, Financial Controller Criteria 2 CFR 200.510 (b)(3) requires non-Federal entities receiving Federal award to (at minimum) provide total Federal awards expended for each individual Federal program and the Assistance Listings Number. Internal controls around the identification of ALNs and reporting of the SEFA should ensure proper presentation for each ALN number. Condition and Context During our planning meetings with management, we were notified that an award was recorded to an incorrect ALN in the 2022 Schedule of Expenditures of Federal Awards. The 2022 Schedule of Expenditures of Federal Awards was corrected and an additional major program, Overseas Refugee Assistance Program for Near East (ALN 19.519), was identified. Corrective Action: As result of the finding, management will be implementing the below steps to further refine internal controls in the identification and reporting of ALNs in the SEFA by: 1. Reinforcing the importance of ALN assignment and tracking through training. 2. Including the ALN attribute as a required element for award setup reviews. 3. Conducting periodic checks of ALNs to source agreements. 4. Documenting and performing additional SEFA data quality checks. Anticipated Completion Date: July 2024

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.

We agree with the auditors’ finding, moving forward all SEFA's will be reviewed by 2 team members to ensure accuracy.

Federal Program Special Education Cluster - Passed through the Berks County Intermediate Unit ALNs 84.027 and 84.173 Education Stabilization Fund - Passed through the Pennsylvania Department of Education ALN 84.425 Criteria Per the Uniform Guidance 2 CFR 200.510, the auditee is required to prepare a schedule of expenditures of federal awards (SEFA). Condition The District prepared a SEFA and provided information relating to the federal programs including grant agreements and other supporting documentation. However, the SEFA prepared by the auditee required material adjustments as a result of audit procedures. Cause The District had turnover in the assistant business manager and other business office positions during and subsequent to year end. As a result of the turnover, certain account reconciliations were not performed prior to the audit, which included amounts reported on the SEFA. Effect Amounts reported on the SEFA provided by the auditee were not accurate. The SEFA was subsequently updated through audit procedures, including inquiry and review of grant documentation of awards received and amounts expended. Questioned Costs None. Context A SEFA was prepared by management; however, several adjustments were required in order for the schedule to accurately reflect the current year activity. Repeat Finding No. Recommendation In order to meet Uniform Guidance requirements, the District should prepare the SEFA from the grant award documentation and any other relevant information including the assistance listing numbers, grant award amounts, grant amounts received, grant amounts expended, and grant revenue recorded. The amounts reported in the SEFA should reconcile to the general ledger. Management Response Exeter Township School District had turnover in their business office during FY22 and in the first part of FY23, new employees were hired and trained. The new Assistant Business Manager is undergoing training in grant management, allowable costs, funding streams and report preparation. The Business Administrator will review all grant reports prepared by the Assistant Business Manager and oversee the preparation of the SEFA utilizing the grant reports that reconcile to the general ledger, information included in grant award agreements, and grant amounts received.

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 2022-211: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly identify COVID-19 Emergency Acts expenditures for multiple programs.Federal Programs:93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises10.551 - Supplemental Nutrition Assistance Program (Snap)84.181 - Special Education - Grants for Infants and Families93.497 - 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 Grants10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, And Children10.561 - State Administrative Matching Grants for The Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-206Agency?s view: The Department agrees with this finding.The Department agrees with this finding but it is important to highlight that our internal controls and review processes are designed to detect and correct material inaccuracies or omissions of required information within the annual SEFA. As this does not constitute a material error, but rather a significant deficiency, the Department?s controls for this process worked as intended.This was a new requirement and Department personnel failed to identify a significant risk related to it and enhance the review procedures accordingly. This requirement will be monitored while we spend down the remaining COVID-19 emergency funding we have already been awarded.Corrective Action: This corrective action plan is complete. Effective immediately, we willmonitor awards for any new COVID-19 funding, but we don?t believe that there will be any newCOVID-19 awards. All existing awards have been confirmed as being reported as COVID-19funding.Anticipated Corrective Action Date: Corrective action has been taken as of April 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

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

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