Corrective Action Plans

2022-006: Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity to 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 CFR Section 200.502(a) and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Planned Corrective Action: County management will develop a closing process to ensure all federal expenditures are identified, recorded, and reconciled on the SEFA. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

Federal Agency: U.S. Department of Agriculture, U.S. Department of the Interior, U.S. Department of Transportation, U.S. Department of the Treasury, Environmental Protection Agency, U.S. Department of Health and Human Services, and U.S. Department of Homeland Security. Program Name: Schools and Roads – Grants to States; PILT – Payment in Lieu of Taxes, National Forest Acquired Lands; Highway Planning and Construction; National Priority Safety Programs; COVID-19 - Coronavirus Relief Fund; COVID-19 – Coronavirus State and Local Fiscal Recovery Funds; Diesel Emissions Reduction Act; Superfund State, Political Subdivision and Indian Tribe Site-Specific Cooperative Agreement; Help America Vote Act; Homeland Security Grant Program. ALN Number: 10.665, 15.226, 15.438, 20.205, 20.616, 20.703, 21.019, 21.027, 66.039, 66.802, 90.401, 97.036 and 97.067. Responsible Official: Donal Firebaugh, County Clerk. Views of Responsible Individuals: The County Clerk takes responsibility. COVID-19 money and ARPA money had me confused.

(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about the nuances of the program and the reporting requirements as it was being implemented. During implementation we recognized that there are some inherent differences with P-EBT from other benefit programs which caused processes to have to be adjusted slightly. Additionally, timing of federal report filing for the P-EBT program is not in synch with our other processes and associated federal reporting requirements and deadlines. This makes it impossible to ensure reconciliation procedures are performed before filing occurs, which is one of our typical internal controls. As a compensating internal control CDHS will ensure that supervisory review processes are performed over P-EBT reporting, and that P-EBT reporting is reconciled to other sources (CBMS and CFMS) as soon as possible after reporting is available. If changes are discovered CDHS will make adjustments to filed P-EBT reports as needed based on reconciliation findings, and communicate changes to necessary parties. (B) CDHS will work to ensure better coordination between program activities and the accounting section relating to federal reporting changes. Accounting will iterate the importance of timely informing the accounting staff when changes are made to program filed federal reports. This message will be delivered in periodic fiscal meetings and identified on the closing calendar. The P-EBT program will ensure that corrections are communicated to accounting on any updates completed on the FNS-292-B report upon discovery, and no later than 30 days after the reporting period. (C) CDHS will ensure that review and approval processes are occurring as designed at various points in the process leading up to entry into CORE. As part of the Requisition (RQS) approval process program and accounting staff independently approve that the correct direct or subrecipient object code is used. These approved RQS transactions are then transitioned into encumbrance documents that drive which object code future expenditures will be booked to. For CCDF transactions related to this finding, both the OEC and Accounting teams inadvertently approved an incorrect object code in 4 RQS's. Staffing shortages coupled with a large increase in workload related to pandemic funding contributed to this oversight. To correct OEC and Accounting will train new staff, periodically familiarize themselves with the appropriate object codes, and perform quality assurance review over object codes before applying approval in CORE. The K1 is compiled from balances derived from expenditure data recorded in CORE. The compilation of the K1 relies on the fact that expenditure balances are accurate, and that prior reviews and approvals of individual transactions have occurred as designed. The K1 currently goes through various levels of review focusing on balance level validation coupled with analytical procedures. To enhance the review process, CDHS will ensure analytical procedures include line level expenditure comparison at the direct and subrecipient levels.

Finding: 2022-001 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: David Drawl, CFO Anticipated completion date: December 2023 MYCAP?s response: Concur MYCAP agrees with this finding and provided the following response for corrective action: U.S. Department of Health and Human Services ? Material Weakness ? Internal Controls over Compliance ? Reporting Plan of Action: The material weaknesses identified by the auditor is correct as presented. Upon learning of the omission, MYCAP immediately adjusted the SEFA and presented the requested information to the auditor in such time that the program mentioned is included in the audit. MYCAP will accept the recommendations presented by the auditor and incorporate them into their fiscal procedures as well as incur additional training in GAAP conversion and preparation for audit.

Finding Number: 2022-002 Condition: The Corporation did not prepare a complete and accurate SEFA for the year ended June 30, 2021. Planned Corrective Action: While technically considered a significant deficiency and audit finding in accordance with CFR guidance for federal award audit compliance purposes, management considers this finding to be an isolated incident. Management had prepared and provided a SEFA summary that properly identified all federal funding, including all of the CARES Act funding, received as of June 30, 2021. Management also prepared and provided information regarding amounts of the CARES Act funding expended and recognized as revenue within the financial statements for the years ended June 30, 2020 and 2021. However, there was interpretation that the amount that was supposed to be reported for the CARES Act funding on the SEFA for the period ended June 30, 2021, should be the amount expended and recognized as revenue as of the financial statements ended June 30, 2020, to align with the Period 1 portal reporting. As such, the amount reported for the final SEFA used for the June 30, 2021 compliance audit excluded $1,271,104 that was appropriately reported as deferred grant revenue liability as of June 30, 2020. The amount of CARES Act funding for the Period 1 portal reporting correctly included the $1,271,104. There was a significant amount of collective confusion regarding the Period 1 CARES Act portal reporting which was for the period ended June 30, 2020, in relation to the SEFA reporting and compliance audit reporting for that same period of time, which was unusually deferred by the federal government from June 30, 2020 to June 30, 2021. The results of the auditors procedures demonstrated that all the information management populated in the CARES Act portal for the June 30, 2020 reporting compliance Period 1 was accurate and that there were no other findings. Contact person responsible for corrective action: Bob Stillman, Chief Financial Officer Anticipated Completion Date: March 31, 2023

Corrective Action Plan Finding No. 2022-001: HRSA COVID-19 Claims Reimbursement for the Uninsured Program Corrective Action Plan Since the inception of the program, the Organization reported the HRSA COVID-19 for the Uninsured based on payment date rather than on date of service/ incurred date. Once the error was identified, management properly reported and corrected the SEFA for the year ended June 30, 2022 to reflect the total amount of claims for services provided during the year ended June 30, 2022 for the Uninsured Program. Corrective Actions Taken Management has implemented the above corrective action. The VP of Patient Financial Services is providing the HRSA COVID-19 for the Uninsured based on date of service/incurred date, therefore the SEFA is properly reported for the year ended June 30, 2022. Completion Date: June 30, 2022 Contact Persons: Deborah Gaugler, Controller Jeffrey Hinkle, VP Patient Financial Services

Finding Number: 2022-005 Condition: The SEFA was not appropriately reconciled to federal grant revenues and expenditures recorded in the financial statements. Planned Corrective Action: The City will work to improve closing processes and communications with various departments and consultants to ensure the SEFA is complete and accurate. Contact person responsible for corrective action: Finance Director and Treasurer Anticipated Completion Date: 6/30/2023

Finding 2022-003 Grantor: Department of Agriculture and Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Schedule of Expenditures of Federal Awards Award Year: Fiscal year 2021 1/1/2022 ? 12/31/2022 Award Number: Various Management agrees with the recommendation. Management will implement the following changes to the management of the Schedule of Expenditures. Corrective Action Plan and Anticipate Completion Date Management?s corrective action plan includes: ? Review and validate that grants are listed under the correct cluster. Responsible Person: Aaron Ufferman, Director, Sponsored Projects, Natasha Collins, Director of Research Accounting Completion Date: December 31, 2023

2022-004 - Aging Cluster - Significant Deficiency in Internal Controls over Compliance Recommendation: We recommend that Metro Meals on Wheels track when Federal funds are disbursed to subrecipients and report these expenditures on the SEFA in the period of disbursement. Planned Action Metro Meals on Wheels will track when Federal funds on a cash basis.

Finding Number: 2022-013 Federal Program, Assistance Listing Number and Name: ALN 21.023, Department of Treasury, COVID-19 Emergency Rental Assistance Program (ERAP); ALN 20.205, Department of Transportation, Highway Planning and Construction Cluster, Highway Planning and Construction (Federal-aid Highway Program); ALN 20.505, Department of Transportation, Metropolitan Transportation Planning and State and Non-Metropolitan Planning and Research; ALN 93.323, Department of Health and Human Services, COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC); ALN 97.036, Department of Homeland Security, COVID-19 Disaster Grants - Public Assistance (Presidentially Declared Disasters) (FEMA) ALN 93.268, Department of Health and Human Services, Total Immunizations Cooperative Agreements, ALN 93.145, Department of Health and Human Services, HIV Related Training and Technical Assistance; ALN 93.686, Department of Health and Human Services, Ending the HIV Pandemic: A Plan for America ? Ryan White HIV/AIDS Program Parts A and B Condition: Original Finding Description: The schedule of expenditures of federal awards (SEFA) was not complete, accurate or prepared timely Contact Person Responsible for Corrective Action: Regina Greear and Keisha Pierce Anticipated completion date: July 2023 Planned Corrective Action: As part of the City Audit finding Corrective Action Plan (AFCAP), in fiscal year 2022 the City developed a checklist to help ensure all Federal expenditures are properly reported. The City will implement additional preparation and review procedures that will include specific timelines and guidelines to ensure completeness, validity and accuracy of the final SEFA reporting. In addition, the City will implement the AFCAP plan to further document the procedure requirements and train the appropriate staff.

Program: Various, including AL 93.767 ? Children's Health Insurance Program, AL 93.778 ? Medical Assistance Program ? Reporting Corrective Action Plan: State Accounting will continue to work with State agencies on correct coding and business unit setup in an effort to reduce agency errors. Contact: Philip Olsen Anticipated Completion Date: Ongoing

Views of Responsible Officials The Department of Administrative Services (DAS) concurs. Financial management of individual federal awards is decentralized throughout state agencies which centralizes annually in the culmination of the State?s SEFA. During this process, each agency is required to complete a standardized SEFA analysis and reconciliation tool for review by the DAS prior to the incorporation of the data into the State?s SEFA. This process also includes an annual Single Audit training and update session organized by the DAS. Additionally, the DAS notes all contracts, including subawards, entered by state agencies over a designated threshold are required to be authorized by the State?s Legislative Fiscal Committee and the Governor and Executive Council. The DAS will examine each of these processes to identify additional control activities to improve the accuracy and completeness of the pass through element of the SEFA. Anticipated Completion Date: April 30, 2024 Contact: Steven Giovinelli, Federal Grants and Cost Allocation Administrator, Department of Administrative Services

U.S. Department of Education Mississippi Valley State University (MVSU) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS 2022-006: SEFA Reporting (MVSU) Education Stabilization Fund - Assistance Listing No. 84.425F Recommendation: We recommend the institution review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Student Accounts Supervisor will make sure that all mandatory reports are provided and posted correctly. If adjustments are required to be made to the initial submission, the Student Accounts Supervisor will submit all adjustments after specifying any changes or updates, noting the date of the change, and post adjustments after the approval of the Vice President of Business and Finance in a timely manner for review and verification prior to the deadline for submission. Name of contact person responsible for corrective action: Brittney Manuel Planned completion date for corrective action plan is July 15, 2023. If the Department of Education has questions regarding this plan, please call Brittney Manuel at 662-254-3914.

U.S. Department of Agriculture Alcorn State University (ASU) and Mississippi State University (MSU) respectfully submit the following corrective action plans for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS 2022-002: SEFA Reporting (ASU) Cooperative Extension - Assistance Listing No. 10.500 Recommendation: We recommend the institutions review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Grants and Contracts staff reviewed the federal awards support documentation and updated the ALN numbers in Ellucian Banner system, as needed. This preventative measure will enable us to properly identify and classify all federal expenditures. Name of contact person responsible for corrective action: Sabrena Johnson Planned completion date for corrective action plan is May 31, 2023. If the Department of Agriculture has questions regarding this plan, please call Sabrena Johnson at 601-877-4711. 2022-002: SEFA Reporting (MSU) Cooperative Extension - Assistance Listing No. 10.500 Recommendation: We recommend the institutions review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Mississippi State University will review and revise current reporting procedures to ensure that federal expenditures are properly identified and classified. Name of contact person responsible for corrective action: Jonathan Tucker, Director of Sponsored Programs Planned completion date for corrective action plan is June 30, 2023. If the Department of Agriculture has questions regarding this plan, please call Jonathan Tucker at jtucker@controller.msstate.edu or 662-325-1930. ____________________________________________________________________________________________ U.S. Department of Health and Human Services The University of Mississippi Medical Center (UMMC) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS 2022-002: SEFA Reporting (UMMC) Maternal and Child Health Federal Consolidated Programs - Assistance Listing No. 93.110 Recommendation: We recommend the institutions review and revise its current reporting procedures and review requirements to ensure that federal expenditures are properly identified and classified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In December 2022, UMMC filled the vacant role of Director, Post-Award. The new Director, Julie Schwindt, a competent professional with the right education and experience, has been hired to step directly into the role and maintain appropriate oversight and responsibility. Julie has 28 years of previous professional experience in this role and related roles. Prior to the implementation of this corrective action, the Director completed a full review of the reports built in Workday to generate SEFA reporting documents with the assistance of the UMMC Department of Information Systems (DIS). The Director has requested removal or renaming of versions that exist relevant to internal purposes, leaving only the version built for financial reporting named as the SEFA or anything similar. The Director has also asked that SEFA report nomenclature have a beginning prefix or name of ?Post Award? affixed to it. In the event future attrition ever causes similar circumstances and a vacancy in a key role, these updates will minimize the possibility that someone unfamiliar with the process will generate the wrong report in Workday, UMMC?s financial reporting system. These recommendations are being fully implemented as an ongoing review and analysis of the Workday SEFA report. Prior to the issuance of this letter, the Director has reviewed operational procedures and has initiated development of written policies and procedures to both the generation and post-generation quality review of the SEFA. The Director has designed operational procedures (detailed below) related to generation of, and post-generation quality review of, the SEFA report to be completed prior to annual submission to MIHL. These updates ensure the balance of expenditures reported on the SEFA are complete and accurate, as well as, reconcile with the Federal revenues identified on the Statement of Retained Earnings and Changes in Net Position. These updates will be added to the UMMC Office of Research and Sponsored Programs Post Award handbook as written policies and/or procedures. SEFA generation and quality review updates: Any reports previously built within Workday utilizing SEFA in the nomenclature that are not intended to function as the external financial reporting template have been renamed or removed; Additional columns have been built into the SEFA report template in Workday to assist post-generation quality review. Columns for Federal revenues by AWD and F&A rate by award have been added to the SEFA reporting template. Inclusion of these details allows Post Award quality reviewers to easily isolate significant differences between balances; and prior to SEFA completion, a Workday report of all project expenditures for the period by sponsor name will be generated and analyzed by Post Award to compare to programs listed on the SEFA. This comparison will assist in determining the completeness of the SEFA and identify programs or contracts lacking an assigned CFDA/ALN number in Workday. These additional Post Award levels of review will ensure appropriate internal controls are effectively in place to address and withstand internal and external audit review. Name of contact person responsible for corrective action: Julie Schwindt, Director Post-Award Planned completion date for corrective action plan: Corrective action plan has been completed prior to the issuance of this letter. Updates to written policy have been requested and are expected to be in place prior to the current fiscal year end, June 30, 2023. Updates as an operational policy are in place prior to the issuance of this letter. If the Department of Health and Human Services has questions regarding this plan, please email Angela Pesnell at apesnell@umc.edu.

Finding 2022-004: Preparation of the Schedule of Expenditures of Federal Awards. District staff are aware of this responsibility and will plan to prepare the SEFA annually in future years.

Finding Number: 2022-002 Condition: The SEFA required adjustments related to expenditures that were both improperly included, resulting in revisions to correct the SEFA. Planned Corrective Action: JAA will strengthen our controls around the grant review process. In addition to the second-level review and approval process for grant revenue, JAA will implement a quarterly review to identify eligible expenditures for Federal and State Grant reimbursements to ensure revenue is recognized in the proper period. Contact person responsible for corrective action: Jose V. Lopez Anticipated Completion Date: 09/30/2023

CAP for Finding: 2022-103 Auditor Recommendation: 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 all prior-year transfers of expenditures in the current year. Planned Corrective Action: The Wisconsin Department of Administration (DOA or Department) Bureau of Financial Management (BFM) will evaluate federal grant expenditures reported in the STAR General Ledger as it prepares its schedule of expenditures of federal awards (SEFA) and ensure it is adjusting expenditures for material prior-year transfers of expenditures in the current year in a manner consistent with requirements of the Office of Management and Budget Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance or Guidance) and additional guidance, if any, provided by the Department?s State Controller?s Office (SCO). The Uniform Guidance requires the preparation of a SEFA for the period covered by the State's financial statements that includes total federal awards expended [ref. 2 CFR 200.510 (b)]; the determination of when a federal award is expended to be based on when the activity related to the federal award occurs [ref. 2 CFR 200.502]; and that the financial statements and SEFA are for the same audit period [ref. 2 CFR 200.514]. As the auditors noted, in preparing DOA?s SEFA, DOA BFM sought to reflect the amount of federal awards expended for DOA?s grant programs based on the amounts reported in the STAR general ledger. Together with reporting negative expenditures resulting from the transfers of FY 2019-20 and FY 2020-21 expenditures within the Notes to the SEFA, which are an integral part of the SEFA and required by 2 CFR 200.510 (b)(6), and absent OMB guidance that prescribes a uniform method for reporting a transfer of prior year grant expenditures, DOA BFM believed its approach was consistent with the requirements of 2 CFR 200.502 and 2 CFR 200.510 (b), more generally. DOA BFM later modified its SEFA to exclude negative expenditures resulting from the transfers of FY 2019-20 and FY 2020-21 expenditures consistent with the manner in which a prior period adjustment would be reflected within current-year activity in financial statements prepared in accordance with generally accepted accounting principles (GAAP), as described in the criteria and recommended by the auditors. The increased expenditures for the Coronavirus Relief Fund (Assistance Listing number 21.019) and Coronavirus State and Local Fiscal Recovery Funds (Assistance Listing number 21.027) in the SEFA of $241.3 million and $192.1 million, respectively, together with any future exclusions of negative expenditures resulting from the transfer of prior-year expenditures, will cause the lifetime expenditures on the SEFA schedule for these programs to reflect more expenditures than federal funding received. The Notes to the SEFA were also modified to indicate that the SEFA does not reflect a reduction for the prior year transferred expenditures. Anticipated Completion Date: Concurrent with the submission of the FY 2022-23 SEFA, which is anticipated to be November 2023 Auditor Recommendation: Carefully assess the transfer of prior-year expenditures in the current year to determine any potential effects on the total federal expenditures for the prior-year and the effect on the major program expenditures. Planned Corrective Action: DOA BFM will assess the transfer of prior-year expenditures in the current year to determine any potential effects on the total federal expenditures for the prior-year and the effect on the major program expenditures. It has been the practice of DOA BFM to assess the transfer of prior year expenditures in the current year and DOA BFM will continue to prioritize decisions with respect to the same to allow the Department to maximize the availability of federal funding for the purposes intended. Anticipated Completion Date: June 30, 2023 Person responsible for corrective action: Colleen Holtan, Director Bureau of Financial Management Division of Enterprise Operations colleen.holtan@wisconsin.gov

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: 2022-001 Program Name/Assistance Listing Titles: Crime Victim Assistance; Family Violence Prevention and Services/Domestic Violence Shelter and Supportive Services Assistance Listing Numbers: 16.575, 93.671 Contact Person: Jessica Bryson, Finance Administrator Anticipated Completion Date: Completed effective October 2022 Planned Corrective Action: During the audited fiscal year, the organization experienced significant staff turnover in the Finance Department. As a result, the methodology of accounting relative to class/customer tracking changed part-way through the year. This resulted in the inability to immediately produce documentation from the financial reporting software that corroborated the grant billings. Although the organization is confident that expenses were billed to appropriate grants throughout the year (due to backup documentation in the grant billing portals), the organization?s financial software did not directly reflect this. To correct this problem, a new class/customer tracking system has been established to ensure that the financial reporting software more accurately tracks expenditures related to Federal Awards and organizational programs. Furthermore, grant billings are regularly reviewed by an independent accounting firm, the organizations Treasurer, and/or the Executive Director to ensure proper coding/tracking.

INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE OUT AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START PROGRAMS LOW-INCOME HOME ENERGY and WATER ASSISTANCE PROGRAM CFDA # 93.600, 93.568 and 93.499 (Questioned Costs - Undetermined) Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the agency?s financial funding sources, the agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst?s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and uniform guidance regulations. The new automated financial system, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 2023.

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.

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.

Management agrees with the finding and recommendation. Management is working with the accounting team to implement a new process to ensure that an internal SEFA is prepared and reconciled on a quarterly basis, at a minimum. Management will review and approve all reconciliations.

CORRECTIVE ACTION PLAN February 3, 2023 Crossroads Rehabilitation Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Greenwalt CPAs 5432 West Vermont Street Indianapolis, IN 46224 Audit Period: Year ending June 30, 2022 The findings from the June 30, 2022, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. MATERIAL WEAKNESS Finding 2022-001 Criteria: According to 2 CFR 200.508(a), the auditee must prepare appropriate financial statements, including the schedule of expenditures of Federal awards (SEFA) in accordance with 2 CFR 200.510. As instructed in the OMB Compliance Supplement, Provider Relief Funds (PRF) should be reported on the SEFA based on upon the PRF report that is required to be submitted to the HRSA reporting portal. For example, PRF funds received in period 2 (July 1, 2020, to December 31, 2020) should be reported on the SEFA for the fiscal year ends of December 31, 2021 through December 31, 2022. Condition: Federal awards totaling $332,841, including Provider Relief Funds received in period 2 of $178,159, were excluded from the SEFA. Cause: Crossroads had significant turnover within the accounting department and the new personnel had not been aware of the PRF funds received in a prior fiscal year. In addition, there was no overlap in the CFO position to provide for a smooth transition. Effect: An audit adjustment was made to report the three awards on the SEFA totaling $332,841. Recommendation: We recommend that Crossroads retain documentation regarding the information used to prepare the SEFA, along with notes for future years to assist with future personnel transitions. Planned Corrective Action: Crossroads will update policies, procedures and document retention plans to ensure that data is easily accessible. Instructions for completion of all audit related reports will be maintained and available to all finance personnel. Finding 2022-002 Criteria: Accounting reconciliations and supporting documentation should agree to the general ledger and be prepared and reviewed timely. Condition: Investment reconciliations, bad debt analysis and contributions receivable reconciliations had not been performed until requested during the audit. In addition, accounts receivable aging reports and depreciation reports did not agree to the general ledger. Cause: There was significant turnover within the accounting department during the year, including the Financial Accounting Manager and CFO positions. In addition, there was no overlap within the CFO position to provide for a smooth transition. This was the first-year end closing for both individuals in those positions. Effect: Audit adjustments were made resulting in a decrease of assets of approximately $4,700,000, a decrease in liabilities of approximately $400,000, and a decrease in net assets of approximately $4,300,000. Recommendation: We recommend that Crossroads create a schedule of all year-end reconciliations that need to be performed to ensure that required reconciliations are performed and reviewed timely. Planned Corrective Action: The lack of documentation and training of the Financial Accounting Manager for year-end closing processes prior to the former CFO?s departure left a significant knowledge gap. This also hindered the ability of the current CFO, who joined the organization 2 months prior to year-end, to be able to provide the required information or perform the necessary reconciliations. Going forward, all processes for month-end and year-end will be documented and followed. Accounts will be reconciled and reviewed on a monthly/quarterly/yearly basis as determined by the materiality of the account. If there are any questions regarding this plan, please contact Techia Brewer, CFO, at tbrewer@eastersealscrossroads.org.