Corrective Action Plans

The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management which expanded the scope of the financial review. As a result of these monitoring efforts, the Corporation identified ineligible and questioned costs, and efforts are underway to recapture ineligible and unsupported costs. The Corporation has put the following policies and procedures in place to mitigate future risk: 1. Biennial Risk Assessment with Annual Updates 2. Annual Project Compliance Report (APCR) required by subrecipient agencies (with the exception of subrecipients receiving only Department of Energy and LIHEAP grants for the Weatherization Assistance Program, which are governed by separate monitoring procedures). 3. Enhanced Draw Monitoring and draw documentation requirements 4. Expansion of the Corporation’s Compliance and Training Team Given the policies, procedures, and changes outlined above, the Corporation feels confident it will be able to comply with its Compliance Monitoring Plan going forward and identify any concerns with subrecipient compliance in a timely manner. Curtis Stauffer, Managing Director, Housing Contract Administration, and applicable compliance staff will implement by October 1, 2024.

Finding Number: 2023‐002 Federal Program Name: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 State Program Names: State Urbanized Area Formula Program; State Formula Grants for Rural Areas Contact Person: Ted Ross, Executive Director Updated Corrective Action Plan: The District has revised its procurement procedures to meet Uniform Guidance requirements. Enhancements include: • Mandatory documentation of quotes for applicable procurements • Verification and documentation of suspension and debarment checks for all covered transactions • Centralization of procurement records in accordance with best practices Policy training and practices are already in place and are being followed. Certification: The Gulf Coast Transit District affirms that all corrective actions noted above are actively corrected or are being addressed. Additional documentation or clarification will be provided to auditors upon request.

The entity has implemented wording in their vendor contracts that they will not honor invoices that are more than 90 days out.

We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.

Criteria: Regulations require that the Organization must submit the single audit data collection form and reporting package within the earlier of 30 calendar days after receipt of the auditor’s report or 9 months after the end of the audit period, to comply with 2 CFR § 200.512(a)(1). Condition: The Organization submitted their 2022 Single Audit Data Collection form on September 5, 2024, which was 20 months after the end of the audit period. Effect: The Organization did not comply with 2 CFR § 200.512(a)(1). Per 2 CFR § 200.516(a)(2), this results in material noncompliance with the provisions of Federal statues, regulations, and terms and conditions of Federal awards related to major programs. Questioned Costs: No questioned costs were identified as a result of our procedures. Cause: The Organization failed to submit their 2022 Single Audit Data Collection form before the end of September 2023 – the 9 month post-audit period ending deadline.   Recommendations: We recommend management finalize and submit their single audit data collection forms within the 9 month window moving forward. Views of Responsible Officials: The Organization agrees with the finding and will work to implement the recommendations.

Finding: 2023-009 All Programs Description of the Findings: During the review of the procurement compliance requirement related to major program, it was determined that the USWA did not have a document procurement policy in place until August 2023. Views of Responsible Official(s) and Planned Corrective Actions: While the Alliance did not have a standalone procurement policy in place until August 2023, it did have purchasing policies embedded in its Accounting and Finance Manual that covered purchases relative to our work at that time. No further corrective action is needed however policies are reviewed annually to ensure compliance under 2 CFR 200.516(a). Completion Date: August 2023 Responsible Official(s): ShaQuina Davis

Name of Responsible Individual: Bruce Jones, Senior Vice President of Research, Marchon Jackson, Associate Vice President of Research and Brenda Willis, Senior Executive Director of Financial Grants & Contracts Corrective Action: The process to review Payment Request Forms (“PRFs”), used for payment to vendors that do not require the use of a purchase order, will be improved by requiring the review of supporting documents to ensure expenses are allowable by the newly established Sponsored Program Office (“SPO”) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, and reasonable according to university policies and grant terms. PRFs will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. The Director of Compliance will conduct spot checks on all sponsored transactional activity involving PRFs, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO post-award office. The Director of Post Award Compliance will be hired by March 2025. As part of the compliance program, quarterly audit samples will be conducted of PRFs and other high risk sponsored research transactions. Anticipated Completion Date: March 31, 2025

Finding 2023-004 Adequate Allowable Cost Documentation As indicated in the 2022 POFCAP response to Finding 2022-003, and as reiterated herein, POF began to implement additional internal control procedures and practices effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR Part 200 Subpart E and other regulatory requirements. More specifically, vendor invoices as of that date and related supporting documents such as weekly meeting reports and sign-in sheets are being scanned and retained electronically. As in 2022, the contact information from the 2023 weekly reports was transmitted to either Wright State University or The Ohio State University for data mining purposes. On July 22, 20224, the POF Board of Directors unanimously adopted the POF Record Retention Policy, as recommended by the auditors. The Board also unanimously adopted a Code of Conduct along with Conflict of Interest, and Whistleblower policies as further evidence of their commitment to instituting policies and procedures designed to strengthen internal controls and comply with federal regulations. Questioned Cost Totaling $19,179 Effective July 1, 2024, POF's new internal control policies, and procedures will eliminate or drastically reduce future discrepancies of this nature.

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2023 through December 31, 2023 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of January through June 2023, resulting in $261,999 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization met with subrecipients prior to December 31, 2023 to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2023 as of February 2024.

The district made every attempt to follow the federal requirements for 2 CFR 200.317-327 related to procurement, 2 CFR 200.3613 (d) related to Inventory tracking, while the actual written procedures were either created or updated as required and implemented. The Superintendent and/or Business Manager review all requisitions to ensure they meet federal compliance. The District will be identifying and inventorying all existing equipment purchased with federal funds in past years.

Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS originally expected to have all cases corrected at the end of the PHE unwind (July 2024), however, due to some of the mitigation strategies that CMS developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025, as MDHHS completes renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program (CHIP) in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing the Community Health Automated Medicaid Processing System (CHAMPS) payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date May 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Erin Emerson, MDHHS

Finding 2023-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented quarterly case reads beginning in fiscal year 2023, and during April 2023, MDHHS began monthly meetings with BSCs to discuss common errors, answer questions, provide guidance, and on a quarterly basis discuss the results of the SER case reads. In addition, based on the results of the quarterly case reads, MDHHS updated SER policy on October 1, 2023 to require additional verification sources. MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support SER processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Anticipated Completion Date Ongoing Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS Nick Sakon, MDHHS Erich Holzhausen, MDHHS

Finding 2023-056 Low-Income Home Energy Assistance, ALN 93.568 - Client Benefits in Excess of Fiscal Year Cap Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to provide guidance to the local MDHHS offices and BSCs related to the processing of State Emergency Relief (SER) applications. MDHHS developed job aids and trainings that were distributed to local MDHHS offices and BSCs and added to the LIHEAP SharePoint site for reference during May 2024. Anticipated Completion Date Completed Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS Nick Sakon, MDHHS Erich Holzhausen, MDHHS

Finding 2023-047 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS’s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent to local offices and Eligibility Specialists. ESA leadership will reach out to managers of individual Eligibility Specialists regarding issues identified with the Family Automated Screening Tool and Family Self-Sufficiency Plan completion and verification of school enrollment and provide additional guidance as needed. Anticipated Completion Date August 31, 2024 Responsible Individual(s) Brian Sanborn, MDHHS Kenton Schulze, MDHHS

Finding 2023-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS presented the audit findings and planned corrective action to local office workers, managers, and staff at an Adult Services statewide meeting during March 2024. During the meeting, MDHHS reviewed recoupment policies and procedures and the importance of reviewing work for accuracy. MDHHS issued an Adult Services Notification to managers and directors during April 2024 informing them of the recent recoupment audit findings and reminding local office management of the expectation to review hospitalization reports to ensure timely and accurate action is taken. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

Finding 2023-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS developed a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. MDHHS continues to work with DTMB on the underlying issues in Bridges causing synchronization problems between Bridges and CHAMPS, as well as developing mitigation strategies to temporarily address the overpayment concerns while the more permanent system solutions are developed. MDHHS expects all remaining synchronization issues to be resolved once the remaining larger system changes are implemented in March 2025. Anticipated Completion Date March 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS

Finding 2023-013 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Once this is completed, MDHHS will develop mandatory training protocols for eligibility workers. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS originally expected to have all cases corrected at the end of the public health emergency (PHE) unwind (July 2024), however, due to some of the mitigation strategies that the Centers for Medicare and Medicaid Services (CMS) developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025. Anticipated Completion Date May 2025 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

Finding 2023-035 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within ESA, will continue assisting the local office staff and Business Service Center (BSC) staff by providing guidance on updated policies and processes. ESA will inform the local office staff and BSC staff of policy changes or noted trends during PAO’s Bridges Bits and Bytes communications sessions. ESA and MDE implemented a checklist on May 9, 2023, for local office staff to ensure documentation supports eligibility determinations. MDHHS will continue to use the finalized checklist at eligibility determination. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors, and promote integrity efforts for the program. These practices will continue to be carried out by MDHHS and MiLEAP moving forward, including the continuation of monthly meetings to discuss Child Development and Care errors. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MiLEAP

Finding 2023-022 Pandemic EBT Food Benefits, ALN 10.542 - Lack of Documentation for School Modality Data Reviews Management Views MDHHS disagrees that not formally documenting the review details on the log rises to the level of a material weakness and material noncompliance. MDHHS selects a sample of schools that submitted data and verifies the accuracy of Pandemic EBT (P-EBT) school modality data reported, documenting the schools reviewed within a log. Following the written business process, P-EBT staff first identify public information available to verify the school’s modality data such as the school’s calendar or news articles, and then reach out to school administration if public information is not available. If additional steps are required to reconcile the data, P-EBT staff document the support and results, sign off on the reconciliation, and forward to a supervisor for review. For this review period, no discrepancies were identified between what the school reported, and school websites. Since no discrepancies were noted, staff verbally communicated the review results to the manager and the log of sample items reviewed were kept within a shared drive. Planned Corrective Action MDHHS has no corrective action planned at this time as P-EBT benefit issuance ended as of May 11, 2023. No additional benefits will be issued in fiscal year 2024. Anticipated Completion Date Not applicable Responsible Individual(s) Kathy Cornell, MDHHS

Finding 2023-021 SNAP Cluster, ALN 10.551 and 10.561 - EBT Reconciliations Management Views MDHHS disagrees that a material weakness and material noncompliance exist. MDHHS federal reporting conducts a daily reconciliation of federal draws and authorizations to retailers based on vendor EBT reports. In addition, MDHHS conducts a monthly reconciliation between Bridges, Bridges data warehouse, and vendor EBT reports using daily data to ensure the client information in Bridges and Bridges data warehouse is accurate. The monthly reconciliation process does not impact the federal draw because the daily reconciliation of the vendor EBT report is used for this purpose. MDHHS provided detailed and accurate descriptions of MDHHS daily and monthly EBT reconciliations to the designated federal awarding agency contacts at the United States Department of Agriculture Food and Nutrition Service Agency that are familiar with MDHHS processes and received confirmation that the current reconciliation processes in place are sufficient to comply with federal regulations. Planned Corrective Action MDHHS disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Sara Gross, MDHHS

Finding 2023-008 MDHHS, PACAP - Inappropriate PACAP Allocation Management Views MDHHS disagrees the exceptions identified should rise to the level of a significant deficiency and noncompliance. The comprehensive set of quality control processes continue to operate as designed to identify any errors greater than 5.0 percent of the total difference of the given statistical group from the previous quarter and none of the errors identified in the finding fell outside of this range. For part a., the auditor’s review included all related statistical records within each statistical group for the 15 sampled cost pools. This includes all statistics used in the cost allocation process for the entire fiscal year because the costs that originate in these cost pools are referenced in all other cost pools. After review of all fiscal year 2023 statistical data, 6 individual statistical records out of 6,548 were found to be in error. After recalculating the cost allocated amounts related to this error, we identified that approximately $15,346 was overclaimed to the Low-Income Home Energy Assistance Program (LIHEAP) out of $1,732,426,561 (0.0009 percent) of costs allocated in fiscal year 2023 by MDHHS. The other program areas identified were underclaimed. For part b., MDHHS acknowledges the exclusion of a participant from two quarters (quarter three and quarter four) of the Family Independence Specialists/Eligibility Specialists Random Moment Time Study (RMTS) in the sample. Although the actual dollar value impact of excluding a participant is indeterminable, MDHHS concluded the impact would be immaterial because there are over 6,000 RMTS participants each quarter and RMTS results vary little from quarter to quarter from non-programmatic changes. Planned Corrective Action For part a., MDHHS will ensure the vendor’s RMTS report is modified to resolve formatting issues related to trailing zeros in SIGMA codes. Additionally, the vendor and MDHHS staff will individually check to ensure accurate SIGMA codes for those with trailing zeros. For part b., MDHHS will implement additional quality control processes when gathering the participant list for the RMTS. MDHHS will modify the reports used to gather the participant list to eliminate filtered restrictions for sub-unit codes to ensure all eligible participants are included in the time studies. Anticipated Completion Date MDHHS will implement additional quality control measures effective July 2024. Responsible Individual(s) Suzanne Kyes, MDHHS Matt McCool, MDHHS

Prairie-Hills Elementary School District 144 07-016-1440-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-002 Condition: During the audit we noted that the District claimed expenditures in excess of amounts that could be supported by the accounting records by $102,438. Plan: The District will implement a policy that requires the utilization of grant specific expenditure accounts within the accounting software to be used exclusively for managing each individual award. These expenditure accounts will be used to support expenditure claims. Reports from the accounting software system that are utilized to prepare expenditure claims will be reviewed, reconciled and approved by an appropriate member of management prior to final submission. Supporting documentation for each grant expenditure claim submission will be maintained electronically for future reference. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Ms. Sheryl Coleman; Chief School Business Official

Prairie-Hills Elementary School District 144 07-016-1440-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-003 Condition: During the audit we noted that the District claimed expenditures in excess of amounts that could be supported by the accounting records by $52,112. Plan: The District will implement a policy that requires the utilization of grant specific expenditure accounts within the accounting software to be used exclusively for managing each individual award. These expenditure accounts will be used to support expenditure claims. Reports from the accounting software system that are utilized to prepare expenditure claims will be reviewed, reconciled and approved by an appropriate member of management prior to final submission. Supporting documentation for each grant expenditure claim submission will be maintained electronically for future reference. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Ms. Sheryl Coleman; Chief School Business Official

Finding: The Department of Health did not have adequate internal controls to ensure payments to subrecipients were allowable, met cost principles, and were within the period of performance for the Epidemiology and Laboratory Capacity for Infectious Diseases program. Questioned Costs: Assistance Listing # 93.323 93.323 COVID-19 Amount $1,735 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department disagrees with the State Auditor’s Office (SAO) assessment of a material weakness in internal controls over the consolidated contract provider payment process for the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) program. The Department has established processes in place to ensure payments are allowable and meet cost principles for the program. These include: • Perform annual review and approval of detailed subrecipient budgets. • Compare invoice amounts to budgeted amounts for reasonableness before payment approval. • Provide subrecipients with regular technical assistance and training on applicable policies related to fiscal and programmatic processes. • Conduct biennial program and fiscal monitoring visits to subrecipients as part of the Department’s monitoring procedures. In addition, the ELC program has monitoring controls in place and evidence of review at the program level. Program staff maintain a detailed spreadsheet that documents review and approval and includes any amounts that need to be withheld until issues with invoice support are resolved. These reviews are to be completed within the 10-day period before payment is released. The Department is planning on meeting with federal grantors to work through the exceptions and questioned costs identified in the finding. The conditions noted in this finding were previously reported in finding 2022-033. Completion Date: Not applicable Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

Finding: The Department of Health did not have adequate internal controls to ensure payments to subrecipients were allowable, met cost principles, and were within the period of performance for the Immunization Cooperative Agreements program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-19 Amount $416,027 Status: Corrective action not taken Corrective Action: The Department does not concur with the finding. The Department disagrees with the State Auditor’s Office (SAO) assessment of a material weakness in internal controls over the consolidated contract provider payment process for the Immunizations Cooperative Agreements program. The level of documentation received from the subrecipient accounting system provided assurance that the exceptions questioned by SAO met federal cost principles for allowability and period of performance. The Department has established processes in place to ensure payments are allowable and meet cost principles for the program. These include: • Program staff maintain detailed budget information for each subrecipient by project area, and as A-19s are submitted, program and accounting staff update budget spreadsheets. When reviewing the support provided by the subrecipient, staff ensure amounts submitted by project are reasonable and align with expectations for the budget period submitted. • Program staff refer to the federal Immunization Program Operations Manual to determine procedures related to allowable costs, purchases, and procurement. • The Fiscal Monitoring Unit provides technical assistance and training to program staff and subrecipients while onsite and at the request of the entities receiving funding. • Program staff provides policy guidance, technical assistance, and training to subrecipients related to program compliance requirements. The program has continued to strengthen processes to ensure supporting documentation aligns with the agency’s documentation matrix for subrecipients in accordance with assigned risk level. The Department is planning on meeting with federal grantors to work through the exceptions and questioned costs identified in the finding. The conditions noted in this finding were previously reported in finding 2022-031. Completion Date: Not applicable Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov