Corrective Action Plans

School policy committee to create/review a policy under the 2 CRF section 200.516.

Finding: During a review of the awards population for fiscal year 2024, the University identified 6 accounts that had duplicate contact and bank information. After further investigation, these accounts were determined to be fraudulently created. In total, $54,112 in funds were paid out. The school worked with the U.S. Department of Education’s Cyber Incident Division to inform the Department of the fraudulent activity. Corrective Action Plan: Management agrees with the findings and has put the following in place. The Bursar will work with ITS to perform a scan of all students’ accounts for duplicate contact and banking information. If duplicates are found students will be notified and accounts frozen until students are identified. This will be critical before refund checks are dispersed to students every semester. The amount of $54,112 will be paid back with the next draw down before February 28, 2025. Responsible Officials and Implementation Date: The Bursar and Director of ITS will be responsible for this action plan and will implement by July 1, 2025, a scan done by the system. Bursar will spot check for duplicates until the report is built and put in place for the scan.

Corrective Actions Taken Commons has taken the following actions to protect against such fraudulent incidents in the future: • Engaged a firm to assist with managing the incident; • Opened a new bank account; • Added account verification services with our banking partner, which will be utilized to verify account updates; • Limited the amount of per vendor/subrecipient daily payments to our insurance limits, with verifications prior to releasing additional funds when the total payment exceeds the insurance limits; • Subrecipient payment receipt is verified by both the subrecipient and the Commons grants team; • Updated our policy and procedures to direct our subrecipients to request banking changes through our procurement system and not through email; and • Expanded implementation of our Kissflow procurement system across the organization, which includes new vendor process as well as a change of vendor information module. Vendor changes would be approved first by the program/department that works with the vendor prior to Finance approval. Completion Date With the exception of implementing the change of vendor information module in Kissflow, the above actions have all been completed by the date of this report. The projected completion date for Kissflow change of vendor information module is April 30, 2025. Responsible Party Dana Thomas, Chief Financial Officer Angela Allen, Vice President of Finance

The District agrees and has already implemented processes to ensure receivables are created with each claim created in CNIP.

The School Board will ensure to require all contractors funded with federal funds maintain compliance with prevailing wage requirements and obtain documentation certifying compliance.

Type of Finding : Significant Deficiency Over Compliance with Procurement and Suspension Debarment Delta County Joint School District No. 50J had the following regarding internal controls in Nutritional Services: The District did not properly procure one vendor within the Child Nutritional Cluster that incurred questioned costs in excess of the $25,000 threshold, based on 2 CFR 200.516. Delta County Joint School District No. 50J concurs with finding 2024-001 and will implement the following corrective steps: Additional procedures have been put in place, and documentation will be maintained for purchases to satisfy Procurement and Debarment requirements.

Corrective Action Plan Finding No.: 2024 - 004 Condition: The District did not meet its maintenance of effort on either the aggregate or the per capita basis for fiscal year 2024. The shortfall in maintenance of effort was $401,982. Plan: The District will implement procedures and internal controls in FY 2025 to monitor maintenance of effort compliance. Furthermore the District will perform a comprehensive review of fiscal year 2024 expenditures to identify the cause of the decrease in special education expenditures from the FY 2023 amounts to determine if allowable exceptions can be identified in accordance with federal guidelines. Anticipated Date of Completion: 6/30/2025 Name of Contact Person: Sheila Johnson, Assistant Superintendent of Finance and Operations

Management has engaged its current auditing firm to complete the required Single Audits for its fiscal 2023 and 2022 year-ends.

Finding: 2024-002 Name of Contact Person: Michael Coone, Assistant Social Services Director Criteria: In accordance with 20 CFR 681.590, local youth programs must expend not less than 20 percent of the funds allocated to them, except for the local area expenditures for administration, to provide paid and unpaid work experiences. Recommendation: Require the County Program Directors to implement procedures to ensure that earmarking requirements are met. Corrective Action/Management’s Response: Management concurs with this finding and will adhere to the Corrective Action Plan in this audit report. The County has implemented the following process: Gaston County Workforce Development Board staff worked closely with the previous Youth service provider requesting them to assign 100% of their WEX specialist salary towards work-based learning expenses to obtain this goal. With a new service provider, Two Hawk Employment Services, their financial staff have budgeted 20% of all WEX related activities, salaries, staff costs, participant costs, etc. to meet the 20% goal. Gaston County WDB and Two Hawk Employment Services have adjusted staff day sheet logs to reflect 20% of staff activities to ensure all staff are assigning the work appropriately. The Gaston County Workforce Development Board mandated in the service provider Youth contract to meet the 20% WEX Expenditure and future contract awards are determined on successfully meeting the expenditure requirement. Per the state’s most recent Youth Expenditure Report at the end of October 2024, Gaston County Workforce Development Board is 76% towards meeting the goal. The Workforce Development Board staff and management will continue to monitor monthly that 20% of all salaries and WEX activities are accurately reflected on all invoices and financials from Two Hawk Employment Services. Proposed Completion Date: Management and the Board will implement the above procedures immediately with a completion date of June 30, 2025.

Federal Program Title: Postconviction Testing of DNA Evidence; Capital Case Litigation Initiative ALN: 16.820; 16.746 Recommendation: We recommend the University review its current procedures to ensure disallowable costs are not being charged allocated to federal programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Boise State University is reminding faculty and staff about lobbying and the basics of charging costs to a sponsored project with an emphasis on cost allocability. Name(s) of the contact person(s) responsible for corrective action: Jen Lutke Planned completion date for corrective action plan: December 31, 2024

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