Corrective Action Plans

Finding 2023-002 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster State ID Number and Title: 435.283 IMAA State Share Award Number: Unknown Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Agency: Wisconsin Department of Health Services Criteria: The Uniform Guidance and State Single Audit Guidelines require that local entities receiving federal and state awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. The Uniform Guidance and State Single Audit Guidelines further require auditors to obtain an understanding of the local entity's internal control over federal and state programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of monthly reports, which should be reviewed and approved by a responsible party other than the original preparer. Condition/Context: After the Human Services Manager left the County in June of 2023, the County did not replace the position with another individual to continue performing the control of reviewing GEARS reports prior to submission for reimbursement. Two of the three GEARS reports tested in each program were not reviewed prior to submission as required by the state. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Efforts to fill the Human Services Financial Manager position were being actively pursued during the vacancy. The position was re-filled January 29, 2024. Discussion about a backup plan should this position be vacant again are occurring between human services and county administration. Name(s) of Contact Person(s) Responsible for Corrective Action: Mandy Stanley, Human Services Director Anticipated Completion Date: Human Services Financial Manager position was re-filled January 29, 2024.

Finding Number: 2023-007 Finding Title: Local Collaborative Time Study (LCTS) Reporting (Cost Schedules DHS-3220.1 and DHS-3220.2) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Melanie Lupkes/Shelly Staebler Corrective Action Planned: Social Services and Probation staff met as a group to go over the most recent bulletin that includes the instructions for completing the forms and for the allowable expenses. Consulted with OSA staff for interpretation of some of the items and all quarterly reports have been resubmitted, reviewed by Traverse County Social Services Fiscal and accepted by the State. Anticipated Completion Date: Completed, September 7, 2024

Finding Number: 2023-005 Finding Title: Reporting (DHS 2550 and 2556) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services fiscal staff will review the new detailed instructions on how to complete the referenced quarterly reports that include recent changes. Staff will correct an resubmit quarterly reports as requested. Anticipated Completion Date: January 20, 2025

The City will review the reports prepared by the consultant and formally document their review

Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will accept. For many projects, an architect certification for each draw would be financially prohibitive and would likely reduce the financial viability of affordable housing developments. Our office does conduct intermittent on-site or desktop monitoring throughout the course of the project to ensure evidence activities. Additionally, all construction projects must complete permit requirements to ensure housing quality. Evidence of monitoring or activity was provided to the auditors. Expected Implementation Date: October 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development

Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was discovered during the subrecipient monitoring component of this award and was promptly reported and reconciled prior to being presented as an audit finding. Upon identification of the duplicative charges, totaling approximately $22,000, immediate corrective action was taken to address the non-compliance. Dated January 5, 2024, a memorandum was filed disclosing the duplicative reimbursements, documenting the actions taken to rectify these charges, and recommending further steps to enhance the internal controls of the non-profit organization. The following information summarizes the East Baton Rouge City-Parish American Rescue Plan Act (ARPA): Duplication of Benefits - Findings and Corrective Action Memorandum: This memorandum documents the incidental reimbursement of multiple duplicative items associated with the subrecipient’s grant agreement and the corrective actions undertaken to resolve these findings, ensuring compliance with the terms of this award. During the routine subrecipient monitoring reviews, it was discovered that duplicate reimbursements occurred for 12 items between separate federal awards (American Rescue Plan Act SLFRF and CARES Act). In accordance with 2 CFR 200.522(c), a corrective action plan was provided to resolve the non-compliance. To address this, the following actions were taken: 1) Reconciliation of Duplicate Reimbursements: The non-profit entity has since reconciled the total value of $22,222.98 in duplicate reimbursements with an equivalent value of eligible expenses, including all necessary backup documentation to satisfy existing procurement and reimbursement requirements. 2) Development of a Duplication of Benefits Policy: It was recommended that the non-profit entity develop a comprehensive duplication of benefits policy to strengthen their internal controls further. These additional safeguards are considered best practices and are intended to minimize the risk of future non-compliance. Additionally, a comprehensive, grant specific, financial management policy template was provided to support the non-profits action to adopt and implement an appropriate standard of internal controls. The City-Parish is committed to maintaining robust internal controls and ensuring compliance with federal regulations. Immediate corrective measures were proactively taken to address these duplicative charges. Additionally, the City-Parish's third-party grants manager has established recurring weekly monitoring meetings with the non-profit entity to support the development and implementation of an adequate system of internal controls. Continuous efforts are being made to improve these processes to prevent such issues in the future. Expected Implementation Date: January 2024 Contact person: Courtney Scott, Assistant Chief Administrative Officer, Mayor-President’s Office

Section III –Federal Award Findings and Questioned Costs FINDING 2023-002 DEBT SERVICE COVERAGE RATIO COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. The delays had a negative impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2023. The negative impact on overall operations resulted in the Hospital not meeting the required debt service coverage ratio of 1.5. The Hospital did receive a waiver from the USDA regarding this noncompliance matter. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement which continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Anticipated completion date Ongoing

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-004 – Medicaid and CHIP Receipt Controls Name of the contact person responsible for corrective action: Ashley Logan Anticipated completion date for corrective action: June 30, 2024 Recommendation: The DSS through the MHD review, strengthen, and enforce internal controls over Medicaid and CHIP receipts. The MHD should restrict user access within the MMIS for FORU accounting personnel and adequately segregate asset custody and receipt recording duties from accounts receivable duties, or perform documented supervisory reviews of MMIS entries and changes made by employees whose duties are not segregated. In addition, the MHD should establish procedures to account for all cash control numbers to ensure all receipts are deposited or returned to senders. DSS Response: DSS agrees with the auditor's finding. Our Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: MHD has implemented a process to document supervisory reviews of the Finance Manual Checks Quarterly report to ensure segregation of duties in HeathTrack/AHS. MHD will continue to perform the audit of clerk ID adhoc reports to review any segregation of duties within the MMIS. To ensure all cash control numbers are accounted for, MHD is implementing a new cash control number sequence, exclusive to manual checks logged within the FORU. This will resolve the issue of cash control numbers occurring out of sequence due to AHS running files in the background at the same time checks are being logged.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Missouri National Guard (MONG) Audit Finding Number: 2023-018 – MONG Cooperative Agreement Extensions and Final Accounting Name of the contact person responsible for corrective action: Lindsey Hedges Anticipated completion date for corrective action: October 2024 Recommendation: The MONG establish controls and procedures to ensure a final accounting of all funding and disbursements and/or a written request(s) for extension is filed for each CA appendix in compliance with National Guard regulations. Corrective action planned is as follows: Missouri National Guard will implement internal controls and procedures for ensuring final accounting and extension requests are filed timely through regular monitoring of Cooperative Agreement (CA) appendices to identify upcoming lapses in completion of final accounting of all funding and disbursements or for extension request.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

Corrective action planned: Cash flow requirements to fund daily operations will be reviewed more thoroughly so that awarded funds are expended consistent with the terms of their respective agreements. Projects presently on quarterly cost reimbursement schedules will be changed to monthly cost reimbursement requests. Contact person responsible for corrective action: John D. Pepe, Controller. Anticipated or actual completion date: October 1, 2024.

2021-01: Approval for expenditures Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.

2019-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregating certain duties is not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.

Finding 2023-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the projects and related expenses submitted to FEMA for reimbursement. Current Status: In progress. Resolution: Management will develop and implement additional internal controls to ensure documentation is retained to evidence the operating effectiveness of the internal controls. These internal controls will ensure expenses included in FEMA grant applications are reported completely and accurately. The additional internal controls will include a reconciliation of application expense detail to final paid invoices along with a notation that each expense is allowed to be included in the FEMA submission. The reconciliation will be reviewed and approved by the Cottage Health Director of Finance prior to final FEMA submission and evidence of the review will be retained. Contact Person: Lawrence Thomas, Director of Corporate Finance Anticipated Completion Date: November 29, 2024

HSD acknowledges the identified weakness and implemented an updated Accounts Payable control procedure in 2024, that includes an additional standard monthly report and review process to ensure that reimbursements are processed with the required 30-day period.

For the Hill Housing Facility - FINDING 2023-001: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 - SURPLUS CASH NOT DEPOSITED INTO RESIDUAL RECEIPTS ACCOUNT - Recommendation: The Project should deposit surplus cash as of December 31, 2021 into a residual receipts account as soon as possible. Action Taken: The Project agrees with the finding. Management will deposit $14,079 in a residual receipts account as soon as possible.

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-003 Medical Assistance Program / State Health Insurance Assistance Program / Medicare Enrollment Assistance Program – Assistance Listing No. 93.778 / 93.324 / 93.071 Recommendation: We recommend that there is an appropriate reviewer of each grant claim. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The amounts reported were accurate and in compliance. The department will continue to train employees in respective positions to ensure responsibilities align with program requirements. Immediately upon discovery of the omission of the review step, management reiterated to department financial staff the importance of the review process. Name(s) of the contact person(s) responsible for corrective action: Kim Merrill, Finance Manager Planned completion date for corrective action plan: December 31, 2024

Contact Person - Pattie Solberg, Auditor; Corrective Action Plan - The City should follow their procedures for signing off on all requests for reimbursement reports before submitting the federal reimbursement. Completion Date - December 1, 2024.

Contact Person - Pattie Solberg, Auditor; Corrective Action Plan - The City should contact the Contractor to determine if the amount that was overpaid will be refunded or adjusted on the next "Pay Estimate." The City will also need to contact the Grantor to determine if the reimbursed dollars should be returned or adjusted on the next draw. To mitigate the risk of overpayment in the future, the City should reconcile construction payments to the "Pay Estimates." Completion Date - December 1, 2024

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2023, we implemented additional procedures to more efficiently review drawdowns and supporting documentation. We updated our fiscal policies and procedures in 2023 to document a standardized process for review and approval of drawdowns before request for reimbursement by the Fiscal Office and CEO. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

Management Response The Garden did not draw more on awards than had been incurred over the course of the contract. Adjustments in the general ledger were made in subsequent periods to tie out requested reclasses from program staff. Corrective Action Plan: Education and reverification of the processes documenting the flow of information from the general ledge to the federal award billings has been provided to accounting personnel involved in federal award accounting and billing. Contact person(s) responsible for the corrective action: Jaime Kuczkowski, CPA Jaime@balancefm.com, Diane Wondolowski, Director of Finance, dwondolowski@sbbotanicgarden.org Anticipated Completion Date: Education will be complete by August 31, 2024.

Name of auditee: Town of Plattsburgh Housing Development Fund Company, Inc. TIN: 014-EE068 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2023 CAP prepared by: David Kimmel President Two Plus Four Property Management Co,. Inc. (315) 437-2178 Current Finding on the Schedule of Findings and Questioned Costs and Recommendations Finding 2023-002 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. (b) Action taken: Management will deposit the surplus cash in the amount of $11,218 into the residual receipts account during August 2024.

Staff will indicate on grant drawdown approval forms the date that the draw was taken to avoid duplication.

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full - range of controls relating to reporting, including federal program reporting. MARR will take such steps as necessary to ensure that reports are timely and accurately prepared, reviewed, and approved prior to filing. All controls, including review and approval will be documented in such documentation to be maintained. MARR will retain a CPA consultant to implement and adopt formal written policies relating to grants management ordered by Uniform Guidance.

Planned Corrective Actions: MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR’s protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting process be accurate. Further, controls over grant billings will be established to ensure expenditures represent actual costs incurred. All control activities, including independent review, should be documented and evidence of review and approval will be maintained.