Corrective Action Plans

Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned to the grant will review interest income earned throughout the fiscal year and ensure any amount exceeding $500 is returned to the Department of Health and Human Services. Contact person responsible for corrective action: Vanessa Barker Anticipated Completion Date: 06/30/2024

Audit Finding Reference: 2023-003 Internal Controls Over Cash Management and Reporting Planned Corrective Action: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. a. Cash Drawdowns: i. Currently, all cash drawdowns are prepared by our grant accountant; and reviewed and approved verbally by our grant manager. In addition, all cash drawdowns are reviewed and approved by the national office of the grantor. Going forward, prior to the submission to the national office for approval, the cash drawdowns will be reviewed and approved via email or signature by upper management. b. Financial Reporting: i. Currently, all financial reports (FFR; SF-425; etc.) are prepared by our grant manager, with the assistance of information obtained from our grant accountant from the general ledger. These reports are reviewed and approved verbally by our Vice President of Finance, Development and Administration. In addition, all financial reports are reviewed and approved by the national office of the grantor. Going forward, prior to submitting the reports to the national office for approval, the reports will be reviewed and approved via email or signature by upper management. c. Performance Reporting: i. Performance reports are prepared by the grant lead, and verbally approved by their manager. Managers are copied on the emails to the Federal Office, verifying their approval of the report. Going forward, prior to submitting to the national office for approval, the reports will be reviewed and approved via email or signature by upper management. Planned Implementation Date of Corrective Action: 06/01/2024 Person Responsible for Corrective Action: Vice President – Finance, Development & Administration

Audit Finding Reference: 2023-002 Internal Controls Over Disbursements Planned Corrective Action: No documented review of employee reimbursements charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. All employee reimbursement expenses are reviewed and approved by the employee’s direct manager, within the payroll system (Paylocity) prior to processing payment (with bi-weekly payroll). In addition, the grant accountant and grant manager will review the timesheets and allocation of employee expenses to confirm that they agree. The approval is submitted via email to the payroll administrator for processing of the payroll. The payroll administrator will create the journal entry in the general ledger from the approval worksheet. In addition, with the implementation of our new general ledger system, the entries are reviewed and approved within the general ledger system by upper management. No documented review of payroll charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. Payroll has multiple levels of approval. In FY23, the payroll folder, that includes timesheets, grant allocations, and payroll register, would be submitted for approval to the accounting manager. The accounting manager would review and approve payroll and return the folder to the payroll administrator for payroll submission to the payroll company. Starting in FY24, payroll would be submitted via email to the grant accountant, grant manager, and the assistant controller for multiple levels of review and approval. Corrections and approvals are done via email. In addition to the email approvals, upper management approves payroll by initialing the last page of the payroll register after a complete review. Furthermore, with the implementation of our new general ledger system, the entries are reviewed and approved within the general ledger system by upper management. Planned Implementation Date of Corrective Action: 02/01/2024 Person Responsible for Corrective Action: Vice President – Finance, Development & Administration

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will reconcile federal programs to the passthrough agencies 9 months into the fiscal year at a minimum as part of the preparation of the SEFA report.

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another two disbursements included expenses for other clubs outside the grant agreement that was charged to the grant. The last disbursement was missing supporting documentation for the costs charged to the grant. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that the Organization verify that costs submitted for reimbursement are valid and allowable expenses. Additionally, the Organization needs to properly allocate costs in accordance with the grant agreements. Corrective Action. Management concurs with the finding. The Organization will ensure valid and allowable expenses, including proper allocation of costs, are remitted through enhancement of the current review processes. Responsible Person. Stacy Holman, Chief Financial Officer. Anticipated Completion Date. December 31, 2024.

Finding 2023-002: Overdrawn Federal Funding Condition The auditors identified duplicated federal award expenditures amounting to $380,644, resulting in overdrawn federal funds by $380,644. The excess cash on hand was not returned to the funding source in a timely manner. Correction action: NACDD has experienced drastic change in size over the past 3-4 years. Current policies and procedures have not been adequate for the size and volume of the transactions experienced in FY 23. In addition, there has been significant finance/accounting staff turnover including leadership of the Finance team. +The impact of this deficiency was isolated to one cooperative agreement which closed out as of 9.30.23. NACDD performed efficient and effective subsequent disbursement procedures after year end to ensure that expenses for this grant and others were recorded in the appropriate fiscal year. In the process of preparing the FFR and researching further additional expenditures related to this grant, expenses included in the initial subsequent disbursement adjustments, related to this grant were duplicated. +The Correction action plan includes previously implemented augmentation of the Finance staff. Since the end of the FY 23 fiscal year, the finance department has been fully staffed with knowledgeable accounting professionals, many who have financial federal grant experience. There is now a financial analyst on staff whose main responsibility is to reconcile and record federal grant expenditures and receivables. This process is done monthly. We believe that this additional procedure will eliminate the recurrence of this and any other like issues. Procedures related to the weekly PMS drawdown have been expanded to include reconciling the accounts receivable by grant with the PMS accounts to allow only amounts listed in PMS which are supported with appropriate expenditures to be drawn. +Implementation of corrective measures: The above expanded procedures and oversight have been in effect for most of the FY 24 fiscal year. PMS drawdowns are now done weekly with worksheets that tie in detail to the weekly expenditures. In addition, a control checklist will be created and utilized by the Finance staff leadership to monitor and document the successful implementation of corrective measures. + Additional over-arching controls – The Finance team will execute an interim audit process inhouse as of 6.30.24 and every year going forward to further identify errors and irregularities that may exist. If necessary, additional policies and procedures will be implemented to provide greater scope and assurance in preventing financial reporting errors. Responsible Person Trish H. Strong, CFO Anticipated completion date June 30, 2024

Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2024 claim.

Management agrees with the recommendations. We are revising the Financial Management policies and procedures to ensure that the separation of duties is clear, and the report preparation and review process complies with this recommendation.

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.

FINDING 2023-001 – Significant Deficiency in Internal Control over Compliance – Reporting Description of Finding: Controls should be in place to ensure the accuracy of reporting submitted for federal awards programs with proper supporting documentation to agree to the reports being submitted to the Department of Education. As part of the recordkeeping process, each month’s claim for reimbursement and all data used in the claims review process must be maintained on file. Of the eleven monthly claims reports reviewed during the audit, the supporting documentation for one of the claims (April 2023) could not be located. Statement of Concurrence or Nonconcurrence: The Town agrees with this finding. Corrective Action: The Town agrees with the finding and has implemented internal controls to ensure the supporting documentation for each monthly claim are filed and maintained. Each month the monthly claims reports and supporting documentation will be filed away in a designated secure location with a checklist by month to confirm processing. Name of Contact Person: Cynthia Varricchio, MBA, Director of Finance and School Business Operations. Projected Completion Date: June 30, 2024

Finding Reference Number: 2023-02 Description of Finding: Transportation reports were not submitted timely to the DOT per the grant agreement. Statement of Concurrence or Nonconcurrence: The agency does not concur with this Finding Corrective Action: Quarterly reporting and financial reporting are not joined under the same reporting deadlines. All Quarterly reports were submitted within the required timeframe; that is, 10 days after the quarter ends. There is no deadline for submitting invoices to DOT for reimbursement. In summary, NHCOG is of the opinion that the Finding does not accurately reflect the material detail and reporting of our programs, funding streams and administrative difficulties between the state and our providers. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2024

CORRECTIVE ACTION PLAN June 25, 2024 Appalachia Service Project, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 636 Shelby Street, Suite 400 Bristol, TN 37620 Audit period: December 31, 2023 The findings from the December 31, 2023, Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-001: Community Development Block Grant-AL# 14.218, Controls over Reporting Condition: ASP included an amount for reimbursement to the City of Johnson City, TN that had not been paid and was not paid promptly, resulting in ASP receiving funds in advance from the City, which is in violation of the grant agreement ASP has with the City. Criteria: The grant agreerr.e nt with the City states that in no event shall the City provide advance funding to their sub-recipient. Cause: ASP failed to pay an invoice that was submitted for reimbursement prior to the receipt of the reimbursement from the City. ASP's controls over the process of reconciling reimbursement requests and payables from their general ledger to the request were not sufficient to prevent this issue from occurring, resulting in the error. Effect: ASP violated their agreement with the City and received funds in advance. Questioned Costs: NIA Perspective Information: An invoice recorded in their purchasing tracking software was not subsequently recorded in their financial software allowing for request for reimbursement to happen for an invoice that was not promptly paid. Controls were not sufficient to prevent this from occurring. Repeat Finding: No Recommendation: ASP should pay all invoices submitted for reimbursement prior to receipt of the reimbursement from the City in order to stay in compliance with their agreement with the City. ASP should also reconcile between the purchase tracking software and the general ledger to ensure that all purchases are promptly recorded in accounts payable to be paid promptly. ASP should ensure that controls are implemented to help prevent reoccurrence of this issue in the future. Corrective Action: ASP has policies and procedures in place to ensure all reimbursable expenditures are allowable, paid and clear the bank before submitting for reimbursement. However, on one occasion, ASP inadvertently submitted an allowable and paid expenditure of $32.78 that had not cleared the bank. ASP has since repaid this amount and the replacement check has been cashed by the vendor. In the future, ASP will ensure that all expenditures are allowable, paid, and clear the bank before submitting the reimbursement. ASP has re-emphasized the importance of following established procedures when submitting for grant reimbursements and believes proper controls and corrective actions are currently in place to prevent future issues. 2023-002: Community Development Block Grant - AL# 14.218, Reporting Condition: ASP, a sub-recipient, did not submit their Quarter 3 report in a timely manner, which is in violation of the grant agreement ASP has with the pass-through entity, City of Johnson City, TN. Criteria: The grant agreement with the City requires an annual report, a projected expenditures report, and four quarterly reports be submitted by ASP in a timely manner. Cause: ASP failed to submit their Quarter 3 report before it was due. Effect: ASP violated their agreement with the City and submitted their report late. Questioned Costs: NIA Perspective Information: The Quarter 3 report required by the grant agreement between ASP and the City of Johnson City was not submitted timely. Repeat Finding: No Recommendation: ASP should submit all required reports in a timely manner per the grant agreement. Additionally, ASP should review controls and procedures in place to ensure that there are policies to help aid with timely report completion. Corrective Action: ASP is currently engaged in home rehabilitation projects under an agreement with Johnson City CDBG. This agreement stipulates that quarterly reports must be submitted by the 15th of the month following the quarter. Despite completing the required work and accurately tracking expenses, the report due on I 0/16/2023 was submitted a little over 2 weeks late on I 1/2/2023 due to an omission by staff. However, ASP has maintained communication with the grant administrator at Johnson City and has remained compliant with all other aspects of the contract. The delayed submission of the quarterly report has not impacted ASP's favorable standing with the city, and we have promptly rectified the situation, ensuring full compliance with the agreement. ASP believes the proper corrective action has taken place to ensure future reports are submitted in a timely manner. If the Federal Audit Clearinghouse has questions regarding this plan, please call Greg DeGennaro, CFO at 423- 854-8800. Sincerely yours, Greg DeGennaro Chief Financial Officer

Grantee Response: The Association took immediate action to notify the grant administrators when the condition was discovered, performed an investigation, and submitted a report to the grant administrators detailing their findings. As a result of these circumstances, the Association has made several updates to their policies including 1) regularly reviewing cell phone records to detect out of state calls within one month of their occurrence; 2) developing an approval form for out of state travel that must include proof of the grant administrators approval and a detailed agenda of the trip; 3) requiring that expense reimbursement forms include travel dates and times as well as the event that the travel is related to; 4) crosschecking the shared office Outlook calendar each payroll period to personal leave requested in the payroll system; and 5) attending monthly grant administrator meetings to facilitate communication and ensure that the Association is made aware of travel requests.

The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of a draw request for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit a report reflecting summary and detailed reports for all draw requests. This report will include detailed payroll information as well as confirmation that all non-personal services expenditures have been disbursed. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table

Cash Management: As is the case with most higher education institutions and governmental entities, the College has struggled with the COVID pandemic and its aftermath. Essential functions were disrupted, including several key accounting, finance, functions due to employees being out sick. Chief Dull Knife College had a discrepancy occur when drawing down funds in which it was done in error twice and an aggregate difference from the previous year was carried over. This was discovered and the difference was sent back to HEERF. The HEERF funding has been reconciled and concluded. The College had more than sufficient money in the bank to cover all of their expenses so this money was not used to cover any expenses. Chief Dull Knife College takes the responsibility of drawing money from Grant Programs very crucial and will make all efforts and policies to ensure this type of error does not occur.

Even though prevailing wage was paid, contract was bid and awarded as such, in the future, the Treasurer will ensure that prevailing wage rate requirements of necessary clauses are included within all applicable contracts.

Unallowable Costs Criteria: The Organization must submit only allowable costs for reimbursement under the accounting principles contained in Uniform Guidance. Condition: During compliance testing, it was noted that one out of twenty five selections improperly included alcohol in the balances submitted for expense reimbursements. Context: One expense reimbursement was found to have reimbursed alcohol. Cause: There was a lack of consistent review of the receipt before submission for expense reimbursement. Effect: As a result of the condition, one reimbursement was overpaid. Recommendation: In the future, the Organization should review reimbursements closely to ensure unallowable costs are not submitted for reimbursement. Contact: Erin Spaulding, Senior Director of Finance. Corrective Actions Taken or Planned: Management acknowledges the finding and will take action to ensure that no unallowable costs are being reimbursed.

2023-001 Utility Allowances Calculations Corrective Action Plan: If the family selects a unit with a different number of bedrooms than the family unit size listed on the voucher, the PHA must apply the payment standard and utility allowance for the smaller of the family unit size listed on the family's voucher or the unit size selected by the family. 24 CFR 982.S0S(c)(l) Anticipated Completion Date: Management will implement training and procedures to ensure compliance with federal guidelines that relate to the Housing Choice Voucher Program. Training and procedure reviews are currently in progress and will be ongoing.

Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2024

Federal Aid Policies Finding 2023-002 Auditor Description of Condition and Effect: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. As a result, the Authority is noncompliant with 2 CFR 200. Auditor Recommendation: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Corrective Action Plan: The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

El Proyecto will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. El Proyecto will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clinic locations. The training will consist of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. Person Responsible: Leticia Vasquez Position of Responsible Party: Billing Manager Completion Date: September 30, 2024

Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures to require the documented review and approval of all indirect calculations, cash management requests for funds and performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.

2023-006 – ALN 14.872 – Public Housing Capital Fund Program – Cash Management Planned Corrective Action: The Interim Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Christy Amacher, Interim Executive Director Anticipated Completion Date: September 30, 2024

Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project Worksheet #1822 – Award Year 2023 (Application 553330) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. We are committed to strengthening our processes to ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible. To achieve this, we will implement enhanced procedures and controls to ensure full compliance with the Uniform Guidance requirements. Anticipated Completion Date: December 1st, 2024

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