Corrective Action Plans

The Organization is transitioning to a new digital software to electronically receive meal counts

Condition and Cause: As part of our federal compliance testing we reviewed supporting documentation used to submit claims for lunch and breakfast programs. Our review noted one instance where the breakfast meals were submitted as lunch meals. Questioned Costs: $7,864 Criteria: Districts must submit monthly claims for reimbursement for meals served to eligible students within 60 days following the last day of the month covered by the claim. Each month’s claim for reimbursement and all data used in the claims review process must be maintained on file. Accurate records must be maintained justifying all meals claimed and documenting that all Program funds were spent only on allowable Child Nutrition Program costs. Effect: If incorrect amounts are reported, the District could either receive disallowed aid, or be missing out on additional aid. Auditor’s Recommendation: We recommend the District review of current procedures for compiling and reporting the information submitted in order to verify accurate claims are submitted to DPI. Grantee Response: The District is working with DPI to correct the claims and will implement procedures to ensure that claims are accurate. Contact Person: Jessica Lien Anticipated Completion: Ongoing

Finding: The Organization allowed payroll related costs to be submitted for reimbursement under the grant for time that did not match approved timesheets. This is not in compliance with program allowable cost requirements. The amount of payroll and related costs discovered to be incorrect was a net amount of $25, which when projected onto the remaining payroll and related costs that were not tested, amounted to $1,038. Corrective Action Taken or Planned: The Organization will review audit findings and ensure accurate future reimbursements, develop a comprehensive process for verifying time sheets against service delivery, and implement a paper timesheet system in which supervisors must enter time based on timesheets, ensuring 1:1 reimbursement. Name of Contact Person: Jacob Ducey, Grants Manager Phone Number of Contact Person: (540) 907-4555 Projected Completion Date: October 31, 2023

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Winlock School District No. 232 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate controls for ensuring compliance with federal requirements for allowable costs and cost principles. Name, address, and telephone of District contact person: Gloria Dupree, Business Manager, N.E. 1st Street, Winlock, WA 98596, (360) 785-3582 Corrective action the auditee plans to take in response to the finding: Corrective actions for ensuring compliance with federal requirements around cash management, allowable costs, and cost principles. Cash Management 1. Review Policies and Procedures: Ensure the district’s policies and procedures align with federal standards. Regularly audit your cash management practices. 2. Training: Ensure training on federal regulations and the importance of adhering to them for staff members involved in cash management. 3. Internal Controls: Strengthen internal controls to prevent and detect non-compliance, including segregation of duties and regular reconciliations. We hired a new Accounts payable employee in February 2023. 4. Monitoring: Monitor regularly to ensure that federal funds are utilized properly and efficiently. Allowable Costs 1. Guidance Review: Review the federal awarding agency’s guidance on allowable costs to ensure that all costs charged to the award are permissible under the specific federal program. Office of the Washington State Auditor sao.wa.gov 2. Documentation: Implement a robust system to document all costs and ensure they are reasonable, allocable, and necessary. 4. Review: Conduct regular reviews of expenditures to check for compliance with allowable cost principles. 5. Training: Educate all staff involved in financial management about the principles of allowable costs associated with federal awards. Cost Principles 1. Policy Update: Update organizational policies to reflect federal cost principles. 2. Consistency: Apply costs consistently and in a manner consistent with policies and procedures. 3. Direct vs. Indirect Costs: Properly identify direct and indirect costs and allocate them according to federal standards. 4. Record Keeping: Maintain accurate and complete financial records, retaining them for the period specified by the federal award or until all audits are completed and findings resolved. Anticipated date to complete the corrective action: 02/01/2024

Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting U.S. Department of Health and Human Services, AL No. 93.958, Block Grant for Community Mental Health Services U.S. Department of Health and Human Services, AL No. 93.959, Block Grant for Prevention and Treatment of Substance Abuse U.S. Department of Health and Human Services, AL No. 21.027, Coronavirus State and Local Fiscal Recovery Fund U.S. Department of Health and Human Services, AL No 93.778, Medicaid Cluster Medical Assistance Program Criteria Human Resources Development, Inc., and Affiliates’ (HRDI) is responsible for keeping an accurate accounting and all of the required documentation in accordance with applicable federal regulations. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. HRDI has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll & Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. • HRDI’s Human Resources has implemented quarterly audits on all new staff to verify each new staff member hired within the last year has a signed employee offer and appropriate backup support to support the employees’ annual salary. • HRDI has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • HRDI is in the process of implementing a new payroll & HRIS – UKG. The anticipated completion date is March 2024. All manual and onboarding processes will be implemented within the system for tracking and auditing purposes. • HRDI will implement an established month-end checklist for all monthly entries to be completed by assigned finance staff. We will ensure that all staff are trained adequately to handle any assigned task. All monthly entries are required reviewed and approved by the Chief Financial Officer prior to posting to the general ledger within our new Accounting Software. All appropriate backup documentation will be saved and stored within the accounting software. • All Grant related Year-End and Audit Procedures will be transitioned to the Grant Accountant who has experience in audits, compliance, and reporting of City, State, Local, and Federal Grants. • HRDI will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. • HRDI will ensure that Finance staff will receive at minimum of 25 hours of training each year related to GASB, GAAP, Governmental Financial Reporting, or other related accounting trainings annually. • HRDI will ensure that any staff involved in Financial Reporting that the technical expertise to help with the preparation, review, and analysis of the financial statements. The target date for implementation is March 31, 2024. The responsible party for the planned resources will be Gail ViJuk, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615..

The Cost Allocation Plan is being drafted and will be submitted to the regulatory agency when the attendance and payroll program systems are fully implemented.

TCJFS is already working with Richard Johnson from the OFMS-Bureau of County Finance & Technical Assistance to correct this issue. TCJFS is already restricting draws to get the cash on hand under 10 days. The TCJFS will be using tools and reports to assist in keeping the cash on hand in compliance.

Finding 2022-004 Federal Agency Name: U.S. Department of Labor Program Name: AmeriCorps State and National CFDA #: 94.006 Finding Summary: Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost principles provides that amounts for compensation for personnel costs should be accurate. Amounts for certain personnel costs were not reimbursed at the current pay rate for certain employees. Responsible Individuals: Reid Cox Corrective Action Plan: Acknowledged. This error was restricted to FY’22 and was corrected for FY’23 and ongoing. Anticipated Completion Date: Ongoing

Finding 2022-003 Federal Agency Name: U.S. Department of Labor Program Name: AmeriCorps State and National CFDA #: 94.006 Finding Summary: Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Contributions and donations (Uniform Guidance) provides that amounts for the value of services and property donated may not be charged to the Federal award as direct costs. Amounts received for cell services and for salaries were donated to iFoster, Inc. were included in amounts to be reimbursed by the grant. Responsible Individuals: Reid Cox Corrective Action Plan: Acknowledged. This practice was discontinued subsequent to FY’22 and so is not an ongoing issue. Anticipated Completion Date: Ongoing

Action taken: Carpenter Apartments agrees with the auditor’s recommendations and will implement procedures to ensure that required surplus cash deposits are made within 60 days of the projects fiscal year-end. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

Prior to the completion of this audit, EmployIndy already made a number of changes to its financial operations. It parted ways with its Chief Financial Officer and procured the services of an outside Certified Public Accounting firm to begin the process of reviewing and updating its financial operations. In addition, it recently hired an Executive Vice President of Finance and Operations to lead the final development and implementation of updated financial processes. The Executive Vice President of Finance and Operations has worked with EmployIndy’s Board of Directors and Finance Committee to document a plan for improving EmployIndy’s financial operations across the board by the 2nd quarter of Calendar Year 2024. As part of the plan to improve its financial operations, EmployIndy staff and WIOA subrecipients will be retrained to submit accrued expenditure reports and invoices with supporting documentation in a timely manner to ensure that WIOA expenditures are quickly and accurately documented in order to support drawdowns. Further, EmployIndy’s Financial Operations staff, led by EmployIndy’s Controller, will complete monthly reconciliations and financial closeouts in a more timely manner to ensure that drawdowns are supported by documented, allowable expenses that WIOA funds will reimburse. Finally, EmployIndy’s Controller will ensure that any WIOA drawdowns that are based upon estimated expenditures are reconciled with documented, allowable expenditures within the financial management system on a monthly basis. This will ensure that documentation within the financial management system accurately matches annual WIOA drawdown amounts, and that there will be little to no deferred revenue for WIOA and other federal funding clusters.

Assistance listing number and program name: 93.778 Medical Assistance Program (Medicaid Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance Anticipated completion date: December 31, 2024 Agency’s Response: Concur In response to this item, AHCCCS has made holistic, system-wide improvements to the Medicaid payment system, including: 1. Required behavioral health providers to submit additional assessment, treatment plan, and medical records documentation with their claims, 2. Required Fee-For-Service providers billing more than 2 units of hourly codes or 4 units of 15-minutes codes on a single date of service, to provide additional documentation, 3. Added new reporting to flag concerning claims for review before payment, including, but not limited to, claims for services that could not be rendered as billed, claims for substance use treatment for minors age 12 and under, claims for services by different providers that should not be provided on the same day, and overlapping services of the same style, 4. Set billing thresholds and imposed prepayment review for various scenarios including multiple providers billing the same client on the same day for similar services, excessive number of hours per day, and the age of patients, 5. All codes intended for per diem services have been limited in the system and providers must bill each day separately rather than in date ranges, so per diem codes cannot be billed more than once a day on any given date of service, 6. Researched and confirmed that the National Correct Coding Initiative (NCCI) Medicaid coding methodologies, which allow for states to reduce improper payments, are in place and functioning correctly, 7. Set a specific rate for billing code H0015 for drug and alcohol treatment services, a change from the previous rate that paid a percentage of the billed amount, 8. Hired a forensic auditor to review all claims since 2019, 9. Implemented emergency rules to enhance and expand AHCCCS authority to exclude providers affiliated with bad actors, 10. Elevated three behavioral health provider types to the high-risk category for all new registrants, requiring fingerprints, on-site visits, background checks, and additional disclosures, 11. Implemented federal authority to impose a moratorium on new provider registrations for all Behavioral Health Outpatient Clinics, Integrated Clinics, Non-Emergency Transportation providers, Behavioral Health Residential Facilities, and Community Service Agencies, 12. Ended approval of retroactive provider registrations without good cause documentation, 13. Eliminated the ability for providers to bill on behalf of others, 14. Eliminated the ability for a member to switch enrollment from a managed care health plan to the American Indian Health Program (AIHP) over the phone, 15. Added a data request process for law enforcement agencies to assist with missing persons cases, and 16. Revised the Provider Participation Agreement (PPA) to explicitly require that if a provider stops providing services to AHCCCS members during an ongoing investigation, they must help the member transition to a new provider for care. Similarly, they are required to provide to AHCCCS a member census and, upon request, any other information needed to assist in care coordination. If they do not comply, AHCCCS has the right to file an injunction to require the provider to comply with the PPA. AHCCCS plans to implement additional measures to further strengthen the agency’s ability to detect and prevent potentially fraudulent activity. A partial list includes: • Requiring visual attestation of individual billers, • Requiring third-party billers to disclose terms of compensation, and • Determine methodology for AIHP enrollment criteria.

Assistance listing number and program name: 84.425 COVID-19 Education Stabilization Fund-Higher Education Emergency Relief Fund (HEERF) Institutional Portion Agency: Northern Arizona University (NAA) Name of contact person and title: Bradley Miner, Interim Vice President and Comptroller Anticipated completion date: August 18, 2023 Agency’s Response: Concur See University response section at the end of this report for the corrective action response for finding 2022-125.

Department of Housing and Urban Development The Potter County Housing Authority respectively submits the following corrective action plan for the fiscal year ended June 30, 2022. Audit Period: July 1, 2021 – June 30, 2022 The finding from the schedule of findings and questions costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. Finding 2022-1 – Interfund Receivables and Payables Financial Statement Audit Recommendation The Authority should address the repayment of the interfund receivables and payables. The balances of the receivables and payables should be review by management on an annual basis to determine if repayment is expected in a reasonable time period. If repayment is not expected, the interfund balances should be reduced and the amount that is not expected to be repaid should be reported as a transfer from the fund that made the loan to the fund that received the loan. Response The Authority agrees with the Auditor that interfund balances should be reviewed on an annual basis. The Authority will continue to bring old interfund balances in front of our Board to approve write-off and donation transactions. Several interfund balances have been previously authorized and will remain on the financial accounts; The Authority should see a significant reduction in the need for interfund transfers in the future for project development.

Logan Acres will increase documentation with employee time charts by dual confirmation of employee’s time record demonstrating the differential compensation which will include dual verification of employee and staff supervisor.

Finding No. 2022-002 Criteria Federal funds drawn down should be for activities incurred. Condition For two of nine drawdowns selected for testing, the amount of drawdown requested did not agree to the amount of expenses incurred. The funds requested in error were received and the funds were not returned to the U.S. Department of Housing and Urban Development during the accounting period. Corrective Action The Township will review the program drawdown requests against general ledger disbursement records to ensure that federal drawdowns are properly supported and reviewed by program and financial management prior to submission to HUD for reimbursement. The Township will also establish a payable due to HUD and net a future drawdown request for the overdrawn amount. Responsible Party Township Chief Financial Officer Anticipated Completion Date Corrective action procedures are already in place and operating.

Finding No. 2022-001 Criteria Per Uniform Guidance, the required reports for federal awards should include all activity for the reporting period, are supported by applicable accounting or performance records, and are fairly presented in accordance with governing requirements. Additionally, per HUD guidance, the Quarterly Cash on Hand report must be submitted to the respective field office within 30 days after the end of the reporting period. Condition For the seven Community Development Block Grants/Entitlement Grant reports sampled, disbursement and program income data reported on the report submissions did not directly tie to the general ledger. For four of seven reports sampled, the Quarterly Cash on Hand Reports were submitted after the federal report due dates. Corrective Action The Township will implement review procedures to ensure the IDIS system grant program reports are completed timely and are reconciled to the Township general ledger schedules monthly. Responsible Party Township Chief Financial Officer Anticipated Completion Date Corrective action procedures are already in place and operating.

Beginning immediately on the date of the single audit report, management will recalculate expenses monthly as well as on a YTD grant year basis after the month has closed and request reimbursement for only those expenditures.

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager

The finance department of NorthPoint Wellness Center Inc. is incorporating as part of the annual financial closing process a reconciliation directly with the grantors to confirm the financial expenditures, contract agreements and to determine the correct Assistance Listing Numbers (ALN). The reconciliation must be completed by January 20th following the close of the fiscal year, as well as at the end of the contract period. A Government Contract Reconciliation template has been created as part of the verification process and supporting documentation for the grantee organization.

Views of Responsible Officials: In 2022, narrative program reports were prepared by the management team (inputs were provided by each thematic area/department), the Deputy Director (or her designee) reviewed, and the Managing Director approved and typically sent the narrative reports to United Way via email (or in some instances, uploaded to the United Way SharePoint directly). In 2022, financial reports were prepared by CBM, reviewed by the Deputy Director (with support from a Coordinator, when possible), and sent to the Managing Director for approval and signature. The signed documents were then uploaded into the United Way SharePoint, and a note was sent to advise that the documents were ready to review. Reimbursements have never been sent to United Way without the approval and signature of the Managing Director. United Way requires that all financial reports reflect Managing Director signature to be reviewed.

2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time permanent CFO was hired in January 2022 who then immediately increased the team by two new members (1.0 FTE Controller hired in July 2022 and 1.0 FTE Staff Accountant hired in January 2023) and overhauled the Center’s financial policies and procedures manual. With the five-member finance team currently in place, we are on track to complete our FY2022-23 audit process by December 31, 2023. It is also relevant to note that San Francisco community health clinics migrated en masse to OCHIN Epic in 2022 with the overarching goal of our safety net hospitals and all community clinics being on the same EHR system to strengthen patient health outcomes for our city. The Center’s go-live date for this was June 2022 and required extensive time from all executive management, with our newly hired CFO being a key leader in this migration. This one-time, significant event had a direct impact on our ability to complete our audit in a timely manner. Proposed Completion Date: June 30, 2023

2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient files; and, ensuring all patients who apply for the sliding fee scale program receive the correct discount based upon income and family size. During the Center’s HRSA three-day operational site visit in July 2022, the Center made revisions to its Sliding Fee Application form to make space for our eligibility team members to clearly present their mathematical calculations to determine our patients’ annual incomes. This revision contributed to our 100% score that we received after the HRSA operational site visit. In order to further ensure we are in full compliance, the Center has contracted with an external consultant who is aware of HRSA standards and requirements and will thoroughly review current processes, procedures, and systems, and then will provide recommendations to the Center to implement and adopt. The Center will seek additional training and technical assistance to provide specific sliding fee scale training for all employees involved in our Sliding Fee program. Additionally, the Center will continue to implement quarterly audits of all sliding fee scale patients to ensure all sliding fee scale applications are complete and patients receive the correct discount. Proposed Completion Date: October 31, 2023

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing

Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community Development Block Grant award allocations in IDIS. Corrective Action: IDIS drawdowns will be made based on the actual expenditures on the Township’s semi-monthly Bill list. Implementation Date: Ongoing