Corrective Action Plans

Views of Responsible Officials and Planned Corrective Actions: USTTI will prepare FFR's based on actual expenditures for each quarter. USTTI will make best efforts to ensure transactions are reflected in the general ledger before preparation of the FFR's. USTTI will also adjust the work flow of preparation and approval of the FFR' s.

View of Responsible Officials and Planned Corrective Actions: We concur with this finding. We will have the appropriate supervisor review the employee timesheets for accuracy and the employee’s signature before the supervisor signs off on the timesheet and turns it in for payroll processing. The payroll department will also ensure the criteria is met before payroll is processed.

CASEFILE REVIEW Federal Agency: U.S. Department of Commerce Federal Program Name: COVID-19 Economic Adjustment Assistance(Economic Development Cluster) Assistance Listing Number: 11.307 Pass-Through Agency: N/A - Direct Federal Award Identification Number and Pass-Through Number: ED20CHI3070088/06-79-06222/06-79-06392; 2021 Compliance Requirement Affected: Reporting Award Period: Year Ended June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: We recommend the Commission implement procedures to ensure all reports have proof of review and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will ensure that all report reviews are documented in the future, as well as being submitted timely. Name of the contact person responsible for corrective action: Darcy Rylander, Finance Officer Planned completion date for corrective action plan: June 30, 2024

We agree with the intent of this finding but not the dollar amounts. The contribution of $100,000 was received via Title III and Central State matched the $100,000. The total of both amounts is $200,000. Central State matches with $100,000. We did have a time lag for execution of the check and transfer to the endowment. The controller’s office will establish the protocol of being timely in matching the payment and in depositing the funds in the appropriate investment account. Responsible Person: Controller (Trasenna Gray) Completion Date: January 2024 and ongoing

Management will deposit the $54,705 into the residual receipts account.

U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s internal controls were not designed to properly ensure a review over program expenditures occurred that expenses being incurred and the basis for ultimate reimbursement were incurred within the grant award’s period of performance. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will implement controls that address whether expenses incurred have a basis for reimbursement and are incurred within the period of performance. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: March 2024

Corrective Action: The lack of timeliness in payouts to SSVF subrecipients was largely due to the transition CAPO underwent in fiscal providers in 2022, and to a lack of sufficient internal staff to adequately manage the SSVF program’s growing fiscal requirements. The amount of SSVF funding CAPO passes through has increased significantly since 2021, and existing staffing was insufficient to assure timely tracking of draws and payments. Since moving to SMJ and hiring a Finance Manager, CAPO has improved the fiscal management of this grant considerably. CAPO is also hiring an Account Specialist to be assigned directly to SSVF invoicing and accounting needs. They will be charged to the VA grant and will work with the SSVF Program Manager and CAPO’s Finance Manager to process invoices, draw funds, and issue payments. Person Responsible: Janet Allanach, Rose Bradshaw, SSVF Program Manager; Shane Melton, Finance Manager. Timing for Implementation: Partially complete/In progress until December 31st, 2023, completion.

In response to the sole December 31, 2022 Audit finding related to JeffCAP, the finding was corrected for Head Start Birth to Five Program Year 2022- 2023. The department requested and obtained extensive training and professional development from the Office of Head Start related to reporting. Policies and procedures were reviewed and updated to include developing a timeline for submitting all reports and supporting documentation. Additionally, training with the Parish Accounting Department and Information Technology Department to obtain fiscal data and documentation to prepare necessary reports. The department has solicited services from a third-party entity to assist with all fiscal matters and support compliance related to reporting. JeffCAP Head Start Governing Board and Policy Council reviewed and approved all policies and procedures related to Fiscal Reporting and Account Set Up and Emergency Preparedness: Fiscal Reporting, Reimbursement, and Receipt Verification. The Head Start Fiscal Policy and Procedure was written per Head Start Performance Standards 1302.102(d)l23 and local, state, and federal (45CPR 75.400 and 2 CPR, Part 200) standards and compliance regulations. In addition, Head Start Emergency Preparedness Policy and Procedure was written following US Department of Agriculture (USDA) 7CFR Part 226, Food & Nutrition Service (FNS) 796-2, LA Department of Education- CACFP Training Module 7, and local, state and federal (45CFR, Part 74 and 2 CPR, Part 200) standards and compliance regulations.

DEPARTMENT OF AGRICULTURE. Market Access Program and Agricultural Trade Promotion Program Assistance Listing Number: 10.601 & 10.618. Recommendation: We recommend the Organization ensure the completion of the controls within their policies to ensure an adequate review process is in place prior to cash disbursement payments and claims submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Food Export-Northeast, under the direction of the new Executive Director /CEO, has undergone a significant restructuring effective July 2023. This restructure has resulted in the installation of a Chief Financial Officer, reporting directly to the Executive Director/CEO. Similar “C-suite” positions now exist in Operations, Programs, and Communications. This has significantly increased the scope and ability for oversight and internal control. Internal policies and procedures are currently under review; any changes to policies and procedures will be made as needed/identified. Increased monitoring and enforcement of existing internal control measures has already resulted in improved completeness and accuracy of financial reporting. In September 2023, the Food Export staff met with FAS staff to review procedures and policies, including meetings with Management to review and evaluate controls. The feedback from those meetings will be incorporated into any updates on procedure. Names of the contact person(s) responsible for corrective action: Brendan Wilson, Food Export Executive Director/CEO; Michelle Rogowski, Chief Operating Officer, Laura England, Deputy Director/Chief Communications Officer; Robert Lowe, CPA, Chief Financial Officer; Teresa Miller, Chief Program and Partnership Officer. Planned completion date for corrective action plan: December 31, 2023. If the U.S. Department of Agriculture has questions regarding this plan, please call Laura England at (215) 599-9738 or contact via email at lengland@foodexport.org.

While our Human Resources Specialist position was filled in May 2021, we are still working to have sufficient HR and accounting staffing to meet our significant growth. Additional positions of Human Resources Manager and Controller will help reduce/eliminate these types of errors in the future.

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.