Corrective Action Plans

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Management understands that valid data must substantiate Payroll expenses charged to any grant. Therefore, Hood River County has formed a Grant Review Committee to implement processes and procedures to include reviewing after-the-fact time and effort documentation compared to budgeted amounts charged to federal grants to ensure that amounts charged are appropriately supported. This committee has started monthly meetings. New payroll tracking procedures are in the testing phase to see if they are the solution to this problem. This should not be a future problem in fiscal year end 2024.

Management understands that valid data must substantiate Payroll expenses charged to any grant. Therefore, Hood River County has formed a Grant Review Committee to implement processes and procedures to include reviewing after-the-fact time and effort documentation compared to budgeted amounts charged to federal grants to ensure that amounts charged are appropriately supported. This committee has started monthly meetings. New payroll tracking procedures are in the testing phase to see if they are the solution to this problem. This should not be a future problem in fiscal year end 2024.

It is very unusual for the district to ever complete projects with unrestricted Federal funds and in this case it was in the midst of a national crisis. In the event that there are future projects, that are Federally funded in excess of $2,000, Coupeville School District (CSD) will have adequate controls for ensuring compliance with Davis-Bacon Act (Federal prevailing wage rate) requirements. Additionally, when Federal unrestricted ESF funds are received, CSD will be sure to better substantiate expenditures with journal entries so that the program does not appear to be overcharged on the financials.

The City has taken appropriate measures to resolve the finding in future years.

The YWCA will separate the duties of the key functions by adding additional employees, training existing employes and utilizing non-financial personnel where applicable.

The clerk is preparing and reporting COVID-19 funds and will work with the supervisor and treasurer to ensure correct reporting in the future. To be implemented in the next reporting cycle April 2024.

• Condition: During testing of required financial reports and invoices, we noted differences in the amounts of expenses reported to grantors compared to actual expenses incurred during those periods. • Response Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the cost report reflects the correct amounts being reported to the grantors match the actual expenses incurred. • Planned Corrective Action: Again, monthly meetings reviewing the cost reports and GL together will reduce mistakes like this from MHA and the Accounting Rep. moving forward. MHA and the Accounting Rep will review the expenses being submitted for reimbursement together to ensure expenses incurred match the expenses being reported to the grantor.

• Condition: During our testing of reimbursement requests, we identified amounts that were requested for reimbursement prior to the expenses being incurred. • Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the account is being invoiced for the correct expenses during the proper timeframe. • Planned Corrective Action: During the newly established monthly meetings that will take place, MHA and the Accounting Rep will review the expenses being submitted for reimbursement together to ensure no invoices are submitted in advance.

In accordance with federal audit protocols, our organization underwent a rigorous evaluation administered by Jessica Sayles, CPA, representing the prestigious firm Houldsworth, Russo, and Co. for fiscal year 2021-2022. Specifically, the audit was conducted with a focus on our utilization of funds allocated under the ARP grant. This comprehensive audit revealed two distinct facets deserving of meticulous attention. Firstly, we are pleased to report that the examination of our direct expenditures under the ARP grant has yielded an impeccable record of financial stewardship. No anomalies, deficiencies, or discrepancies were identified in the management of these direct expenses. This outcome reaffirms our unwavering commitment to fiscal diligence in the administration of public funds. However, the audit did unveil an issue of significance, pertaining to our handling of indirect expenses and fringe rates. Ms. Jessica Sayles, discerned that our organization had inadvertently transgressed established regulations governing allowable indirect cost rates, particularly in relation to payroll and other miscellaneous expenses. This misapplication resulted in the disbursement of funds beyond the thresholds specified under the Uniform Guidance framework, consequently necessitating reimbursement to federal agencies. This disclosure is an acknowledgment of the audit findings and represents our steadfast commitment to forthrightness, transparency, and responsible financial management. We deeply respect the critical importance of precision and adherence to federal guidelines in matters of fiscal accountability, and we are dedicated to addressing these issues with utmost professionalism. Issue 1: Material Adjustments to the Financial Statements We acknowledge the discovery of material current and prior period adjustments necessary to ensure that our financial statements are fairly stated in accordance with generally accepted accounting principles (GAAP). We understand the importance of accurate financial reporting and have already taken steps to address this concern. Our response to this issue includes: Comprehensive Review: We have initiated a thorough review of our accounting records to identify the root causes of these material adjustments. This process includes examining internal controls and financial reporting procedures. Rectification Plan: A plan has been developed to rectify these adjustments promptly, with a focus on maintaining compliance with GAAP. This includes improved monitoring, internal auditing, and reporting protocols. Training and Development: Our finance and accounting team have undergone additional training and development to strengthen their understanding of financial reporting standards, and GAAP compliance. Issue 2: Uniform Guidance - Allowable Indirect Cost Rates We acknowledge the findings related to the misapplication of allowable indirect cost rates for payroll and other expenses. We deeply regret the misunderstanding that led to this issue and take full responsibility for it. To address this matter, we have initiated the following actions: Immediate Compliance: We have already taken steps to ensure that allowable indirect cost rates are correctly applied in accordance with Uniform Guidance. This includes a review of all grant expenditures and related indirect costs. Training and Education: We are committed to improving our management's understanding of allowable indirect cost rates. Specialized training sessions will be conducted to clarify the proper application of these rates to prevent such errors in the future. Reconciliation and Repayment: We have worked closely with federal agencies, who opted for a refundable advance, to reconcile the amounts overdrawn on federal requests for reimbursements and promptly addressed any amounts due as a result of the misapplication of indirect cost rates. We recognize the gravity of these findings and are actively working to ensure that such misapplications will not recur in the future. In tandem with this, we commit to working diligently alongside Ms. Sayles and her esteemed team to expeditiously rectify these concerns and establish a robust framework for accurate financial reporting in our future endeavors. This organization remains firmly committed to upholding the highest standards of integrity, accountability, and compliance in its financial operations. We extend our appreciation to your department for your dedication to ensuring responsible fiscal oversight and the judicious allocation of federal resources. Should you require additional information or wish to engage in a more detailed discussion of these matters, we are readily available for dialogue. Andrea L. Gregg Chief Executive Officer High Sierra AHEC 639 Isbell Road, Suite 290 Reno, NV 89509 (775) 507-4022 andrea@highsierraahec.org

Recommendation: The Association should ensure source documentation is maintained for all costs and elements of a cost calculation reimbursed by federal awards. Explanation or disagreement with audit finding: There is no disagreement with the audit finding from responsible officials that two out of forty wage rate authorization forms requested were not located. Other documentation was submitted that supported the wage rates, including results of a salary survey performed by an HR consulting company. Actions taken in response to finding: In response to the finding, the Association generated detailed pay rate change history reports from the payroll system for these two employees and took a random sample of pay history for three other employees. Nothing unusual was identifiable. The Association will ensure source documentation is maintained for all federal award cost reimbursements by taking the following actions: • At least two Association leadership staff members will review all payroll changes and save documentation in secure, electronic personnel files and payroll processing files. • An improved human resources information and payroll system with more robust time tracking, reporting and document storage features is being implemented. • Detailed requirements for payroll changes will be added to revised finance and human resources policies and procedures (currently under revision). Name(s) or the contact person(s) responsible for correction action: Laura Dale, Director of Finance Bob Marsalli, CEO Planned completion date for corrective action plan: January, 2024

Agree with the finding. We will implement the segregation of duties matrix as part of SOPs. We will ensure that authorization and review of cash draws of fedral funds are done by some one other than the individual who initiates and records the transaction . We have implemented the same and Dr EIli (pi) is reviewing and approving the report before each withdrawal. The Finance Head ( Nafih) is withdrawing the fund .Anticipated Completion Date : 12/31/2022 Actual date of implementation :01/24/2023

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Finding number 2022-001: CFDA 14.157 - Section 202 Capital Advance Recommendation: When the financial statements are reviewed the surplus cash computation be printed and submitted for disbursement if it shows an amount due. Action Taken: The overdue deposit will be made in 2023. In the future, audited financial statements will be reviewed upon finalization and any required deposit to residual receipts will be made in a timely manner. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Matthew Fontaine at (860) 951-9411 extension 249.

Children and Youth Programs Assistance Listing 93.090 Guardianship Assistance Assistance Listing 93.645 Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing 93.658 Foster Care Title IV-E Assistance Listing 93.659 Adoption Assistance Assistance Listing 93.778 Medical Assistance Program Assistance Listing 93.556 MaryLee Allen Promoting Safe and Stable Families Program Act 148 Pennsylvania Department of Human Services Views of the Responsible Officials and Corrective Action Plan: After a recent discussion with the [PA] Office of Children, Youth, and Families (OCYF), DHS was informed that compensation plans for FY21 and FY22 were on file and under review. However, approval was pending. OCYF explained that the State reviews plans on a calendar-year basis. However, city pay plans change during a July-June fiscal year. Therefore, the possibility of overages can occur because of salary increases or other personnel changes. The process is that once the new compensation plan is received, the reviewing authority would flag any items that are in excess of the existing approved rates. At that time, DHS would be permitted to submit a waiver for the items in question. Contact Person: Landuleni Shipanga, Controller, Department of Human Services, 215-683-6366.

Views of Responsible Officials: Mary's Center now has a robust process where the agreed upon provisional indirect rate or (if applicable) the specific rate included in the final Grant agreement is the governing default rate used for each Grant. In any scenarios where a change in rate is being requested, the Program Manager alerts the Senior Grant Accountant assigned to the grant and provides supporting documentation from the Grant funder of an addendum to the existing Grant agreement. If for any reason the Finance team is using an upward or downward adjustment to the provisional indirect rate or what was agreed upon in the Grant agreement the EVP Finance and Director of Grants must approve this change and notify the EVPs of Health and Programs and Development prior to implementing this change. All changes are documented. In addition, to ensure the rate in the agreement is the same rate being used when invoicing Grant funders, the Finance team conducts a thorough reconciliation process during the year.

Views of Responsible Officials and Planned Corrective Actions Management acknowledges the finding, and the management staff of the Institute take seriously the federal compliance requirements that apply to drawing funds from the DHHS Payment Management System. The Institute recognizes that it has drawn down excess funds. The Institute plans to improve policies and procedures for cash management in 2023 that will ensure the calculation for allowable cash draw for actual immediate cash needs is complete and accurate. Action Taken Scintillon plans to improve policies and procedures for cash management in 2023 that will ensure the calculation for allowable cash draw for actual immediate cash needs is complete and accurate.

Planned Corrective Action: The Planned Corrective Action is to instruct future GID Grant Managers the importance of having qualifying receipts or invoices that correspond directly to the amount of Federal funds being requested for reimbursement. To facilitate this successfully, Project costs must be paid with non-Federal entity funds before summitting a payment reimbursement request from the Grant program funds. Name of Contact Person: Erling A. Juel, District Manager, will be responsible for implementing this corrective action by working with the District’s grant managers to properly implement the corrective action for on-going and current grants. Anticipated completion date: The Corrective Action will be implemented immediately and applied to the administration of on-going Federal grants.

The Organization will deposit $15,814 of surplus cash into residual receipts as soon as possible. The anticipated completion date is December 31, 2023.

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will also hire an additional grant accountant to ensure proper controls are in place.

The Organization will enhance its procedures and internal controls with respect to preparation and requests of funds. Grant agreements will be reviewed to confirm if expenditures being requested are allowed. The Organization will also hire an additional grant accountant to ensure proper controls are in place.

The Organization experienced turnover in accounting management at the end of 2020 and throughout 2021. At that time, the interim management did not have the background with the grant RFR submitted necessary to reconcile to the grant general ledger. Effective March 2022, a Director of Finance was brought onboard to develop and strengthen the financial function for AIDS Outreach Center Inc., The presence of the new Director has greatly improved the financial processes, and internal controls. However the Director of Finance, has not had adequate time to fully implement the corrective action plan as the prior audit was completed in September 2022. For YE 2023 AIDS Outreach Center Inc., will have had the time to fully implement controls over the grant RFR process to avoid the risk of noncompliance related to proper recordkeeping for reporting documentation.

The County plan has been implemented.