Corrective Action Plans

The School Board agrees that, while the reimbursable expenses did not include personnel costs, the Wage Rate (Davis Bacon Act) was not included in the contract language as required for federally funded projects. Management has implemented processes to ensure that any current and future contracts for federally funded projects will include the Wage Rate (Davis Bacon Act) and DOL regulations to ensure compliance.

The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. This finding has since been resolved in 2025, with a new policy developed and implemented on April 1, 2025.

Management agrees that the amount needs to be deposited as soon as possible.

Finding No.: 2024-053 Special Test and Provisions – Project Accounting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will create a Standard Operating Procedure (SOP) to establish internal policies and procedures in compliance with applicable special tests and provision requirements. GHS will also identify department personnel responsible.

Finding No.: 2024-036 Cash Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Federal and Compliance section will establish a Standard Operating Procedure for drawdowns. As well as, conducting drawdowns daily to minimize the time between the drawdowns of federal funds and the disbursement for federal program purposes.

Finding No.: 2024-033 Cash Management Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza, Director Request to DOA will require immediate collaboration between Guam EPA and DOA, as all Guam EPA reimbursement requests are accompanied by the FGIA balance report and, currently, the GFMIS expenditure reports.

Finding No.: 2024-030 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to make sure reports are submitted on time. BBMR will also retain documentation of submitted reports.

Finding No.: 2024-010 Cash Management Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Federal and Compliance section will establish a Standard Operating Procedure for draw downs. As well as, conducting drawdowns daily to minimize the time between the drawdowns of federal funds and the disbursement for federal program purposes.

Management will monitor major programs and ensure that they are tested when necessary. The grant in question was tested during 2024.

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-012 1. Finding Summary The auditor determined that the institution disbursed Pell Grant funds more than 10 days prior to the first day of classes, in vio]ation of federal Title IV disbursement timing requirements. As a result, the institution could not demonstrate compliance with applicable federal regulations governing the timing of Pell Grant disbursements. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that Pell Grant funds were disbursed earlier than permitted under federal Title IV disbursement timing requirements due to a miscalculation of the days. 3. Root Cause Analysis The root cause of this finding resulted from by inaccurate or prematurely scheduled disbursement dates, limited coordination between the Financial Aid and Business Offices on the approved disbursement calendar, and insufficient controls to ensure Pell Grant funds were released in accordance with federal timing requirements. 4. Corrective Action(s) Management will implement a standardized calendar of disbursement dates annually based on the academic calendar. Description of Corrective Actions Management will prepare an annual disbursement calendar based on the academic calendar, which will be reviewed by both the Business Office and Office of Financial Aid to ensure compliance to federal Title IV disbursement timing requirements. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions reduce the risk of early federal disbursements by strengthening oversight, implementing a disbursement calendar, and reinforcing staff understanding of federal timing requirements. 6. Responsible Party • Office/Department: Business Office • Title of Responsible Official: Senior Accountant • Name (optional): ___ _________ _ 7. Implementation Timeline • Corrective action implemented: (Yes) No • If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) (Fully implemented) Partially implemented Not yet implemented Evidence of Implementation Academic Year 2026-2027 Disbursement Calendar. 9. Monitoring and Sustainability The University will continue to prepare a disbursement calendar annually before any new year disbursements are made.

Assistance listing numbers and program names 97.024 Emergency Management Performance Grants Agency: Department of Emergency and Military Affairs (DEMA) Name of contact person and title: Keith Tagaban, Audit Supervisor Anticipated completion date: September 18, 2026 Agency’s Response: Concur The Department of Emergency and Military Affairs (DEMA) will maintain complete, accurate, and auditable documentation to support all federal award expenditures, matching contributions, and financial reporting in accordance with 2 CFR Part 200 and applicable award terms and conditions, with records retained for a minimum of three years following submission of the final Federal Financial Report (FFR). DEMA will ensure all FFRs are reviewed for accuracy, completeness, and compliance prior to submission and will promptly correct any identified discrepancies in coordination with the federal awarding agency. The Department will implement and enforce written policies and procedures governing reimbursement requests, financial reporting, matching requirements, and record retention, including management review to ensure costs reported are allowable, allocable, reasonable, and adequately supported, and will maintain sufficient staffing and oversight to sustain ongoing compliance.

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid 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 Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.

Recommendation: The Organization should contact HUD to facilitate the remittance of excess residual receipts. Action Taken: The management of Edsil’s Place Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will contact HUD to ensure that all excess residual receipts are remitted to HUD as soon as possible.

Finding 2024-014: Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Community Development Block Grants (CDBG) Entitlement/Special Purpose Grants Cluster (14.218), For the entitlement funding allocated to the City, they were required to submit four quarterly reports during the year and two annual reports. Of the three entitlement reports selected for testing, each one was submitted after the deadline. For the COVID-19 funding allocated to the City, they were required to submit quarterly reports duringthe year for two separate awards, for a total of eight quarterly reports, and one annual report. None of the required COVID-19 funding reports were submitted during the current year. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized reporting process under a designated grants/finance lead, including a recurring quarterly close schedule and a two-level review (preparer and approver) prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.

Name of Contact Person: Yolanda White, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepancies found in two out of twentythree employee day sheets vs. timesheets resulting in more program time reported on the day sheets than the approved timesheets. Supervisors are responsible for ensuring that time reported on an employee day sheets match the timesheets. Bertie County DSS utilizes an Excel spreadsheet provided by Bertie County Government that is completed by each employee monthly to report time worked. As it is the Supervisor's responsibility to verify and approve the accuracy of employee day sheets, the Supervisor is expected to reconcile time reported on employee day sheets to time reported on employee timesheets. Plan of Action: • Provide employees training on how to complete their Day Sheets • Reiterate the importance of employees reporting the same amount of time on the day sheet vs. the timesheet. • Communicate with Supervisors the importance of reconciling employee day sheets vs. timesheets. Proposed Completion Date: As soon as the discrepancy was identified by the auditor, management began working with staff on the importance of tracking their time and the procedures they need to follow to ensure the compliance with federal and state guidelines for the year ending June 30, 2024 while continuing training staff in FY 2025 to ensure compliance.

Action taken: CRMHS management concurs with the finding. During the fiscal year ended June 30, 2024, CRMHS did not consistently operate internal controls over federal cash management as designed. Specifically, a federal draw was processed in excess of immediate cash needs and was not fully reconciled to supporting allowable expenditures prior to submission. This resulted in federal funds being drawn in advance of program disbursement requirements. Management acknowledges that this practice does not comply with 2 CFR §200.305, which requires non-federal entities to minimize the time between drawdown of federal funds and their disbursement for program purposes. While the funds were ultimately expended on allowable program costs, the timing of the draw created a compliance exception and reflects a material weakness in internal control over compliance. Management takes this matter seriously and has implemented corrective measures to strengthen cash management oversight and reconciliation procedures. Such actions include: • CRMHS has completed a full reconciliation of all drawdowns under Assistance Listing 93.696 to supporting allowable expenditures through June 30, 2024. • Any excess cash balances identified were evaluated and adjusted to ensure compliance with federal cash management requirements. • Pre-Draw Reconciliation Requirement—No draw request may be submitted without documented reconciliation to recorded allowable expenditures. • Segregation of Duties and Review—the draw request and documented reconciliation will be reviewed and signed off on by a second qualified member of the accounting team. • Monthly Grant Cash Monitoring—CRMHS will compare cumulative drawdowns to cumulative allowable expenditures to identify and resolve any excess cash position.

Finding Number: 2024-048 Finding Name: Inadequate Review of Cash Draw Calculations Finding Condition(s): The Illinois Criminal Justice Information Authority (ICJIA) did not adequately document its review of cash draw calculations for the Crime Victim Assistance (CVA) program. Name of Contact Person(s): • Hemant Modi, Chief Fiscal Officer – Illinois Criminal Justice Information Authority, Office of Fiscal Management • Precious Taylor, Accounting Supervisor – Illinois Criminal Justice Information Authority, Office of Fiscal Management Corrective Action(s): ICJIA re-implemented reviews and approvals of its cash draw calculations in fiscal year 2025. Proposed Completion Date: October 22, 2024 – Completed

Finding Number: 2024-040 Finding Name: Inaccurate Information Included in the Financial Reports Finding Condition(s): The Illinois Department of Transportation (IDOT) did not prepare accurate federal financial status reports for the Airport Improvement Program. Additionally, the auditors noted the supervisory review procedures performed for this report were not at an appropriate level of precision to identify the errors identified in our testing. Finally, the auditors concluded that IDOT does not perform analytical procedures to identify potential errors or unusual fluctuations in reported amounts. Name of Contact Person(s): Joe Segobiano, Bureau Chief of Administrative Services – Illinois Department of Transportation, Division of Aeronautics Corrective Action(s): IDOT Aeronautics has developed requirements for and has published a request for proposal for a new Airport Project Management Systems (APMS). The replacement APMS will have an automated Federal Reporting Tool. One of the main requirements for the APMS replacement system is a real-time automated Federal Reporting Tool. Proposed Completion Date: July 1, 2026

Finding Number: 2024-035 Finding Name: Failure to Perform Cash Draws in Accordance with the Treasury-State Agreement Finding Condition(s): The Illinois Department of Commerce and Economic Opportunity (DCEO) did not perform its cash draws in accordance with the funding technique prescribed in the Treasury-State Agreement (TSA). Additionally, the auditors noted that internal controls have not been established to ensure cash draws are calculated and recertified in accordance with Treasury regulations and the funding technique prescribed by the Treasury-State agreement. Name of Contact Person(s): • Lisa Clement, Audit Liaison – Illinois Department of Commerce and Economic Opportunity, Office of Accountability • Jared Ebel, Chief Accountability Officer – Illinois Department of Commerce and Economic Opportunity, Office of Accountability • Phil Keshen, Deputy Director – Illinois Department of Commerce and Economic Opportunity, Office of Financial Management Corrective Action(s): The DCEO’s Office of Financial Management (OFM) has requested that the Governor’s Office of Management & Budget (GOMB) change the funding technique for the Low-Income Home Energy Assistance Program within the Treasury-State Agreement to Pre-Issuance. This corrective action was implemented during State fiscal year 2025. Proposed Completion Date: July 1, 2025 – Completed

Finding Number: 2024-034 Finding Name: Failure to Re-certify to the Accuracy of the Clearance Pattern Finding Condition(s): The Illinois Department of Commerce and Economic Opportunity (DCEO) did not properly review or re-certify the accuracy of the clearance pattern specified in the Treasury-State Agreement related to cash draws for the Low-Income Home Energy Assistance Program (LIHEAP). Name of Contact Person(s): • Lisa Clement, Audit Liaison – Illinois Department of Commerce and Economic Opportunity, Office of Accountability • Jared Ebel, Chief Accountability Officer – Illinois Department of Commerce and Economic Opportunity, Office of Accountability • Phil Keshen, Deputy Director – Illinois Department of Commerce and Economic Opportunity, Office of Financial Management Corrective Action(s): The DCEO’s Office of Financial Management (OFM) has requested that the Governor’s Office of Management & Budget (GOMB) change the funding technique for the Low-Income Home Energy Assistance Program within the Treasury-State Agreement to Pre-Issuance. This corrective action was implemented during State fiscal year 2025. Proposed Completion Date: July 1, 2025 - Completed

Management, under new leadership and with the appointment of a new Vice President of Finance, is taking proactive steps to address the timely completion and submission of the Single Audit. The organization is strengthening its finance department by enhancing staffing levels and providing targeted training to ensure team members are fully equipped to meet reporting requirements. In addition, management is leveraging support from third-party advisors and an external consultant to improve reporting processes and internal controls. These combined efforts are focused on ensuring that the Single Audit is completed and submitted to the Federal Audit Clearinghouse within the required timeframe, thereby enhancing compliance and financial accountability.

Federal Program - U.S. Department of Housing and Urban Development Assistance Listing Number 14.157 - Supportive Housing for the Elderly (Section 202) Material Weakness & Noncompliance Category of Finding - Cash Management Name of contact person – Nation Wright, AICDC Chief Operating Officer Corrective action – The Corporation has changed management agent to Tapestry which has the procedures and controls in place to detect and prevent a similar finding to occur in the future. Completion date – Management and the Board of Directors implemented the above as of December 2024.

2024-003 Document Policies and Procedures Over Federal Awards Cluster/Program: All federal programs Type of Finding Compliance – Other Matters Internal Control over Compliance – Significant Deficiency Condition: The Town has not formalized written policies and procedures related to federal awards required under the Uniform Guidance. Criteria: OMB’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (UG) requirements stipulate that federal award recipients must document their policies and procedures over certain aspects of financial and program management. Specifically, written policies are required for the following: • Cash management • Determination of allowable costs • Employee travel • Procurement • Conflicts of interest • Subrecipient monitoring and management Cause: The Town has not developed written formal documentation of internal controls to encompass all required areas per the Uniform Guidance. Effect: The Town is not in compliance with the requirements of the Uniform Guidance as it relates to the requirement to have documented policies and procedures pertaining to the management of federal awards. No questioned costs are reported as this requirement is procedural in nature. Recommendation: Written policies and procedures should be implemented in accordance with the Uniform Guidance. Views of Responsible Official: The reconciliations of retirement board accounts were handled through a third party prior to January 2024. There have been delays in obtaining the files from the third party. With the hiring of the new director in January 2024, the reconciliations are now performed in the Retirement office, by the retirement staff. We anticipate that the records will be available upon request in the future.

Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2024-001: During the year ended June 30, 2024, the Corporation did not make the required deposits to the reserve for replacements in the amount of $12,747. Recommendation: Management should request approval from HUD for a transfer from the residual receipt account to the reserve for replacement account in the amount of $8,498 to correct the error. Management should also make the additional deposit of $4,249 or request a suspension of deposits from HUD. Action(s) taken or planned on the finding: Management has requested approval from HUD to transfer the funds to the reserve for replacement account and will make the additional deposit during the year ended June 30, 2025.

The Tallapoosa County Board of Education will implement additional controls to ensure accurate meal counts are reported on Claims for Reimbursement for the School Breakfast Program. Procedures will be strengthened to ensure meal counts are taken daily at the point of service (where students walk through the cafeteria lines) and verified against student attendance records when preparing reimbursement claims. The Child Nutrition Program staff will review meal count reports prior to submission to ensure the number of meals claimed does not exceed the number of students in attendance. Additional oversight will be provided to ensure compliance with federal Child Nutrition Program requirements.