Corrective Action Plans

Management's Response: We concur. View of Responsible Officials and Corrective Action: The CEO and the Project Manager have created a tracking document to closely monitor the utilization of marketing services completed and accounted for within the requested reimbursement. The CEO will review the assessment tracker to account for only those marketing services completed in 2023-year end financials. Anticipated Completion Date: The tracking documentation has been deployed at the start of services with subcontractor. With new accounting software completely implemented in 2024, the correction to this accounting of services has been corrected by June 30, 2024.

Finding No.: 2023-011 Federal Agency: U.S. Department of Education AL Program: 84.403 Consolidated Grant to the Outlying Areas Area: Period of Performance Questioned Costs: $11,004 Views of Auditee and Corrective Actions: GDOE disagrees with condition 1 related to FY 2024 purchase orders (PO). GDOE PO 20240171 is a copy over of the third-party fiduciary agent (TPFA) PO 20230010 which was issued in December 2022, within the CG 21 period of performance. GDOE acknowledges that the re-issued GDOE purchase order was not timely processed, however the purchase order which encumbered the funds occurred in the appropriate performance period. Additionally, relative to payroll, FPD requests a list (i.e. Staffing Pattern) of all Federally funded personnel from HR. FPD distributes the list to CG Project Leads to validate and compare to the Federal Roster as approved in the Consolidated Grants (CG) Application. The list is updated to make any corrections necessary. Once validated by Project Leads and FPD, HR is given a memo requesting to change/correct the funding year to the new grant award. In GDOE’s Munis system, if the Human Resources (HR) employee salary records are not accurately updated, GDOE payroll will reflect dated pay tables until such time HR makes the appropriate updates based on project lead requests to update accounts to current grant year. GDOE recorded journal entries to transfer the improperly charged payroll expenditure to the appropriate grant year. Plan of action and completion date: The GDOE will perform a monthly review of all transactions to ensure charges are recorded in the appropriate grant year. Additionally, Grant Project Managers and Program Coordinators will work with the HR and Business Office any changes to accounts charged for federally funded payroll expenditures. IAO now provides an independent review of drawdown requests - a control that will help prevent liquidation after applicable period of performance Plan to monitor and responsible officials: Financial Affairs under the leadership of the Deputy of Finance and Administrative Services, Morgan W. Paul, and the GDOE Comptroller (vacant), will ensure an accountant is monitoring the expenditures of federal grants and the corresponding periods of performance and liquidation periods. Grant Project Managers and Federal Compliance review team will also provide timely communication for changes in grant year funding to HR relative to federal payroll.

Finding No.: 2023-009 Federal Agency: U.S. Department of Education AL Program: 84.027 Special Education Grants to States Area: Period of Performance Questioned Costs: $80,983 Views of Auditee and Corrective Actions: GDOE agrees with Condition 1 questioned costs of $560. The questioned charges are related to TPFA purchase orders issued in fiscal year 2019, which falls outside of the period of performance. The expenditure for the 2019 purchase order was transferred from the TPFA Munis and recorded in the incorrect GDOE Munis account. GDOE disagrees with Condition 2 questioned costs of $18,041. In line with federal regulations, GDOE paid (liquidated) the obligations in question on January 4 and 26, 2024, which is before the liquidation end date of January 28, 2024.E&Y auditors are citing GDOE for the issued checks clearing the bank after the liquidation end date, however, liquidation occurs when the recipient draws funds from the grants management system and pays obligations and not specifically when checks clear the bank. GDOE agrees with Condition 2 $62,382 questioned costs. While GDOE Munis system has recorded expenses of $62,382 related to Special Education (SPED) obligations, funds were not drawn for these expenditures. In GDOE’s federal review process, drawdowns are reviewed in alignment with specific conditions for allowability and in compliance with period of performance timelines. The identified funds were not expended from SPED grants. To correct this reporting deficiency, GDOE will record journal entries to transfer the expenditures to appropriate funding sources. Similarly, GDOE improperly charged $3.1 million in payroll expenditures to SPED grants after the period of performance. Subsequently, GDOE corrected this finding by making the appropriate journal entries to transfer the improperly charged payroll expenditure to the appropriate grant year. Plan of action and completion date: The GDOE will perform a monthly review of all transactions to ensure charges are recorded in the appropriate grant year. Additionally, Grant Project Managers and Program Coordinators will timely communicate to the Human Resources and Business Office any changes to accounts charged for federally funded payroll expenditures. The IAO now provides an independent review of drawdown requests - a control that will help prevent liquidation after applicable period of performance Plan to monitor and responsible officials: Financial Affairs under the leadership of the Deputy of Finance and Administrative Services, Morgan W. Paul, and the GDOE Comptroller (vacant), will ensure an accountant is monitoring the expenditures of federal grants and the corresponding periods of performance and liquidation periods. Grant Project Managers and Federal Compliance review team will also provide timely communication for changes in grant year funding to HR relative to federal payroll.

Finding No.: 2023-007 Federal Agency: U.S. Department of the Interior Pass-Through Entity: Government of Guam AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Period of Performance Questioned Costs: $113,767 Views of Auditee and Corrective Actions: GDOE agrees with the finding. GDOE is in receipt of Department of Interior grants and manages said funds in coordination with BBMR and Guam Homeland Security. GDOE established projects that were allowable for the use of these funds on a reimbursement basis. In an effort to maximize federal funding, GDOE initiated a transfer of expenses which was tied to a purchase order in FY 2016. Plan of action and completion date: GDOE Financial Affairs has recorded an adjusting journal entry to record the expenditures under FY 2021 but will have to reclass the expenditure in to FY 2020. GDOE will assign an accountant to reconcile GDOE’s Department of Interior budget availability with BBMR and will monitor AS400 for proper recording of transactions. Plan to monitor and responsible officials: The Comptroller (vacant) will monitor on a quarterly basis expenditure from the Department of Interior grant and will prepare a progress report on a semi-annual basis to the Deputy of Finance and Administrative Services, Morgan W. Paul, for review and approval.

The School District concurs with the findings reported in Finding 2023-004 and does not dispute the details reported under the Criteria or Specific Requirement section, Condition section, and Effect section of the report. Your findings identify charging of unallowable costs that involved federal funds received by the School District. You noted that the unallowable costs involved payment of employment compensation to an employee on multiple dates, during times and for reasons that were suspect and unauthorized. The School District also concurs with the guidance you provide in the Recommendation section of the report. Corrective actions are already being taken, and training has already begun. The School Board will adopt appropriate policies to ensure appropriate oversight over the manner in which funding is expended for employee compensation, including situations when the sources of funding involve federal awards that obligate the School District to meet specific control requirements. Currently, the School District is reviewing all uses of federal funds, starting with Title 1, the 21st Century Center Learning Center Cohort, and the Education Stabilization Fund. The following additional corrective steps will be taken by the Superintendent: 1. All change of job assignments, program assignments and/or employee compensation must be approved by the Superintendent and memorialized in writing as evidence of approval. The Human Resources Department shall cause the necessary documentation containing the Superintendent's approval to be prepared, signed, and maintained in employee payroll and personnel records, and ensure that employee compensation is paid when owed for the appropriate amount(s). 2. The Superintendent will require the employees, supervisors, and management operating or overseeing individual programs and operations to become and remain familiar with their respective program and/or operation requirements, including those that govern which costs are allowable/authorized and steps required to demonstrate compliance. 3. In light of the Findings, the Superintendent will also identify one or more key administrative staff members who will be tasked with overseeing the use of federal funds for Title I, the 21st Center Learning Center Cohort, and the Education Stabilization Fund. 4. The Superintendent will direct staff to immediately confer with general counsel and with appropriate federal or state agency points of contact when compliance steps or obligations are unknown or require clarification. 5. Individuals compensated through federal funds shall be obligated to comply with applicable rules as a condition of employment. No staff member will have lone or sole responsibility for administering or overseeing administration and/or payment of their own compensation from federal funding sources. 6. At least twice annually, the Superintendent shall direct a review of wheterher funds have been appropriately reused for costs that are authorized and allowable. Title I, the 21st Century Center Learning Center Cohort, the Education Stablization Fund, and other programs/operations where noncompliance is known or suspected will be reviewed at least four times during the following school year, or more frequently when deemed necessary by the Superintendent. Additional program or operation areas may be identified for review through random sampling. Training on the rules governing authorized and allowable costs and expenditures of federal funds shall occur by August 12, 2024, prior to the start of the 2024-2025 school term. Training will be conducted by the Superintendent (Sam Moore), CFO (DaVona Howard), general counsel (Doug Lawrence), members of the School District's business office staff and others designated by the Superintendent.

Response - Management agrees with the recommendation and will implement the necessary components of the recommendation. Accounting policies and procedures have been developed which pertain to our subrecipient reporting and monitoring and are in the process of being implemented. Also, by adding the bookkeeper in March of 2021, receipt spot checking of subrecipients on a monthly basis has been implemented to help ensure compliance.

Response - Management agrees with the recommendation and will continue to work at implementing the necessary components of the recommendation. New board members have come aboard and are working to implement changes. A finance committee has been established (independent of the CEO) and their role will be to ensure the adoption and recommendations of the CAP to ensure transparency and accountability. A bookkeeper was added March 2021 as another tier of financial control, along with CEO handing over some financial duties to the financial advisor and bookkeeper. Regular meetings are held by bookkeeper, financial advisor, and finance committee member of the Board. Please note though, that the small size of our staff, precludes the total elimination of this weakness.

CAMcare has made significant changes to the patient payment collection process. Updates were made to the Patient Payments, Refusal to Pay, Waiver/Reduction of Charges Policy, Sliding Fee Scale Policy, and Patient Payments Policy, and a Patient Payments Policy was introduced. The new EMR system allows for individual Patient Service Representatives (front desk personnel) to monitor management's adherence to collection efforts.

Federal Agency: US Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2205MN5ADM, 2023 Award Period: January 1, 2023 through December 31, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the County puts in place the proper procedures to ensure it has proper controls in place to properly document the review of all the LCTS reports submitted by each collaborative member each quarter for accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will ensure there are proper financial procedures and controls in place to properly document the review of all required reports for the program. Name(s) of the contact person(s) responsible for corrective action: Angie Larson, Auditor-Treasurer / Chief Financial Officer Planned completion date for corrective action plan: December, 31 2024

Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the Medicaid Cluster 93.778 COVID-19 Medicaid Assistance Program 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 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 initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following: · 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 (“CAF”) 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. · Behavioral Health 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 Behavioral Health 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 (“NCCI”) standards and confirmed no edits had been turned off. · Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. Stop gap strategies in process include, but may not be limited to, the following: · Implementing eligibility integrity requirements for AIHP enrollment. · Linking BHP to BH companies they work for. · Link BH Providers to BH facilities they work at. · 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. · Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements. AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.

Assistance listing numbers and program names: 84.425D COVID-19 - Education Stabilization Fund—Elementary and Secondary School Emergency Relief (ESSER) Fund 84.425R COVID-19 - Coronavirus Response and Relief Supplemental Appropriations Act, 2021 – Emergency Assistance to Non-Public Schools (CRSSA EANS) Agency: Arizona Department of Education (ADE) Name of contact persons and titles: Michelle Udall, ADE Associate Superintendent Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: November 30, 2024 Agency’s response: Concur ESSER Reporting will be validated by at least 2 people before submitting to U.S. Department of Education. This validation will include the reconciliation of data from the LEA to ADE's report. ADE is finalizing policies and procedures for validating the data prior to submission. ADE has already begun implementing a reconciliation system to ensure accurate reporting in the EANS annual performance report. This system tracks obligations by category, expenses, and appropriate earmarking of nonpublic schools (e.g., DUNS/UEI, grades served). ADE is finalizing general policies and procedures for how this data is compiled, interpreted, and reported based on the initial implementation and corrections of the EANS program.

The following steps have been taken or will be taken to address Finding 2023-001: Shalom Health Care Center, Inc. has made some changes in how the draws are done with each payroll versus previously per month. Shalom has also hired new staff to help keep up with the grants and payrolls and entering data into the accounting system, as we had previously had turnover and were using temp services for some of the prior year. Contact Person: Michael A. Nino, Chief Financial Shalom Health Care Center, Inc. anino@shalomhealthcenter.org 317-269-7198

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

Management acknowledges that improvements were necessary in assuring that drawdowns of grant funds are in compliance with regulations. Accordingly, drawdowns of grant funds will be more aligned with bi-weekly and/or monthly expenditures as supported by an analysis of payroll and accounts payable system activity by the Chief Financial Officer prior to authorizing any drawdowns. This process revision will be implemented no later than March 31, 2025.

Finding Number: 2023-003: Allowable Costs – 1 of the 25 payroll transactions tested, the amount of time charged to the grant did not agree wo the employee’s timesheet. Planned Corrective Action: Turning Point has as an established Grant Activity Reports – Time and Effort Recording policy. We will ensure strict adherence to our policy by verifying that all hours charged to grants match employee timesheets. Staff will receive additional training on proper reporting procedures, and monthly audits will be conducted to ensure compliance moving forward. Anticipated Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance

Auditor’s Recommendation: The Organization document internal control over compliance procedures and document written procedures to ensure compliance with 2 CFR 200.305. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

Management will continue to attempt to contact the Project's HUD Project Coordinator in order to obtain the required approval for the withdrawal from the reserve for replacements account

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

Timesheets are approved by directors and approvals are tracked by the Fiscal Manager on an ongoing spreadsheet. Any missing approvals are requested. In addition, a Payroll Review Report has been developed and presented to and approved by the Executive Director at the issuance of each payroll.

2023-003 – ALN 14.850 – Public & Indian Housing – Activities Allowed or Unallowed Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned for amounts due back to the Project: The management company previously advised HUD that it is in the process of marketing and selling its affordable property portfolio. The management company has reached an agreement in principle with a buyer for the sale of a significant portion of its affordable property portfolio. The buyer has significant experience in the affordable housing industry and is well-positioned to own and manage these properties. The parties are in the process of drafting all necessary documents and will work with HUD on all necessary documentation and approvals promptly once the underlying documents are fully negotiated. The management company is confident that there will be sufficient funds at the conclusion of the collective transactions with the buyer for the (re)payment of amounts to address the Findings identified herein. The management company anticipates closings by the end of 2024.

Corrective Action Plan: The Fogarty Center ("the Center") had this finding in 2022-02 as well. The Center reported in the 2022 corrective action plan, that the Center was in contact with the State of Rhode Island representative regarding these items throughout the year; however, some of the email conversations occurred after the deadlines had passed. At the end of the contract, the State of Rhode Island did send an email stating that they understood the reasons for the delays and that the reports were accepted as submitted and are in compliance.

Finding 2023-003: Internal Control Deficiency Cash Management Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: There is no evidence of internal controls in place to ensure that requests for reimbursement are based on expenses paid for by AdviseWell. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-02 finding, to ensure drawdowns are made on expenses paid for by AdviseWell and not on unpaid obligated funds before proceeding by having a secondary review by appropriate staff. Documentation will be maintained to support those payments preceded drawdowns and secondary review has been completed. Management will ensure all duties are appropriately segregated. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

The University agrees with the finding. The University has had a significant amount of staff turnover and reorganization in FY 2023 in the financial aid office. The Interim Director of Financial Aid is collaborating with the controller’s office to make sure that the University has internal controls in place over Federal programs to assure that the Pell reporting requirements are executed in compliance with Federal statutes, regulation and terms and conditions of the federal award. The University is investing in making sure that the Financial Aid Office is staffed and create policy and procedure that assure that we improve internal controls on the Pell process.

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