Corrective Action Plans

Historic Hudson Valley will adopt written policies and procedures, and standards of conduct as required by 2 CFR 200, Subparts D and E.

Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement. Responsible Party: Vice President Finance Completion Date: November 30, 2024

WIA management will implement the following corrective action plan: In order to ensure compliance with the timeliness of disbursements of federal funds contemplated under 2 CFR 200.305(b), WIA will implement the following additional procedures for federally-funded expenses. A detailed evaluation of project deliverables and timelines will be conducted by the Project Manager and Project Director for any program subject to compliance with Federal guidelines. The timelines, deliverables and affected funding mechanism(s) will be aligned to determine if there may be a delay beyond a reasonable period which would impact the submission and processing of payments to subcontractors. If it is determined that a delay is possible or likely, consideration will be given to contract amendments which better support the processing of payments aligned with 2 CFR 200.305(b). Further, the Finance team member assigned to the associated program will provide regular guidance to the project team which may include a detailed briefing on the CFR and any relevant concerns with cash management. Disbursements of federal funds will be issued in a timely manner in all instances. The additional set of procedures described above will be implemented in September 2024. In addition, we are currently working through finalizing the contract for Phase 2 of the specific contract related to this finding. We anticipate these negotiations will be completed by October 31st, 2024. Once the Phase 2 agreement has been reached, we will immediately release the Phase 1 funds to the vendor and obtain guidance from The Ohio State University as to the proper disposition of any interest that has been earned by WIA from the withheld Phase 1 payment. Marta Sokol, Chief Financial Officer is the individual responsible for oversight of this corrective action plan. Mrs. Sokol can be reached at 703.535.7447 or Marta.Sokol@wia.org.

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109 Award Period: January 1, 2023 through December 31, 2023 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring the Organization of the Treadway Commission (COSO).” Condition: During testing of reporting, it was noted that, for one sample, documentation was not retained of approval of financial reporting. Questioned Costs: None Context: A sample of 9 financial reports was made from a population of 54 total reports. Of the 9 sampled, 1 was missing evidence of authorized personnel review and approval. Cause: In this one instance, verbal approval was given rather than emailed approval. Effect: Without adequate documentation and controls in place to ensure costs are reasonable and intended for the program charged, Sound Generations could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that Sound Generations is entitled to under the terms of the grant. Repeat Finding: No. Recommendation: CLA recommends that documentation is retained as proof of authorized personnel review. Views of responsible officials and planned corrective actions: Sound Generations agrees with the finding. Sound Generations has revised its approval process to include digital signatures with time stamps by authorized personnel on all documentation rather than emailed approvals. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: March 31, 2024

Conservation Research and Development Program – Assistance Listing #81.086 Plan completion date for corrective action plan: October 31, 2024 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost- reimbursement related to federal grants which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Grants Accountant in 2024 to take over the responsibility of preparing invoices for cost-reimbursement. This allows for the additional control of the Senior Finance Manager reviewing the invoices. This review is now being documented in writing. Additionally, there are procedures in place to ensure if the Senior Finance Manager prepares the invoice, the Director of Finance & Operations reviews and documents approval of the invoice. We will establish written policies and procedures to document this process by October 31, 2024. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Ronald Tran, Senior Finance Manager

The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts.

Recommendation UVNR should implement procedures to ensure thorough monitoring and accurate accounting of all subrecipient expenditures. Subrecipients should be required to submit properly supported invoices with their reimbursement requests. It is also recommended that authorized grant personnel diligently review and approve these invoices to ensure that reimbursements are made only for actual expenditures. Management Response Corrective Action: 1. Meet with subrecipient to clarify compliance issues with 2023 disbursements and to discuss plans of action for 2024 through grant period end (occurred on 9/10/24). 2. Subrecipient will invoice monthly providing grant personnel with an invoice and general ledger of expenses. 3. Grant personnel will adopt a policy of reviewing subrecipient’s monthly invoices and supporting documents, including adding a requirement for grant personnel to approve and sign subrecipient invoices before drawing down from the federal award’s payment management system. 4. Signed and approved grant invoices and supporting documentation will also be shared with accounts for approval before drawing down from the federal award’s payment management system. 5. Grant personnel will meet regularly with accountants for thorough and continuous monitoring of the award, including accurate accounting of subrecipient funds Due Date of Completion: September 30, 2024 - ongoing Responsible Party(ies): Co-Executive Directors

Condition: During compliance testing, it was identified that an employee's wages were being charged to the grant after the employee was terminated. Corrective Action Taken or Planned: Management noted there was turnover in fiscal year 2023 which led to lack of some reviews. Controls have been put in place to ensure all worksheets are viewed for accuracy by the CFO prior to requesting drawdown amount. Name(s) of Contact Person(s) Responsible for Corrective Action Coleen Elias, Chief Executive Officer, Community Clinical Services. Anticipated Completion Date: Controls have been implemented as of the date of the audit report.

Contact Person: Tracy Carr, Andrew Hall Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: Monthly grant reimbursement reports have a limited window before the due date. Additional requirements have added time to properly prepare reimbursement reports. Gathering all supporting documentation before submission has increased the time needed before the complete reimbursement request package is ready. Each member of the finance team is sharing in the responsibilities to meet the deadline. Completion Date: Beginning September 1, 2024 and thereafter.

The Authority has reviewed the facts surrounding the draw down of funds not expended within a reasonable time and will review 2 CFR Part 225, Subtitle A, Part 85.20 to familiarize themselves with the regulations.

Congregation Oros Bais Yaakov of Lakewood, Inc, respectfully submits the following corrective action plans for the year ended December 31, 2023. Finding 23-1: The school’s net cash resources exceeded three months average expenditures are the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed three months of average expenditures. As such, the required correction actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of July 19, 2024. Person Responsible for Implementation: Nechama Prager, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: 732-730-6049

Significant Deficiency in Internal Control over Compliance, Other Matters 2023-002 Reporting Recommendation: We recommend the County review its processes and implement controls to formally review these quarterly reports and that they are compared and reconciled to the general ledger. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County is planning a more in-depth checklist of accounts to be reconciled and journal entries to be made along with regular check in and team meetings to meet the deadlines. Name(s) of the contact person(s) responsible for corrective action: Michelle Uitenbroek, Finance Director Planned completion date for corrective action plan: December 31, 2024 If the granting agencies have questions regarding this plan, please call Michelle Uitenbroek, Finance Director at 920-832-1674.

Finding 2023-002 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster State ID Number and Title: 435.283 IMAA State Share Award Number: Unknown Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Agency: Wisconsin Department of Health Services Criteria: The Uniform Guidance and State Single Audit Guidelines require that local entities receiving federal and state awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. The Uniform Guidance and State Single Audit Guidelines further require auditors to obtain an understanding of the local entity's internal control over federal and state programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of monthly reports, which should be reviewed and approved by a responsible party other than the original preparer. Condition/Context: After the Human Services Manager left the County in June of 2023, the County did not replace the position with another individual to continue performing the control of reviewing GEARS reports prior to submission for reimbursement. Two of the three GEARS reports tested in each program were not reviewed prior to submission as required by the state. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Efforts to fill the Human Services Financial Manager position were being actively pursued during the vacancy. The position was re-filled January 29, 2024. Discussion about a backup plan should this position be vacant again are occurring between human services and county administration. Name(s) of Contact Person(s) Responsible for Corrective Action: Mandy Stanley, Human Services Director Anticipated Completion Date: Human Services Financial Manager position was re-filled January 29, 2024.

Finding Number: 2023-007 Finding Title: Local Collaborative Time Study (LCTS) Reporting (Cost Schedules DHS-3220.1 and DHS-3220.2) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Melanie Lupkes/Shelly Staebler Corrective Action Planned: Social Services and Probation staff met as a group to go over the most recent bulletin that includes the instructions for completing the forms and for the allowable expenses. Consulted with OSA staff for interpretation of some of the items and all quarterly reports have been resubmitted, reviewed by Traverse County Social Services Fiscal and accepted by the State. Anticipated Completion Date: Completed, September 7, 2024

Finding Number: 2023-005 Finding Title: Reporting (DHS 2550 and 2556) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Shelly Staebler Corrective Action Planned: Traverse County Social Services fiscal staff will review the new detailed instructions on how to complete the referenced quarterly reports that include recent changes. Staff will correct an resubmit quarterly reports as requested. Anticipated Completion Date: January 20, 2025

The City will review the reports prepared by the consultant and formally document their review

Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will accept. For many projects, an architect certification for each draw would be financially prohibitive and would likely reduce the financial viability of affordable housing developments. Our office does conduct intermittent on-site or desktop monitoring throughout the course of the project to ensure evidence activities. Additionally, all construction projects must complete permit requirements to ensure housing quality. Evidence of monitoring or activity was provided to the auditors. Expected Implementation Date: October 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development

Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was discovered during the subrecipient monitoring component of this award and was promptly reported and reconciled prior to being presented as an audit finding. Upon identification of the duplicative charges, totaling approximately $22,000, immediate corrective action was taken to address the non-compliance. Dated January 5, 2024, a memorandum was filed disclosing the duplicative reimbursements, documenting the actions taken to rectify these charges, and recommending further steps to enhance the internal controls of the non-profit organization. The following information summarizes the East Baton Rouge City-Parish American Rescue Plan Act (ARPA): Duplication of Benefits - Findings and Corrective Action Memorandum: This memorandum documents the incidental reimbursement of multiple duplicative items associated with the subrecipient’s grant agreement and the corrective actions undertaken to resolve these findings, ensuring compliance with the terms of this award. During the routine subrecipient monitoring reviews, it was discovered that duplicate reimbursements occurred for 12 items between separate federal awards (American Rescue Plan Act SLFRF and CARES Act). In accordance with 2 CFR 200.522(c), a corrective action plan was provided to resolve the non-compliance. To address this, the following actions were taken: 1) Reconciliation of Duplicate Reimbursements: The non-profit entity has since reconciled the total value of $22,222.98 in duplicate reimbursements with an equivalent value of eligible expenses, including all necessary backup documentation to satisfy existing procurement and reimbursement requirements. 2) Development of a Duplication of Benefits Policy: It was recommended that the non-profit entity develop a comprehensive duplication of benefits policy to strengthen their internal controls further. These additional safeguards are considered best practices and are intended to minimize the risk of future non-compliance. Additionally, a comprehensive, grant specific, financial management policy template was provided to support the non-profits action to adopt and implement an appropriate standard of internal controls. The City-Parish is committed to maintaining robust internal controls and ensuring compliance with federal regulations. Immediate corrective measures were proactively taken to address these duplicative charges. Additionally, the City-Parish's third-party grants manager has established recurring weekly monitoring meetings with the non-profit entity to support the development and implementation of an adequate system of internal controls. Continuous efforts are being made to improve these processes to prevent such issues in the future. Expected Implementation Date: January 2024 Contact person: Courtney Scott, Assistant Chief Administrative Officer, Mayor-President’s Office

Section III –Federal Award Findings and Questioned Costs FINDING 2023-002 DEBT SERVICE COVERAGE RATIO COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and electronic health record (EHR) system in May of 2023 and experienced significant delays in being able to bill and process claims. The delays had a negative impact on overall operating results as additional accounts receivable allowances for both contractual adjustments and bad debts were necessary at June 30, 2023. The negative impact on overall operations resulted in the Hospital not meeting the required debt service coverage ratio of 1.5. The Hospital did receive a waiver from the USDA regarding this noncompliance matter. Views of responsible officials and planned corrective actions The implementation of the new electronic health records created a delay in operational workflow processes which required vendor modifications and corrections to the system. This delayed submitting insurance claims for reimbursement which continued throughout fiscal year 2024. Operations have now stabilized and the debt service coverage ratio is expected to be in compliance in fiscal year 2025. Anticipated completion date Ongoing

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) Audit Finding Number: 2023-004 – Medicaid and CHIP Receipt Controls Name of the contact person responsible for corrective action: Ashley Logan Anticipated completion date for corrective action: June 30, 2024 Recommendation: The DSS through the MHD review, strengthen, and enforce internal controls over Medicaid and CHIP receipts. The MHD should restrict user access within the MMIS for FORU accounting personnel and adequately segregate asset custody and receipt recording duties from accounts receivable duties, or perform documented supervisory reviews of MMIS entries and changes made by employees whose duties are not segregated. In addition, the MHD should establish procedures to account for all cash control numbers to ensure all receipts are deposited or returned to senders. DSS Response: DSS agrees with the auditor's finding. Our Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: MHD has implemented a process to document supervisory reviews of the Finance Manual Checks Quarterly report to ensure segregation of duties in HeathTrack/AHS. MHD will continue to perform the audit of clerk ID adhoc reports to review any segregation of duties within the MMIS. To ensure all cash control numbers are accounted for, MHD is implementing a new cash control number sequence, exclusive to manual checks logged within the FORU. This will resolve the issue of cash control numbers occurring out of sequence due to AHS running files in the background at the same time checks are being logged.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Missouri National Guard (MONG) Audit Finding Number: 2023-018 – MONG Cooperative Agreement Extensions and Final Accounting Name of the contact person responsible for corrective action: Lindsey Hedges Anticipated completion date for corrective action: October 2024 Recommendation: The MONG establish controls and procedures to ensure a final accounting of all funding and disbursements and/or a written request(s) for extension is filed for each CA appendix in compliance with National Guard regulations. Corrective action planned is as follows: Missouri National Guard will implement internal controls and procedures for ensuring final accounting and extension requests are filed timely through regular monitoring of Cooperative Agreement (CA) appendices to identify upcoming lapses in completion of final accounting of all funding and disbursements or for extension request.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

Corrective action planned: Cash flow requirements to fund daily operations will be reviewed more thoroughly so that awarded funds are expended consistent with the terms of their respective agreements. Projects presently on quarterly cost reimbursement schedules will be changed to monthly cost reimbursement requests. Contact person responsible for corrective action: John D. Pepe, Controller. Anticipated or actual completion date: October 1, 2024.

2021-01: Approval for expenditures Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.

2019-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregating certain duties is not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.