Corrective Action Plans

Internal Control over Compliance and Compliance with Cash Management Requirements  Contact: Chris Holmes   Title: Controller  Phone Number: 202-235-1938  Estimated Completion Date – ongoing  Corrective Action  During 2023, PSI refined its method for calculating drawdowns on federal awards that are near the end of the period of performance dates in response to the 2022-02 finding, however additional training with the Program Management Teams and cash projections is still ongoing in 2024.

Finding No: 2023-001 Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.498 Program: COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Compliance Requirement: Activities allowed or unallowed/allowable costs Award Year: January 1, 2020 through December 31, 2022 (a) Criteria or Requirement 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. (b) Condition Found The System did not have adequate controls related to determining allowability of expenditures for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Grant. Our testing identified one charge within the population that had been charged incorrectly to the federal program. This charge was for government contract labor totaling $126,313 that was determined to be an unallowable expenditure that should have been removed prior to submission to the federal agency. In addition, during our testwork over expenses, we selected for testing a sample of 40 expenses charged to the program. One of our samples related to COVID lab tests was identified with a cost that should have been zero as the tests were voided and the vendor invoice reflected a zero balance; however, a standard test was inappropriately charged to the federal program in excess of the vendor invoice. Further, one sample was identified as having the incorrect price applied to the cost due to the drug being purchased from a different vendor, which had a lower price. This resulted in a higher price being charged to the federal program.The resulting impact of the above two items was $508 inappropriately charged to the federal program. In addition, the System was unable to provide evidence of management review and approval for three of the 40 expenses sampled. These three disbursements were for allowable costs under the terms and conditions of the program. (c) Cause The System’s review process in place over the recording of these costs did not operate effectively to prevent unallowable charges and inaccurate amounts from being submitted for reimbursement by the federal agency. The System was unable to provide evidence of certain management reviews and approvals due to system limitations that only maintain electronic approvals (via email) for 365 days. (d) Effect Federal funds were expended for unallowable purposes or for inaccurate amounts and evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (e) Questioned Cost Expenditures related to contract labor and other costs of $126,821. (f) Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding (h) Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs. (i) View of Responsible Officials The Monthly Cost Capture detail for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (ALN No. 93.498) reporting was developed to appropriately track expenditures that qualified under the grant. A wide variety of costs from across the company were charged to a COVID cost department. These costs originated in a variety of ways. While the overall amounts were tracked and reviewed, a comprehensive 100% review was not conducted. As a result, the government labor expenditure and the cost for a COVID lab specimen that spilled in transit were inappropriately included. Additionally, a higher cost per unit was used to allocate for a specific drug used by COVID inpatients. Furthermore, there were three Morris and Dickson invoices that were submitted to AP electronically approving payment via email, but the emails automatically delete after 365 days. (j) Corrective Action Plan The expenditures for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (ALN No. 93.498) were reported through the PRF Reporting Portal using quarterly financial data. The portal restricted the entry of expenses up to the awarded amount plus interest earned. Consequently, we have sufficient expenses to cover any ineligible expenditures identified in this audit. As the program has concluded, no further actions are required for COVID drug and COVID lab test findings, as these were already accounted for in system reports that are now obsolete due to surpassing the Period of Availability dates. A new process will be implemented for manager sign-off on Morris and Dickson invoices submitted to AP electronically to ensure proper approval evidence is captured and documented correctly. Anticipated Completion Date: 6/30/2024 Name of Contact Person for Corrective Action: Sharon Nobles, Chief Financial Officer

CORRECTIVE ACTION PLAN The following is our response to findings in the audit as of December 31, 2023 FINDING 2023-001 - Uniform Guidance written policies and procedures During our audit, we discovered the City did not develop written procedures as required by the Uniform Guidance. Corrective Action Plan (CAP): 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The City Council will adopt written federal grant policies and procedures. 3. Official Responsible for Ensuring CAP: Nick Bishop, Finance Director, is the official responsible for ensuring corrective action. 3. Planned Completion Date for CAP: Fiscal year end 2024. 4. Plan to Monitor Completion of CAP: The City Council will be monitoring this corrective action plan. Sincerely, Nick Bishop City Finance Director 14

Implementing Improvement for Quarterly Reports – Epi and Lab Capacity (ELC) Contract with DSHS. -Weekly supervisor meeting for the Epidemiology Division. Data needed to complete the quarterly report is to be discussed at the end of the quarter. -The Associate Director for Disease Control and Prevention to meet monthly with the Epidemiology Division Manager on contract deliverables. -In addition to the activities in the Epidemiology Division, data needed from other divisions will be solicited by the Epidemiology Division manager within five days of the quarter end to include in the report. This includes employment status of employees funded by the contract via the position control report, and project activities related to the contract that should be included. -The Epidemiology Division Manager is to present the quarterly report to the Associate Director for review and approval before the report deadline. -The reports for the most recent 2 quarters, Sept through November 2023 and December 2023 through February 2024 were submitted by the due date. -The last two quarterly reports in the current cycle are due June 15, 2024 and August 15, 2024 (only covers two months).

Views of Responsible Officials and Planned Corrective Actions – We have since developed an organization policy for cash management for federally sponsored grant programs. SEH has provided and will continue to provide staff education on this policy in the future.

The School District should always reconcile its reimbursement requests with documented workpapers.

Management agrees with this finding. CASS does not have any subrecipients. However, if CASS has subrecipients in the future, comprehensive written policies and procedures will be in place to ensure all subrecipients payments are made on a timely basis and all required documentation and communications will be retained as result of missing or inaccurate information in the subrecipient’s drawdown requests prior to remittance.

Corrective Action Plan For the year ended December 31, 2023 Identifying Number: 2023-001 Finding: The overall process for tracking federal funds spent and the reimbursement process is a manual process performed by one department. The Foundation lacks formal policies for reimbursement and timely review of calculations throughout the year. Corrective Action Taken or Planned: Management is actively working with the awarding agencies to fully understand the compliance requirements and implement appropriate policy and process to administer the federal programs. Management is reviewing the current procedures and formalizing the process for tracking and reporting of federal funds. The responsible individuals for the plan are the Chief Executive Officer and Controller.

Management will have the employee responsible for the review of the LIHEAP Agency Invoice Reports sign each weekly report as approved.

Kid Power, Inc. agrees with the finding. The Organization will implement effective and written procedures for the review of cost allocation journal entries, allowable costs and activities, period of performance, matching, and reporting. The written procedures will explicitly lay out the processes for review and approval of each of these compliance components per each federal Assistance Listing that the Organization receives. Curtis Leitch, Deputy Director, will use the most up to date 2 CFR Part 200, Appendix XI - Compliance Supplement to identify the specific compliance requirements for each of the Assistance Listings and create the written procedures. Procedures for internal controls include monthly expense reports completed through Brex by the Operations Manager, Charles Thomas, and stored in Kid Power, Inc.’s Google Drive; allowability and expense allocations will be reported in Google Drive on monthly basis and completed by the Deputy Director, Curtis Leitch; cost allocation journal entries will be inputted into QuickBooks on monthly basis by the Deputy Director, Curtis Leitch. Federal allocation and reimbursement reporting will be prepared by the Deputy Director, Curtis Leitch; reviewed by the Executive Director, Andria Tobin; and submitted by the Deputy Director, Curtis Leitch, on a quarterly basis.All reviews and approvals will be documented henceforth in Kid Power, Inc.’s Google Drive. Curtis Leitch, Deputy Director, will oversee the implementation of this corrective action.

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 – Replacement Reserve Withdrawals Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Special Tests and Provisions) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (CFDA# 14.157) Condition. Certain capital expenditures, amounting to $6,135, were requested and reimbursed from the reserve for replacements after already having been requested and reimbursed from the reserve. Management corrected this oversight and transferred the duplicate reimbursed funds from the Project's operating account to the reserve for replacements in May 2024. Effect. As a result of this condition, the reserve for replacements account was underfunded during 2023. Plan. Management agrees with finding 2023-002 and has developed the following plan. All invoices submitted for reserve disbursement requests will be compared to those on prior withdrawals. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2024

Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.

The District will disaggregate the budget to actual review process to correspond to the level provided in the approved budget. Expenditures in excess of program budgets will be excluded from program costs. Stuart Parks, Superintendent 815-436-7000

The district will review control procedures over disbursements to ensure all payments are properly supported by proper documentation. Vendor invoices will be matched with purchase orders and shipping documents to identify vendor double billings and prevent duplicate payments. The District recovered $46,700 overpaid for the classroom furniture and is in discussions with the subrecipients to recover the remaining $5,663 overpaid for laptops. Stuart Parks, Superintendent 815-436-7000

The Corporation is working to make the required deposits as cash flow permits.

FINDING 2023-003: Unauthorized receipt of COVID-19 Supplemental Payments (CSP) Name of contact person – Megan Netland, Vice President of Asset Management Corrective action – The applications for reimbursement for program periods 1 through 3 were made in error. The Corporation has contacted HUD and is awaiting a response. Proposed completion date – Management has contacted HUD and is awaiting a response.

Part of the payroll reconciliatiion will be revised to include review of employees charged to grants to ensure they are assigned to the grant and tracking their time properly including salaire snad stipends.

2022-004 – Reimbursement Claims Reported Meals Delivered to Unidentified Participants Corrective Action – GYAC has purchased an electronic system that assists with the tracking of meal count sheets and attendance rosters. This system compares the names on the roll with the number of meals being claimed, ensuring that participant rosters are accurately maintained and matched with meal delivery records, thereby preventing discrepancies and reducing the error rate in submissions.

2022-003 – Untimely Submission of Claim Amendments for Reimbursement Corrective Action – This is a repeat finding, and improvements have been made since the release of the December 31, 2022, audit. In addition to retraining staff to enhance the accuracy of meal counts, GYAC has purchased an electronic system (KID KARE) to assist with tracking both meal count sheets and attendance rosters. This system ensures that meal counts and attendance rosters are reconciled, reducing the error rate in submissions. The system also checks for errors prior to claim submission and compares names on the roll with the number of meals being claimed for accuracy.

2023-002 – Reimbursement Claims Not Supported by Meal Count Sheets Corrective Action – This is a repeat finding and improvements have been made since the release of the December 31, 2022, audit. In addition to retraining staff to enhance the accuracy of meal counts, GYAC has purchased an electronic system (KID KARE) to assist with tracking both meal count sheets and attendance rosters. This system ensures that meal counts and attendance rosters are reconciled, reducing the error rate in submissions. The system also checks for errors prior to claim submission and compares names on the roll with the number of meals being claimed for accuracy.

Finding # 2023-001 Material Weakness over Preparation of Schedule of Federal Expenditures (SEFA) The Organization did not identify all federal expenditures and significant adjustments were required to the SEFA prepared by management. Corrective Action: The Organization agrees with and independently identified this issue and proactively implemented a new payroll process as of January 2024 in order to address this issue. This will ensure all expenses are tracked in one system for all purposes. In addition the Organization created a new grant tracking field in the chart of accounts which tracks the Assistance Listing numbers of all grants, allowing for the automated creation of the SEFA, as well as providing an internal control to ensure that revenue recognition policies and relevant federal guidelines are correctly applied to all funding sources. Anticipated Completion Date: January 2024

2023-001 Segregation of Duties: Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. However, during the 2023 fiscal year, LDSC created a financial policies handbook that outlines controls and responsibilities in the financial reporting cycle. We will ensure the areas recommended above are added to our current policy to the extent it is economically feasible. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

Finding 2023-001: Allowable costs – significant deficiency in internal controls over compliance and compliance finding. Management Response CCGD was issued monitoring findings by HHSC for the monitoring period October 2021 (FY 21) -November 2022 (FY 22) in April 2023. As a result of that finding, CCGD received a finding in its 2022 audit. Because of the timing of the findings, as noted in the 2023 audit report, there was not time to resolve the issue before 2023. Therefore, even though the below described plan was implemented in 2023, immediately upon receipt of the initial finding, CCGD was still issued a finding in its FY2023 audit. The notification was received in the 7th month of fiscal year 2023, the following plan has been implemented. o Timesheet and GL mismatch i. Management Response: 1. Perform an audit of existing setup of HRIS-Paycom system to determinecause of mismatch 2. If needed, reimplement Paycom with required setup or change vendors 3. All departments along with respective service categories werereestablished in Paycom to only display employees applicable servicecategories based their respective grants. 4. Conduct quarterly audits of timesheets and GL to ensure there are nomismatches. 5. Time study was performed on quarterly basis to ensure individualperformance complies with funders mandate. ii. Progress Update - GL and Timesheet Mismatch: 1. Audit of existing setup to review the following: a. Department(s) - revised department names/descriptions i. Made changes to all applicable employees’ setup. b. Home Allocation(s) – revised home allocation(s)i. Revised/edited the default home allocation description ii. Assigned correct default home allocation to employees c. Service Categories i. Revised/edited service categories assigned to each department 2. Observations: a. Following Paycom updates, CCGD experienced technical challenges due to software glitches which continued to result in timesheet and GL mismatches. CCGD is continuing to work with Paycom to identify and eliminate the problem. b. CCGD subsequently sought assistance from Paycom in the troubleshooting process. 3. Departmental training of timekeeping process a. Personalized standard operating procedures used b. Real-time examples/instruction provided to staff in training session(s) 4. Post-training audits conducted to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheetsiii. Future Steps and Anticipated Timeline: 1. Continuation of post-training audits to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheets 2. With an anticipated deadline completion date of December 31, 2023, for adherence of full compliance, CCGD effectively implemented system updates prior to this deadline to ensure payroll processing is now based on the actual time and effort performed. iv. Progress Update – Performance Activity Report 1. To provide further back up to time and effort, an additional option in Paycom was enabled for staff to enter notes on day-to-day activity. 2. Departmental training on this goal was performed and completed as of March 31, 2024. 3. Continuation of post-training audits to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheets v. Post implementation plan and observation: CCGD is fully committed to complying with funders and audit standards. Furthermore, CCGD will continue to monitor and identify any potential errors in its payroll reporting to bring a timely solution if required. Furthermore, minor reporting errors occur in payroll GL reports on a random basis. The errors appear to be technical, and as such, we are currently working with Paycom to resolve this issue. Additionally, CCGD will continue to perform time study to ensure that all salary expenses and allocations are adhered to the respective program budget. Parties Responsible: Chief Executive Officer, Chief Financial Officer, and Director - Human Resources

Finding 2023-002, Significant Deficiency – Allowable Costs Corrective Action Plan: Goal: To ensure that duplicative expenses are not drawn down in state funding. Plan: The County identified the duplicate transaction of $20,740 reported for drawdown for Project AA 362 was due to an issue with the reporting mechanism. Specifically, the report used to extract project costing details included a commitment number column, which inadvertently resulted in the creation of duplicate records for each commitment associated with a single invoice. Performance Improvement Strategies: To address this issue and prevent its recurrence in the future, immediate steps have already been taken. County Finance has amended the report to exclude the commitment number parameter, thereby eliminating the possibility of duplicate records being generated. Responsible Parties: Nursing Supervisor Brooke Hamby and Assistant Health Directors Nicole Priddy & Marie Stephens Timeframes: Brooke Hamby will reach out to the Division of Public Health, Women & Children’s Health/Children & Youth section, no later than June 15, 2024, to inform them of the Audit finding of this duplicate expense and request what the process is for returning the funds.

Failure to Return Residual Receipts to HUD Name of Contact:Kendrick D. Blais, President Management's view:Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2024