Corrective Action Plans

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review and approval of wage rates prior to the submission of the reimbursement request to SAMHSA for three months selected for testing. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer and Mark Copps, Finance Director / Controller Corrective Action Plan: During 2023, management implemented a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: October 2023

Finding 2023-003 Federal Agency Name: Legal Services Corporation Program Name: Legal Services Corporation – Basic Field Grant FFAL#: 09-542026 Finding Summary: Testing identified one instance where a case was improperly entered into Legal Server as no application was completed. Responsible Individuals: Lea Wroblewski, Executive Director. Corrective Action Plan: ERLS will train staff on application procedures, modify outreach procedures, and will not enter interested clients in Legal Server until an application is completed. Completion Date: May 2024

Finding 2023-002 Reporting – Internal Control and Compliance over Reporting (Significant Deficiency) Criteria: CODE OF FEDERAL REGULATIONS, Title 49 – TRANSPORTATION, Part 18 – UNIFORM ADMINISTRATIVE REQUIREMENTS FOR GRANTS AND COOPERATIVE AGREEMENTS TO STATE AND LOCAL GOVERNMENTS, Subpart C – Post-Award Requirements: 18.41 Financial Report (a) General (4), Due date. When reports are required on a quarterly or semiannual basis, they will be due 30 days after the reporting period. When required on an annual basis, they will be due 90 days after the grant year. Final reports will be due 90 days after the expiration or termination of grant support. 18.58 (a) General. The Federal agency will close out the award when it determines that all applicable administrative actions and all required work of the grant has been completed. 18.50 (b) Reports. Within 90 days after the expiration or termination of the grant, the grantee must submit all financial, performance, and other reports required as a condition of the grant. Upon request by the grantee, Federal agencies may extend this time frame. These may include but are not limited to: (1) Final performance or progress report, (2) Financial Status Report (SF 269) or Outlay Report and Request for Reimbursement for Construction Programs (SF-271) (as applicable), (3) Final request for payment (SF-270) (if applicable), and (4) Invention disclosure (if applicable). U.S. OFFICE OF MANAGEMENT AND BUDGET CIRCULAR A-133—AUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONS (OMB Circular A-133), Subpart C— Auditees, Section .300—Auditee Responsibilities (b) Maintain internal control over federal programs that provides reasonable assurance that the auditee is managing federal awards in compliance with laws, regulations, and the provisions of contracts or grant agreements that could have a material effect on each of its federal programs. Condition: For the Airport Improvement Program (AIP), the City did not submit the reports within the required deadline: Report Type Award Number Period Ending Date Due Date Submitted SF-425 Financial 3-06-0034-018-2020 5/2/2022 8/2/2022 11/8/2022 SF-425 Financial 3-06-0034-021-2020 5/2/2022 8/2/2022 11/8/2022 Two (2) financial reports were tested and all reports were not submitted by the required deadline. City’s Corrective Action Plan: The City will take steps to improve identification and monitoring of required grantor reporting deadlines. Corrective Action Plan (Continued) Contact person responsible for corrective action: Sandra Fonseca, Interim Finance Director Anticipated completion date: June 30, 2024

2023-006 — Material Weakness and Material Noncompliance — Cash Management Person responsible for the corrective action: Jim Larson-Shidler, CFO Corrective action planned: Monthly review and analysis of budget to actual will be performed with cash requests processed monthly for all grants. Variances will be discussed with directors of programs and principals to determine the cause and possible need to file timely grant and budget amendments. Budgets will be entered into the Smart General Ledger and reconciled to grant awards and budgets submitted to Michigan Department of Education to provide program directors and principals' information to properly expend grants. Perform adequate planning, communication, monitoring, and knowledge of grant information submitted to Michigan Department of Education. Anticipated completion date: June 30, 2024

Finding: 2023-028 - Of the two FY 23 FMAG quarterly progress reports (QPR) selected for testing, one was not filed. Testing of the QPR for quarter ending June 30, 2023, identified incorrect amounts and data. Questioned Costs: None Assistance Listing Number: 97.046 Assistance Listing Title: FMAG Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DNR agrees with this finding Corrective Action (corrective action planned): DNR Forestry staff responsible for preparation, review and submission of the FMAG QPR reporting will review procedures and provide corrective updates to the process. This plan will establish written policies and procedures, including independent review and validation before submission. Completion Date (list anticipated completion date): March 2024 Agency Contact (name of person responsible for corrective action): Norman McDonald, Forestry Acting Director

Finding: 2023-027 - DNR Support Services Division staff did not file the FY 23 Federal Cash Transaction Reports for quarters ending September 2022, December 2022, and June 2023. The audit reviewed the March 2023 quarterly report filed and determined inaccurate cumulative cash receipts and cash disbursements were reported. Questioned Costs: None Assistance Listing Number: 97.046 Assistance Listing Title: FMAG Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DNR agrees with this finding. Corrective Action (corrective action planned): DNR fiscal staff responsible for preparation and review and submission of the FCTR reporting will review procedures and provide corrective updates to the process. This plan will establish written policies and procedures, including independent review and validation before submission. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Theresa Cross, Administrative Services Director

Finding: 2023-050 - Sixty Medicaid and sixty CHIP recipients were randomly selected for eligibility testing. Testing revealed the following errors: Medicaid: • Twelve of the sixty recipients tested (20 percent), the State did not process applications in a timely manner or redetermine eligibility. The delays for completion of processing of the applications ranged from 46 days to 279 days as of June 30, 2023. CHIP: • Six of the sixty recipients tested (10 percent), the State did not process applications in a timely manner or redetermine eligibility. The delays for completion of processing of the applications ranged from 56 days to 225 days as of June 30, 2023. • One of the sixty recipients tested (1.6 percent), the beneficiary was due to have eligibility redetermined, however no information was submitted to the State for review and staff did not independently conduct a redetermination. For recipients following the Modified Adjusted Gross Income methodology, the State should have attempted to redetermine eligibility through electronic interfaces. Questioned Costs: None Assistance Listing Number: 93.767; 93.775, 93.777, 93.778 Assistance Listing Title: CHIP; Medicaid Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding. Corrective Action (corrective action planned): DPA will assess available resources to address timeliness of eligibility redeterminations. The division will also continue eligibility redeterminations in accordance with CMS approved public health emergency (PHE) unwinding requirements and plans. Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2025. Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Finding: 2023-071 - UAS had twenty-two stale Title IV checks greater than 240 days. Questioned Costs: None Assistance Listing Number: 84.007, 84.038, 84.063, 84.268, 84.379 Assistance Listing Title: Student Financial Assistance Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The UAS Bursar’s office, the Financial Aid Office are working with the Budget, Grants and Contract Office to send funds back to the Department of Education for the stale dated Title IV checks. A quarterly review will be performed to ensure future compliance. Completion Date (list anticipated completion date): November 2023 Agency Contact (name of person responsible for corrective action): Jonathan Lasinski, Vice Chancellor for Administrative Services, 907-796-6497

Finding: 2023-057 – DOT&PF management lacked internal controls to ensure the annual SF-271 equivalent report was supported, accurate, and complete. Questioned Costs: None Assistance Listing Number: 20.106 Assistance Listing Title: Airport Improvement Program Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The support documentation for the SF 425 and SF 271 equivalent are documented in the FFR Working File. The FFR Working File goes through reviews by the Grants & Projects team to ensure no errors are found before reporting. DOT&PF has updated the procedures for the current FAA FFR that was submitted in December 2023. The update adds two signatures to document the preparation and approval of the SF 271 equivalent on the FFR Working File that will be converted to PDF and filed. Completion Date (list anticipated completion date): January 31, 2024 Agency Contact (name of person responsible for corrective action): Elizabeth Dunayski, Financial Services Manager

Finding: 2023-032 - Pandemic Electronic Benefit Transfer Food Benefits (P-EBT) benefit payments were not issued in accordance with the process and timeframes outlined in the federally approved state plan. Testing a sample of 136 payments found 37 issuances (27 percent) were sent to unauthorized or unsupported addresses and one issuance included unauthorized benefits. Additionally, no benefits were issued during FY 23 to Supplemental Nutrition Assistance Program (SNAP)-enrolled children in child care. Questioned Costs: AL 10.542: $27,387 Assistance Listing Number: 10.542 Assistance Listing Title: P-EBT – COVID-19 Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH partially agrees with the finding. The Division communicated with FNS regarding manual benefit issuance for Alaska expressing timelines would be affected and FNS did not request an updated timeline. Communication with FNS regarding issuance remained consistent, with no indication to alter our issuance plan. Address verifications were conducted at the time of benefit payment, because addresses are subject to change from the date of eligibility. Updates to addresses were made when more recent information became available. The division has no control over DEED eligibility records including the addresses they have on file. Corrective Action (corrective action planned): Shall the Division agree to administer this federal program in the future, the commissioner will allocate resources necessary to prevent the necessity to manually administer the federal program. Completion Date (list anticipated completion date): Not applicable. This federal program is complete. Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Finding: 2023-034 - The amount of FY 23 SNAP benefits reported as issued by the State’s Electronic Benefit Transfer (EBT) contractor was $19,689,126 more than the amount of authorized benefits reported in data from DPA’s Eligibility Information System. Questioned Costs: AL 10.551: $19,689,126 Assistance Listing Number: 10.551, 10.561 Assistance Listing Title: SNAP Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH does not agree with the finding. The Division performs monthly reconciliations and balancing efforts to ensure accuracy with FIS, EIS, and reporting. No discrepancies have been identified by the Division. None of the parties involved in the audit have been able to pinpoint the origin of the discrepancy described in this finding. The Divisions’ monthly reconciliation processes are rigorous, consistent, and thorough, ensuring accuracy and alignment with USDA data from AMA Bank. The reconciliation efforts encompass federal SNAP reports; FNS 388, FNS 46, and the EIS Balance Issuance report, all of which consistently reconcile. The reconciliation extends to ASAP and AMA batch values, with annual certification further validating accuracy. Monthly, the AMA raw data is meticulously balanced in the 388/46 reports, with only the PEBT and EA issuances requiring manual entry from the 292B report. With this steadfast commitment to monthly reconciliation and alignment with AMA data, we are confident in the absence of errors or discrepancies. Corrective Action (corrective action planned): N/A Completion Date (list anticipated completion date): N/A Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following is the finding as noted in the Altarum Institute and Subsidiaries Single Audit report for the year ended December 31, 2023, and the corrective action to be completed. 2023-001 – Payroll and Fringe Benefit Charges Auditor Description of Condition and Effect. The Institute has self-reported one individual that was working on the research and development cluster that had impermissible time charged to the grant for salaries and fringes. As a result of this condition, the Institute did not fully comply with the Uniform Guidance applicable to the above noted grant. Auditor Recommendation. It is our understanding that the Institute has already enhanced its practice facilitator oversight and management protocols by requiring check-in calls with participating clinics to verify practice facilitator engagement. It has also provided employees with compliant timekeeping and employee reimbursement training in 2023. Corrective Action. Altarum conducted quality assurance investigations and meetings with affected participating practices. To prevent this type of issue in the future, Altarum enhanced its practice facilitator oversight and management protocols to ensure that practice facilitators are appropriately conducting their assigned activities. This includes continuing the check-in calls with participating clinics. Altarum also provided employees with Compliant Timekeeping and Employee Expense Reimbursement training in July 2023, as well as the leadership team reiterating to the project team the importance of accurate books and records, including timekeeping and expense reporting. Altarum also launched its annual Government Contracting education module shortly thereafter, which also includes training on timekeeping and expense reporting. Lastly, Altarum took appropriate personnel actions and offered the Government a credit. Responsible Person. Tracy M. Lawyer, General Counsel and Secretary Anticipated Completion Date. 2024

1. Current Findings on the Schedule of Findings and Questioned Costs During the year ended December 31, 2023, Grand Manor Mutual Housing Association, Inc. distributed $115,000 in excess of surplus cash available for distribution. 2. Finding 2023-001 a. Comments on the Finding and Each Recommendation The funds were repaid too soon. b. Action(s) Taken or Planned on the Finding Our action plan includes documentation, management approval, and will remedy the problem going forward. Advances are to be recorded in a liability account that doesn’t roll up into the AP module. This will eliminate paying advances in error. The payment is only moved into the AP module, for processing, after we determine we have excess cash and have the appropriate supporting documentation and approval. Surplus cash can only be calculated semi-annually and at year-end. If the calculation reflects excess cash, we must make payment within 90 days.

Finding ref number: 2023-003 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and federal wage rate requirements. Name, address, and telephone of District contact person: Gabriela Chacon (509) 932-4565 EXT 3031 411 E Saddle Mountain Drive Mattawa, WA 99349 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Wahluke School District is currently working on implementing adequate internal controls for prevailing wages We now have new staff in place, so we are currently creating internal controls over prevailing wage requirements by doing the following: 1. Policy and Procedure Documentation: Establish clear policies and procedures outlining the school district's commitment to complying with prevailing wage requirements. 2. Training and Education: Provide training to relevant staff members responsible for payroll, human resources, and project management on prevailing wage requirements. 3. Vendor and Contractor Oversight: Require contractors to provide certified payroll reports regularly, detailing wages paid to each worker on prevailing wage projects. 4. Recordkeeping and Documentation: Maintain detailed records of all labor costs associated with prevailing wage projects. This includes employee time cards, payroll records, fringe benefit payments, and any other documentation required by state law. 5. Segregation of Duties: Implement segregation of duties to prevent one individual from having sole control over the entire process. For example, separate individuals should be responsible for approving timecards, preparing payroll, and reconciling payroll records. 6. Regular Audits and Reviews: Conduct regular internal audits or reviews of payroll records to ensure compliance with prevailing wage requirements. This can help identify any discrepancies or errors that need to be addressed promptly. 7. Monitoring and Enforcement: Establish mechanisms for monitoring compliance with prevailing wage requirements.Enforce consequences for non-compliance, such as withholding payments until issues are resolved or terminating contracts with repeat offenders. 8. Communication Channels: Maintain open lines of communication with employees, contractors, and relevant government agencies regarding prevailing wage requirements. 9. External Assistance: Consider engaging external consultants or legal counsel with expertise in prevailing wage compliance to provide guidance and assistance as needed. By implementing these internal controls, Wahluke School District can help ensure that it meets its obligations under prevailing wage laws, minimizes the risk of non-compliance, and maintains transparency and accountability in its operations. The Wahluke School District has established internal controls to track expenses diligently and ensure that the claims submitted are only for allowable activities and cost. Program Directors and Building Administrators receive weekly budget reports that they review for accuracy to ensure that only allowable activities are charged to their grants. The district has also included the Grants Manager in the review and approval of requisitions and time cards. This ensures that all proposed expenditures and time worked is allowable and aligns with the grant spending plan. Anticipated date to complete the corrective action: 8/31/2024

Organization’s response: After the former finance director completed the federal webinars on the guidelines for requesting funds through the Payment Management System and submitting Federal Financial Reports, it was identified and disclosed to the auditors that drawdown procedures had not been in compliance. SAMHSA was notified and accounts were reconciled with the return of unspent funds. All drawdowns are currently only occurring when funds are expended. Current finance personnel are trained and have extensive experience in federal reporting guidelines.

CORRECTIVE ACTION PLAN April 23, 2024 Goodwill Industries of Michiana, Inc. respectfully submits the following corrective action plan for the year ended 2023. Audit Period: Year Ended December 31, 2023 SIGNIFICANT DEFICIENCY FINDING – FEDERAL AWARDS 2023-001 ALLOWABLE COSTS An employee requested expense reimbursement through payroll which was default coded to the grant. The expense was for a different grant and noted as such in the description. The unallowed cost was charged to the incorrect grant and reimbursed by the grantor. Recommendation: Management should implement a review process to ensure payroll reimbursements are accurately allocated to the correct grant for reimbursement. Action Taken: The payroll expense reimbursement process has been reviewed and steps added to ensure expenses are being charged to the correct grants. This includes reviewing the notes included in the expense reimbursement submission. Correcting entries will be made when needed to ensure expenses are charged to the correct grant. Contact Person: Karman Eash, CFO keash@goodwill-ni.org Effective Date: April 23, 2024

Plan: The District acknowledges the discrepancies in the quarterly reports and will continue to review its procedures for compiling and submitting the quarterly financial submissions to ensure that all salaries, benefits, and contracted costs are properly reported in the SBS Medicaid system.

The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/27/22 to 7/8/22, with a pay date of 7/15/22). Reports to the funder for the year ending 6/30/22 were due on 7/10/22, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder. Moving forward, the organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year. Additionally, in May 2024, the organization will be implementing a new electronic payroll system that will allow us to obtain this information more quickly at the close of each fiscal year to complete billing reports.

FCFS does not agree with the statement of misreporting from the auditor. 1. FCFS will enlist the service of a 3rd party accounting firm to review the accuracy of the prepared SEFA. Person Responsible: Bridget Rebo, Fiscal Officer; Sarah Johnson, Operations; Pinion Accounting Services. Timeline for Completion: July 2024

2023-001 – Deposit of Surplus Cash into a Residual Receipts Account Corrective Action Plan No later than 90 days past the end of the fiscal year, we will identify surplus cash in the project funds account and deposit into the residual receipts account. Person(s) Responsible: Greg Shinn, Agency CPA Timing for Implementation: Immediate

The district has changed internal verifications and has engaged a new Medicare processing provider which will ensure future compliance with having all M5 forms on file.

Finding Number: 2023-006 Condition: Currently one person prepares the reimbursement requests and no one reviews them for accuracy prior to submitting the requests to the State through the Operating Assistance Report (OAR) for reimbursement. Planned Corrective Action: Management will identify a new process for OAR assignment and submission. Currently the OARs are prepared and submitted by the CFO due to staffing limitations. Nevertheless, the CFO will work to identify an individual within the Finance Department that has the skillset and capacity to prepare the OARs for CFO review prior to submission. Contact person responsible for corrective action: Colette Champine, CFO Anticipated Completion Date: July 10, 2024

Finding:  2023‐006:  Significant Deficiency over Eligibility  Name of Contact Person: Daphine Little, Director of Bertie County Department of Social Services Corrective Action/Management's Response: Recommended Improvement:  Immediate re‐training of specific policy on child support  Post eligibility training after application disposition on child support procedures  ACTS data is viewed on all parent‐child cases at recertification and application  Make sure all single parent cases with children have compliance addressed with child support  Make sure all child support referrals are done at all applicable recertifications of determining eligibility and post eligibility for applications  Make sure on how to do referral for child support by job aid through NC Fast help Goal:  Decrease technical errors with child support by 100%  Request online data for ACTS at all recertifications and applications  Recheck all evidences on dashboard pertaining to child support enforcement for accuracy  Supervisors  and  Caseworkers  retain  all  Fast  Help,  Learning  Gateway  Trainings,  Administrative  Letter,  Change Notices, and Medicaid Manual Information to properly complete their job requirements Training Information:  Medicaid Manual and Policy Training (MA‐3365 Child Support)  Child Support Post Eligibility (MA‐3205 Post Eligibility Verification)  DHB  Administrative  Letter  No:  2‐20,  Child  Support  Guidance  Eligibility  Verification  During  COVID‐19(Guidance During This Audit)  DHB‐22000 Absent Parent Information Form  Current Guidance Child Support During CCU. DHB Administrative Letter No: 13‐23, Child Support Cooperation and Applying For Other Monetary Benefits Post Eligibility Benefits During The CCU Period  Child Support (IV‐D) Referrals for MA, CA, & MAGI Cases (Job Aid from NC Fast Help) Corrective Action Plan  Additional Training on Child Support Policy and Procedures for Recertification and Applications  Additional Training on Child Support Referral Job Aid and How to Complete it in NC Fast System  Staff training will be conducted monthly during staff conferences which will include child support training on child support referrals and how to key them in the NC Fast system  Sign in sheet for caseworkers attending training and staff conference Proposed Completion Date: February 29, 2024

Finding: 2023‐005: Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Daphine Little, 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 twenty‐three employee daysheets vs. timesheets resulting in more program time reported on the daysheets than the approved timesheets. Supervisors  are  responsible  for  ensuring  that  time  reported  on  employee  daysheets  matches  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 daysheets, the Supervisor is expected to reconcile time reported on employee daysheets to time reported on employee timesheets. Plan of Action:  Provide  employees  with  a  copy  of  Power  Point  Training ‐Day  Sheets:  Time  Reporting  and  Reimbursement  for County DSS (2022).  Reiterate the importance of employees reporting the same amount of time on the daysheet vs. the timesheet.  Communicate with Supervisors the importance of reconciling employee daysheets vs. timesheets. Proposed Completion Date:  March 1, 2024

Finding 2023-103 Allowable Costs/Cost Principles/Reporting (Material Weakness, Compliance Finding) Repeat Finding. Responsible Individuals: William Bridgeman, Chief Fiscal Officer Natalie Alvarez, Chief Operating Officer- Head Start Director Corrective Action Plan: Greater Phoenix Urban League (Delegate Agency) will continue its on- going collaborate with the City of Phoenix (Grantee) in evaluating the process and effectiveness of inserting and updating the “quarterly administrative reporting package”, relatively to its use and the accuracy of the content that flows within the excel workbooks. Anticipated Completion Date: On going throughout the contract period on an annualized basis. July 1, 2024