Corrective Action Plans

Finding 2023-102 – Allowable Costs/Cost Principle (Material Weakness, Compliance Finding) Responsible Individual: William Bridgeman-Chief Fiscal Officer Corrective Action Plan: The organization tracks all revenue and expenses specifically and directly related to the Head Start Program CFDA 93.600 by individual general ledger. Each revenue and expenses account are supported with documentation. Classes within QuickBooks are available within the platform. However, using classes is optional and with the purchase of the more advance version of QuickBooks “QuickBooks Enterprise Platinum” it’s the intent of the organization to move to enhanced detail general ledger accounts (which will provide detail data relating to each individual transaction). As it relates to Assistance Listing No 93.185 National Urban League Vaccine Equity 2021-22 in the amount of $40,000 and Assistance Listing no. 10-551 in the amount of $52,129 is not affiliated with Head Start from a program perspective. No staff time or expenses of the two grants are related to the Head Start Program. Each of the reference programs are stand-alone funded through a third-party pass through grantee and not a direct grant from a federal agency. However, the organization will establish separate classes within QuickBooks Enterprise Platinum for each federal and state contract. The implementation of the vertical classes within the QuickBooks Enterprise Platinum platform will consist of the reconciliation of cost reimbursements with a separate and dedicated “in kind” calculation of 25% within the class where applicable as per grantee requirement. Implementation Date: July 1, 2024

Finding 2023-101 Allowable Costs/Cost Principle and 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 has received great support from our community partners by providing in-kind space in 4 school districts and the abundance of parent volunteer support for our Head Start program, however, the program struggles to identify the in-kind match during the turn to full on campus instruction. COVID19 has had a considerable impact on the programs ’s ability to meet the non-federal share obligation as families and community volunteers are not allowed fully back onto Head Start Campuses and enrollment has declined. The program was unable to open several classrooms due to lack of qualified staff and low enrollment. In the past, Greater Phoenix Urban League Head Start has relied heavily on in-kind Space as the main source of program match and with the closing of classrooms in-kind was very difficult to collect. We believe we have worked towards meeting the challenge of program in-kind match. We have used ARPA funds to develop “A grow your own program.” Greater Phoenix Urban League Head Start has recruited parents and the community to participant in a workforce development program to train and hire new Head Start staff as classroom aides and teacher assistances. We also have contracted with an organization to provided contracted instructional support to open up temporarily closed classrooms. The program will continue to identify non-federal share to meet the obligations of the grant award. COVID will continue to have an impact on the programs ’s ability to meet non-federal share but it certainly opens new channels of identifying non-federal share. The following steps are in progress of being implemented in fiscal year 23-24 within the grantee: • An internal control process has been developed to review the current system to document the resources for non-federal share. A Data Assistant will review and analyze at our process in collecting in kind. • Revised Policies and procedures will be developed to assisted instructional staff to collect parent volunteer hours. • Parent Policy Committee will be trained on the non-federal share in-kind as it relates to their important role within the Head Start Program. • Greater Phoenix Urban League Head Start will continue to review the internal control process annually to ensure compliance with the Head Start Program Performance Standards, federal regulations, and City of Phoenix Grantee regulations. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • Greater Phoenix Urban League will continue their efforts to identify citywide partners that can provide non-federal share to the Head Start Program. • Greater Phoenix Urban League Chief Fiscal Officer, fiscal staff, Program Director and Grantee Fiscal and Program staff will meet monthly to review fiscal reporting and requirements, to ensure grant obligations are on track. • All third-party appraisals will be conducted in May 2024 to reflect the current market value of space and real property. • The activities mentioned above will assist the Greater Phoenix Urban League-Head Start Program in meeting its obligations in the coming years. Anticipated Completion Date: Ongoing throughout the contract period on an annualized basis. May 1, 2024

Views of Responsible Officials: SCC's Previous CFO was unaware of the G5 3 day calendar rule for drawdowns for non-financial aid funds. As of 6/30/23 there are no further G5 HEERF funds to draw down.

Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2024

3. Finding 2023-003. Fund Balance Management Corrective Action: Previous audit year expenses were classified as “General” funds when they should have classified as “Food Service”. This, in aggregate, has led to an excess fund balance. Management, will work with the state on how to transfer the large arrear fund balances between accounts. Management will also endeavor to assure that all ongoing expenses are allocated to the correct fund. Responsible Person/Position: Rod Iberg/COO and Linda Heidrich/Staff Accountant

Recommendation: The City used grant funds to pay expenditures that were already requested for reimbursement from the LCDBG grant and Clean Water State Revolving Funds. The City should implement policies and procedures to ensure that expenditures are not charged to multiple federal programs. Corrective Action Plan: The City agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.

Recommendation: The City used grant funds to pay expenditures that were already requested for reimbursement from the LCDBG grant and Clean Water State Revolving Funds. The City should implement policies and procedures to ensure that expenditures are not charged to multiple federal programs. Corrective Action Plan: The City agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.

Establishing a better process for federal contract procurement and prevailing wage requirements. Working with outside consultant to ensure vendors meet the federal compliance requirements as well.

Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.

The Center did not retain the eligibility documentation for one student and there was an incorrect computation for one student. Response and Planned Corrective Action: The Center acknowledges this finding, and will take the steps necessary to ensure that the information in the system is updated regularly. Planned Corrective Action: to be implemented immediately. o The Director of Food Service will review the controls currently in place and revise accordingly to ensure that accuracy and completeness of data is maintained. o Proper documentation will be maintained by school staff and will be reviewed regularly by the Director of Food Services and or the Business Manager/Asst. Business Manager.

2023-017 Oregon Housing and Community Services Ensure review of federal cash draws are adequately documented to support the draws are for the immediate cash needs of the program MANAGEMENT RESPONSE: We agree with this recommendation. Additional training has been provided to new team members, to ensure adequate documentation exists to support immediate cash needs. Two-step verification of all draws is also required. Refresher training has been provided to staff to ensure oversight is in place at all times. The funds inadvertently drawn were corrected the first week of March 2024. Anticipated Completion Date: June 20, 2024 Contact person: Dean Criscola, Controller

Finding 2023-066 – Corrective Action Plan This audit finding refers to retroactive Medicaid billing from BHDDH for dates of service in 2022 and 2023 once the IMD status was removed from ESH. That provider type currently does not require the Medicare information to be submitted to EOHHS for processing. They bill with a type of bill and if there is eligibility on file for Eleanor Slater, the claim is paid. EOHHS will pursue a project to correct this finding. Anticipated Completion Date: To Be Determined – State Fiscal Year 2025 Contact Person: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health & Human Services hector.l.rivera@ohhs.ri.gov

Finding 2023-064 – Corrective Action Plan 2023-064a – Death reporting: Permanent system fix will deploy 28 June 2024; enhancement will trigger a 1A code from RI Bridges to send date of death to MMIS when date of death is added on a case with closed eligibility. This fix should remedy audit finding plus financial impact in the MMIS when members are not closed properly. Anticipated Completion Date: June 28, 2024 2023-064b – Death reporting addressed in response to 2023-064a. Residency/Out of State: State resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, State will benefit from future use of The Work Number Employee Address data to verify residency. Anticipated Completion Date: August 1, 2024 Contact Person: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov 2023-064c – EOHHS will identify and return any potential ineligible costs by end of the current Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2024 Contact Person: Allison Shartrand, Assistant Director, Financial & Contract Management, Executive Office of Health & Human Services allison.shartrand@ohhs.ri.gov

Finding 2023-061 – Corrective Action Plan EOHHS has met expectations on aligning the FSR and FDCR reports, has updated files to Milliman, and continues to monitor compliance. EOHHS is currently in a maintenance phase and will continue monthly oversight going forward. Anticipated Completion Date: Current and Ongoing Contact Person: Bill McQuade, Chief of Program Analytics, Executive Office of Health & Human Services bill.mcquade@ohhs.ri.gov

Finding 2023-057 – Corrective Action Plan 2023-057a – Residency/Out of State: Rhode Island resumed PARIS residency verifications and is pursuing secondary residency checks with Accruint/Lexis Nexis data and automation of manual NCOA database verification process. Additionally, the State will benefit from future use of The Work Number Employee Address data to verify residency. Income/Wage Validation: EOHHS completed implementation of an interface on 23 March 2024 between The Work Number (TWN) and RI Bridges. Contract and budget actions for TWN services are in progress with a goal of initiating TWN wage verifications in July-August 2024. Anticipated Completion Date: September 1, 2024 2023-057b – EOHHS will return any potential ineligible costs by end of the Federal Fiscal Year (FFY). Anticipated Completion Date: September 30, 2024 Contact Person: Brian Tichenor, RIBridges Medicaid Administrator, Executive Office of Health & Human Services brian.tichenor@ohhs.ri.gov

Finding 2023-044 – Corrective Action Plan 2023-044a – RIDE has developed written policies and procedures for the maintenance of AcceleGrants user accounts that will have all inactive users removed after 12 months of inactivity. Anticipated Completion Date: October 31, 2024 2023-044b – RIDE finance and IT offices will review the user complementary controls noted in the vendors most currently available SOC2 report and implement suggested controls that are deemed appropriate, reasonable, and necessary by the joint RIDE team. RIDE will have this finding resolved by December 31,2024. Anticipated Completion Date: December 31, 2024 2023-044c – Finance and IT at RIDE are working together to determine the correct schedule for regular IT risk assessments. The departments are also in the process of reviewing the disaster recovery plans for the vendor, and a vendor management plan. Anticipated Completion Date: December 31, 2024 Contact Person: Mark Dunham, Chief Financial Officer, Department of Elementary & Secondary Education mark.dunham@ride.ri.gov

Name of Responsible Individual: Vice President of Finance and Administration (David Byrd) and Controller (Michelle Lane) Corrective Action: The University concurs with the finding. The University will make disbursements as soon as they are available, but no later than the three (3) business days following receipt of funds. University policies and procedures will be followed closely to ensure there is no excess cash. All funds will be returned in a timely manner. Anticipated Completion Date: June 30, 2024

Since taking over the financial management of ELFHCC in December 2022 we have hired an auditing firm (Louis Plung & Company) to perform the 2021, 2022, and 2023 Single Audit submissions and are now up to date. Moving forward, all audits will be completed before the submission due dates each year

The Treasurer will review both the elementary and the jr high/high school lunch and breakfast counts prior to the claims being submitted to CRRS.

The Organization was fortunate to have sufficient cash on hand in order to continue to provide the highest quality of care to its residents during the COVID-19 pandemic, primarily as a result of federal and state stimulus funds, which were restricted in usage, received during 2020 and 2021. The Organization made it a priority to ensure that its staff continued to be compensated throughout the pandemic. Accordingly, the Organization kept cash on hand in order to meet the needs of the residents cared for daily and the dedicated staff who serve them. The Organization was not expecting a surplus cash situation at December 31, 2020 or June 30, 2021. Had the Organization not received stimulus funds through programs such as the Provider Relief Fund and Paycheck Protection Program, the Organization would not have had surplus cash at both December 31, 2020 and June 30, 2021. The required deposit due to the residual receipt account for the year ended December 31, 2020 was made on May 31, 2022. The Organization is currently in the process of discussing repayment terms for the deposit due for the period June 30, 2021 with its asset manager.

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #370645239 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: During our testing, there was no documentation of review and approval of the expenditure listing or lost revenue calculation. The Organization also miscalculated the portion of an expense that was reimbursed by another source.Responsible Individuals: Paul Courtney, CFO Corrective Action Plan: Management will implement internal control policies and procedures to ensure the expenditure listing and lost revenue calculation are reviewed and approved to ensure that all payments are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 30, 2024

Finding Number: 2023-005 Assistance Listing, Federal Agency, and Program Name 10.558, U.S. Department of Agriculture, Child Care and Adult Food Program Federal Award Identification Number and Year 15-016-271P-00 Pass through Entity Illinois State Board of Education Finding Type Material weakness Repeat Finding No Criteria Per 2 CFR 200.303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal 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 Organizations of the Treadway Commission (COSO). Other requirements include: a) Per 7 CFR 226.10(c)(1), prior to submitting its consolidated monthly claim to the State agency, each sponsoring organization must perform edit checks on each facility's meal claim; per 7 CFR sections 226.16(g) and (h), a sponsoring organization must disburse advance and meal reimbursement payments to centers and day care homes under its sponsorship within five working days of receiving them from its state agency. b) Per 7 CFR 226.15(f), each sponsoring organization of day care homes shall determine which of the day care homes under its sponsorship are eligible as tier I day care homes c) Communication from the passthrough entity to return to pre COVID 19 monitoring, as required under 7 CFR 226.16(d)(4)(iii), effective October 1, 2022, where sponsoring organizations are required to perform onsite monitoring of each of its facilities three times every year, which includes requirements to ensure the amount of time between reviews does not exceed six months (unless review average is used). Condition A lack of documented controls as evidence of supervisory review and segregation of duties to ensure compliance with Federal program requirements, specifically over: a) monthly expenditure reports submitted to the passthrough entity b) tier (day care home eligibility) determinations c) subrecipient monitoring Questioned Costs None Identification of How Questioned Costs Were Computed N/A no instances of material noncompliance noted that would result in questioned costs Context a) During testing a sample of 5 monthly expenditure submissions, we noted no formally documented supervisory review in place. Additionally, during testing of 40 disbursements to providers, we noted no formally documented supervisory review to ensure disbursements to providers are made within 5 working days of receipt from the State passthrough entity. b) While gaining an understanding of controls over tier (day care home eligibility) determinations, we noted no controls established to ensure supervisory review of these determinations. c) While testing a sample 40 provider monitoring visits, we noted 3 visits without evidence of supervisory review and 6 visits where the visit was completed and validated in the software by the same individual. Additionally, we noted 16 day care homes and 2 day care centers with less than the required 3 annual on site monitoring visits for the year, and 15 day care homes and 2 day care centers where onsite monitoring performed were more than the required 6 months apart. Cause and Effect A lack of effectively designed, implemented, and operating controls in any of these areas could result in a material noncompliance with program requirements or Uniform Guidance. Recommendation We recommend management formalize documentation of a supervisory review of: a) monthly expenditure submissions before submitting to the passthrough entity, including documented supervisory controls to ensure disbursement timeliness is met within 5 working days as part of this review; b) of data used in making tier/eligibility determinations for accuracy and completeness; and c) of subrecipient monitoring. Additionally, we recommend management work with its passthrough entities to confirm compliance requirements, especially when compliance requirements change as the result of ending or expiring waivers and flexibilities. Planned Corrective Action Plan –Organization will document process that is used for second review of the monthly expenditure submissions by 04/30/2024. There are no instances of the Organization not providing funds to provider within the mandated 5 days, however, the Organization will document the process for provider payments within 5 days by 04/30/2024. The software required to be used by the funder for management of the program does have limitations on how the data input for making tier/eligibility determinations second review is documented. Organization will design process to document this second review has occurred by 04/30/2024. Staffing shortages coming out the COVID-19 waivers resulted in the inability to perform all required Subrecipient monitoring. This staffing shortage was rectified by 08/31/2023. Contact person responsible for corrective action: Loukisha Pennex, Chief of Youth and Family Potential, Anjanette Brown, CFO and Teresa Rodriguez, Senior Director of Grants and Contracts. Anticipated Completion Date: April 2024

FINDING 2023-007 Compliance Requirement(s): Non-Profit School Food Service Accounts Audit Findings: Material Weakness, Other Matters Summary of Finding: There was no documented control in place over the receipt of monthly meal reimbursements. One individual received notification of deposit, received funds into accounting software, and prepared bank reconciliations. There was no documented review of the receipt of monthly meal reimbursements by a second individual not involved in the original receipt process. Views of Responsible Officials: We Concur with this finding. Description of Corrective Action Plan: The Business Manager and Cafeteria Manager will meet monthly to review the deposit statement from the bank to verify all deposits are accurate and accounted for the Food Service Fund. The bank statement will be initialed by both parties and retained on file in the business office. Anticipated Completion Date: Immediately

FINDING 2023-006 Compliance Requirement(s): Reporting Audit Findings: Material Weakness, Other Matters Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Reporting There was no documented control in place over the review of monthly reimbursement claims. Claims were prepared and submitted by one individual without documentation that they were being reviewed by a second person not involved in the original process. The lack of controls resulted in overstatements in the number of meal counts used for reimbursement purposes when compared to School Corporation supporting documentation. Views of Responsible Officials: We Concur with this finding. Description of Corrective Action Plan: The food service director will enter the claims into CNPWeb Claim reimbursement site using the information from the Point of Sale system reports for reimbursable meals. The Business Manager will then confirm the meal counts before submitting the Claims. The FSMC food service director meets with the Superintendent monthly to review all claims and food service financials. A meeting agenda will be signed by all parties involved and retained on file in the business office. Anticipated Completion Date: Immediately

UWGC has developed a procedure to ensure that prior to submission of invoices to federal awarding agencies, management prepares a monthly analysis based on 211 call logs to support the actual amounts allocated across all programs and invoiced to the awarding agencies that are reconciled to payroll reports, which then will allow UWGC to present evidence that all hours submitted for reimbursement are supported with the appropriate allocation. The process will include management staff from both 211 and finance departments thus maintaining internal controls. Additionally, this procedure will be reviewed at least annually by both departments as it relates to the allocation methodology to ensure that its appropriate given changes in the program and workforce.