Corrective Action Plans

Unallowable Costs Criteria: The Organization must submit only allowable costs for reimbursement under the accounting principles contained in Uniform Guidance. Condition: During compliance testing, it was noted that one out of twenty five selections improperly included alcohol in the balances submitted for expense reimbursements. Context: One expense reimbursement was found to have reimbursed alcohol. Cause: There was a lack of consistent review of the receipt before submission for expense reimbursement. Effect: As a result of the condition, one reimbursement was overpaid. Recommendation: In the future, the Organization should review reimbursements closely to ensure unallowable costs are not submitted for reimbursement. Contact: Erin Spaulding, Senior Director of Finance. Corrective Actions Taken or Planned: Management acknowledges the finding and will take action to ensure that no unallowable costs are being reimbursed.

2023-001 Utility Allowances Calculations Corrective Action Plan: If the family selects a unit with a different number of bedrooms than the family unit size listed on the voucher, the PHA must apply the payment standard and utility allowance for the smaller of the family unit size listed on the family's voucher or the unit size selected by the family. 24 CFR 982.S0S(c)(l) Anticipated Completion Date: Management will implement training and procedures to ensure compliance with federal guidelines that relate to the Housing Choice Voucher Program. Training and procedure reviews are currently in progress and will be ongoing.

Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2024

Federal Aid Policies Finding 2023-002 Auditor Description of Condition and Effect: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. As a result, the Authority is noncompliant with 2 CFR 200. Auditor Recommendation: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Corrective Action Plan: The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

El Proyecto will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. El Proyecto will continue to provide ongoing training to clinic staff who evaluate the sliding fee application at its clinic locations. The training will consist of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. Person Responsible: Leticia Vasquez Position of Responsible Party: Billing Manager Completion Date: September 30, 2024

Finding 2023-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20232575-00, E20233017-00, E20233431-00 Award Year End: September 30, 2023 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Organization will establish the necessary policies and procedures to require the documented review and approval of all indirect calculations, cash management requests for funds and performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2024.

2023-006 – ALN 14.872 – Public Housing Capital Fund Program – Cash Management Planned Corrective Action: The Interim Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Christy Amacher, Interim Executive Director Anticipated Completion Date: September 30, 2024

Findings Related to the Financial Statements Reported in Accordance with Government Auditing Standards None Findings Related to Federal Awards 2023-001 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: U.S. Department of Homeland Security: Passed through the State of New Jersey, Department of Law and Public Safety Program Titles and Assistance Listing Numbers (ALN): Disaster Grants – Public Assistance (Presidentially Declared Disasters) – ALN 97.036 Federal Grant Numbers: State of New Jersey pass-through number: UH1WX, Project Worksheet #1822 – Award Year 2023 (Application 553330) Contact Person: Donna Wilser, Deputy Executive Director, 732-750-5300 Corrective Action: Management agrees with the finding. We are committed to strengthening our processes to ensure that all physical timesheets related to FEMA-declared disaster events are properly maintained and readily accessible. To achieve this, we will implement enhanced procedures and controls to ensure full compliance with the Uniform Guidance requirements. Anticipated Completion Date: December 1st, 2024

Finding 2023-014 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS originally expected to have all cases corrected at the end of the PHE unwind (July 2024), however, due to some of the mitigation strategies that CMS developed to ensure children did not lose eligibility, not all cases had their coding updated when they were renewed. MDHHS expects that all existing cases will be updated by May 2025, as MDHHS completes renewals for existing cases. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children’s Health Insurance Program (CHIP) in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing the Community Health Automated Medicaid Processing System (CHAMPS) payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date May 2025 Responsible Individual(s) Brant Cole, MDHHS Logan Dreasky, MDHHS Erin Emerson, MDHHS

Finding 2023-053 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Timeliness of Cash Draws Management Views LEO agrees with the finding. Planned Corrective Action LEO has filled a staff vacancy which previously contributed to late draws. Also, LEO will implement additional staff training and management oversight to ensure reimbursement requests are made timely and in accordance with CMIA. Anticipated Completion Date September 30, 2024 Responsible Individual(s) Lora MacKay, LEO

Finding 2023-009 Treasury - Recertification of Clearance Patterns Management Views Treasury agrees with the finding. When the Cash Management Improvement Act (CMIA) program transferred to Treasury FSD in early 2022, there was a lack of well-documented procedures on how to complete program clearance pattern reviews. FSD created a procedure for the review process, but it is not complete. Planned Corrective Action Treasury FSD will continue to gain a better understanding of the clearance pattern review process and thoroughly document the procedures for future fiscal years to ensure compliance with federal regulations. FSD will research how the clearance patterns are determined for each program, identify which programs require clearance pattern review each year, ensure that the SIGMA BI queries are functioning properly for each program under review, and clarify how to interpret the BI query results. Anticipated Completion Date September 2024 Responsible Individual(s) Melanie Alvord, Treasury Lauren Markwart, Treasury

Finding 2023-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action EGLE’s Water Resources Division’s Administration staff reviewed the existing process with staff conducting the administrative review to ensure the technical review will be completed in advance of making any payment. If Administration staff have received a request for payment without the technical review, Administration staff will forward all documents received to the project manager to obtain the technical review. Once the technical review has been completed, Administration staff will conduct the administrative review and process the payment request. Additionally, EGLE subsequently reviewed the reimbursement request noted in the finding to ensure that the cumulative totals requested have been for projects that are consistent with the grant award. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE

Finding 2023-006 MDE, Security Management and Access Controls Management Views The Michigan Department of Education (MDE) agrees with the finding. Planned Corrective Action For part a., as part of the Michigan Nutrition Data (MiND) 2.0 Implementation Project, MDE will institute a mechanism to capture the person to whom the access has been delegated. MDE will review the policies and procedures with department staff that is responsible for security access controls for the Next Generation Grant, Application and Cash Management System (NexSys) to ensure proper access control policies are followed. For part b., MDE will update policies and procedures to ensure review of all accounts on a semi-annual basis. For parts c. and d., MDE will continue to work with DTMB to find more efficient ways to ensure all non-privileged users are recertified and improve the technical solution to deactivate users after 18 months of inactivity. For part e., as part of the movement of the grants management unit at MDE to a different office, MDE is reviewing the policies around high-risk transactions and will update the policies to meet established standards. Anticipated Completion Date October 1, 2024 Responsible Individual(s) David Judd, MDE

Finding 2023-021 SNAP Cluster, ALN 10.551 and 10.561 - EBT Reconciliations Management Views MDHHS disagrees that a material weakness and material noncompliance exist. MDHHS federal reporting conducts a daily reconciliation of federal draws and authorizations to retailers based on vendor EBT reports. In addition, MDHHS conducts a monthly reconciliation between Bridges, Bridges data warehouse, and vendor EBT reports using daily data to ensure the client information in Bridges and Bridges data warehouse is accurate. The monthly reconciliation process does not impact the federal draw because the daily reconciliation of the vendor EBT report is used for this purpose. MDHHS provided detailed and accurate descriptions of MDHHS daily and monthly EBT reconciliations to the designated federal awarding agency contacts at the United States Department of Agriculture Food and Nutrition Service Agency that are familiar with MDHHS processes and received confirmation that the current reconciliation processes in place are sufficient to comply with federal regulations. Planned Corrective Action MDHHS disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Sara Gross, MDHHS

Based on prior year (FY22) findings, the City established the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment. Four of the 19 sampled payment requests were received or processed after receipt of the FY22 audit findings, and all of those requests for reimbursement were paid within 30 days of receipt.

2023-003 Finding - Federal Award - Significant Deficiency - Reporting US Department ofCommerceAL#11.611 Context and Cause - The Organization was not made aware by grants, CMTC or prior auditors that the final upload package of the federal reports and requests for reimbursement should have internal control oversight procedures and did not exercise such oversight. Only one individual was responsible for preparing and filing these final documents after such details were reviewed individually throughout the month by other individuals responsible for that review. The payroll time sheet review process was consistently followed, however, and there is not a process for the final processed payroll rep01ts to be reviewed by a second individual.Recommendation: We recommend management implement procedures to ensure the Uniform Grant Guidance and the Compliance Supplement requirements for controls over Reporting, Allowable Costs, and Cash Management are designed and performed. The month­ end checklist currently being used is a good start, and this could be enhanced by adding sections for the above items, and having specific individuals' initial and date on the checklist when the procedures are completed. A fiscal policy and procedure manual would also be a good tool. Action Taken: Manex will update fiscal Policy to include oversight on reporting to funders

In Finding 2023-005, a condition was noted that during the year, the Organization made a draw of federal funds that were not disbursed in a timely manner for program expenditures. Management recognizes the importance of the requirements to disburse federal funds in a timely manner. In response to Finding 2023-005, procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization.

Finding 2023-002 Condition The Organization did not have timely approval of non-payroll expenditures to support preparation of reliable financial reports to grantors. Corrective Action Plan Corrective Action Planned: Improvements have already been made to this process in the current year regarding the timely submission of supporting documentation and authorization and this will continue to be an area of focus in both operations and finance. Name(s) of Contact Person(s) Responsible for Corrective Action: The Director of Accounting, Dawn Bonderczuk, and the Account Payable Clerk or Accountant. Anticipated Completion Date: July 31, 2024.

As noted above, The Trust for Tomorrow continues to add compensating controls each year when possible. For example, a Director of Financial Operations was hired during the last half of the fiscal year under audit and this individual has taken over certain responsibilities, including but not limited to general ledger coding, review and approval of invoices, processing timesheets, and handling expense reimbursement requests. Further, we will continue to review our processes to determine where duties can be segregated amongst existing staff. Additionally, the board will continue to provide close oversight of the Organization and evaluate that oversight on a consistent basis.

Management of the Organization concurs with the audit finding. The Organization has provided increased training to the providers to ensure correct documentation is kept. The Organization has implemented a policy where providers are required to have a CACFP Binder where all required forms, including original enrollment forms and annual renewal forms, will be stored and must be available for review. Children with missing forms will have meal reimbursements disallowed until forms are completed correctly. These binders will be checked during the monitoring reviews.

We concur. According to previous findings, daily expenditures have been recorded into the general ledger as they occur and reconciled in a timely manner monthly. Adjustments will be recorded into the general accounting system daily, after a review by the Executive Director on completion of entries by the Office Manager. In corrective action steps already in place from the previous year’s findings, adjustments have been recorded in the general accounting system and accounts have been reconciled in a timely manner.

We concur. According to prior audit findings, the implementation of new accounting policies, including all expenditures, funds, and monthly bank statements, have been reviewed by the Executive Director and Office Manager in a timely manner. Since the previous year’s findings, all accounts have been reviewed and compared to the requested funding amounts, utilizing drawdown worksheets, two-person verification, and actual expenditure amounts entered within the accounting system. As a corrective measure, a printout from the accounting ledger page will be attached to each invoice or expenditure for comparison of the amount charged to the amount requested from each grant.

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