Corrective Action Plans

ORCCA's current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are currently implementing this internal control at the program level to document the information and proper coding to the correct period. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

ORCCA's current process at the program level has improved to ensure proper documentation of eligibility. The Housing director and staff have implemented this internal control at the program level. The finance department's internal control (as noted earlier) is in place to ensure the payment requests have sufficient supporting documentation. As for record retention, ORCCA hired additional temp workers to ensure completed transactions are filed timely with the goal of going paperless in the near future. Responsible party: Bonnie Foroudi, Finance Director Estimated completion date: December 31, 2025

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2022 Finding: 2022-014 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Corrective Action for Findings 2022-012, 2022-013, 2022-014 also apply to the State Award findings. Section IV - State Award Findings and Question Costs April 11, 2024 Heather Starr Thomas, Medicaid Supervisor Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. Section III - Federal Award Findings and Question Costs (continued) 137

Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. April 11, 2024 Section III - Federal Award Findings and Question Costs (continued) N/A - Caseworkers will adhere to the policy in Administrative Letter 13-23.

Finding: 2022-012 IV-D Non-Cooperation Name of contact person: Corrective Action: Section II - Financial Statement Findings (continued) As noted in Findings 2022-001 and 2022-006, the county finance staff is diligently working to improve the timeliness of transaction processing and anticipates timely completion of the FY24 audit which will resolve this finding. Melissa Miller, Interim Finance Officer Heather Starr Thomas, Medicaid Supervisor At the time the determinations under audit were completed this was a requirement. However, under current policy referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). This became effective August 18, 2023. Please see Administrative Letter 13-23.Proposed Completion Date: Finding: 2022-013 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. April 11, 2024 Section III - Federal Award Findings and Question Costs (continued) N/A - Caseworkers will adhere to the policy in Administrative Letter 13-23.

Thank you for bringing this to our attention. There were several factors that contributed to the difficulties we encountered submitting the required quarterly reports and have since remedied those issues. The Human Services Department has worked with Treasury on the challenges we encountered uploading the required reporting templates and we now has multiple people with access to the reporting portal and in the event of staff turnover we can continue to submit required reports. The Human Services Manager and the Budget and Finance Analyst have created reminders on their calendars to ensure reporting is completed on time and with accurate data.

Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town does not have policies and procedures in place to ensure that they do not contract with or make subawards to parties that are suspended or debarred. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action The Town will review the district’s suspension and debarment policy and make sure that it is following the criteria as set out in the 2 CFR sections 200.213. The policy will then be updated and communicated to all personnel involved in the procurement process. Name of Contact Person Robert J. Civetti, CPA, Finance Director Projected Completion Date June 30, 2025

Temporary Assistance for Needy Families (TANF), CFDA #93.558, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review. Recommendation: As per Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the TANF Program, should have a completed eligibility determination on file which is available for audit review. Corrective Action: PCBSS have created a DIMS unit, where files are scanned and stored in DIMS. Implementation Date: Commenced 2022 and ongoing.

Medical Assistance Program (Medicaid, Title IXI), CFDA #93.778, Grant Period 1/1/22-12/31/22. There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review. Recommendation: As per Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the Medicaid Program, should have a completed eligibility determination on file which is available for audit review. Corrective Action: PCBSS have created a DIMS unit, where files are scanned and stored in DIMS. Implementation Date: Commenced 2022 and ongoing.

Recommendation: Strengthen controls over compliance, reporting, and cost allocation. Action Plan: - Immediate Actions (Q2 2024): - Review and document grant compliance requirements. - Implement a structured approval process for financial reports. - Long-Term Actions: - Conduct quarterly compliance training for grant managers (Q3 2024). - Engage an external consultant for a mid-year compliance review (Q4 2024). Responsible: John Opalinski Completion Date: Within 3 months of CAP issuance.

Views of Responsible Officials and Planned Corrective Action: To address the issue, the management will develop and document a clear policy for obtaining and retaining eligibility documentation. This policy should outline the specific types of documentation required and the procedures for collecting and storing them. Set up a monitoring and reporting system to track the status of eligibility documentation. Regularly review reports to ensure that all required documentation is up-to-date and complete. Anticipated Date of Completion: Ongoing analysis; expected to be completed by December 1, 2025.

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The affected files relate to clients that have been on the program for decades and as files get large, archiving takes place. To correct this finding, a directive will be issued to staff that will ensure that when files are archived the original application must be placed in the current working file going forward. Diana Ruiz, Interim Director of Housing Programs, will be responsible to implement this corrective action by June 30, 2023.

Management agrees with the finding and has developed a set of policies and documented them. The Business Manager has implemented the changes as of June 2023.

PayChex is GCI's payroll provider and automates the GCI employee onboarding process, including having new employees complete the applicable hiring forms. GCI has directed PayChex to ensure that all new employees complete the required payroll forms prior to starting work at GCI. Estimated Correction Date March 1, 2025.

Reporting - Material Weakness in Internal Control over Compliance and Noncompliance Deemed not Material Identification of the Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - 93.498. Finding Summary: The Authority tracked patiet care revenues internally within a spreadsheet. The calculations of revenue by payor within the spreadsheet and included in Period 2 report to HRSA, which are utilized to calculate lost revenues, contained errors. Responsible Individual: Dawn Ballard. Corrective Action Plan: While there were errors in the reported net patient revenue by payor for specific quarters, the total net patient service revenue, by quarter, was accurately reported and did not impact the calculated lost revenue. Management believes that the control process in place is sufficient to identify material errors in reported amounts. Anticipated Completion Date: January 15, 2025

Management agrees with the auditors’ findings and has implemented policies and procedures to improve recording accuracy of grant funds, including ensuring that all finance staff are properly trained. A guide will be created for current and future staff.

Auditee Response: The auditee agrees with the finding. This was a perfect storm of events that created this scenario including COVID requiring the discontinuation of our Point of Sale (POS) System, tally sheets by classroom being used in place of that system, a change in head cooks during the year, and a failure to communicate properly between the Director of Food Service and the new Head Cook. Action Taken: The district has and will reinstitute the use of its POS system so that a child purchasing lunch types in their number and it is credited to that child's account. This system can then be used to track meal purchases throughout the day, week, or month. Since the HeadStart classroom are not MWSD students, they do not have numbers within the system. The Director of Food Services will use this system to report meal purchases and reimbursement rather than rely on head cooks and their tally sheets. Despite this, training should be conducted annually with all head cooks as to the qualifications of a reimbursable meal within the school district, so as to provide a fail safe in the event the POS system goes down for a period of time. Timelines/Contract: Most of this has taken place already in that we have returned to using a POS system. This system has the ability to track data and run reports, so it makes it error free when available. However, people ultimately must have the knowledge too so that they understand the parameters of a reimbursable meal should the system go down. Therefore, annual trainings will be instituted regarding such operations effective immediately. The Director of Food Service will be directed to use one in-service day annually for the purpose of teaching all staff members about reimbursable meals and how the HeadStart Programs fit into that. This should be completed no later than fall of 2025. The contact person would be Joe Stroup, Superintendent.

Responsible Persons: Director of Community Support, Executive Director, Case Managers Anticipated Completion Date: February 1, 2025 / On-going Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and fully agrees with the recommendation to enhance the design of our control activities to ensure that CSBG participant files are adequately maintained, and to strengthen controls surrounding management review of participant files during intake process. Case Managers are responsible for initiating and developing participant files for the purpose of determining eligibility for the CSBG Program. Once the file has been developed and the participant deemed eligible for assistance, the file is forwarded to the Director of Community Support for additional review and approval. Only after the file has been approved by the Director of Community Support or Executive Director will the payment request/transmittal be submitted to the Fiscal Department for processing of payment. The Fiscal Department will not process any transactions or transmitt als without the required signature approval from the Director of Community Support or Executive Director indicating the participant is eligible for benefits.

The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions

The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions.

County Commission gave former County Manager direction to consult with legal counsel to determine premium pay for County staff who worked throughout the Pandemic. A meeting was held between Former County Manager, Financial Specialist, County Sheriff and VMDC Warden to discuss premium pay for all staff as well as public safety recruitment and retention. Former County Manager stated after consulting with County Legal Counsel and NMC General Counsel, all County staff including, Elected Officials were eligible to receive “premium pay” in compliance with the American Rescue Plan Act Rule. Financial Specialist and County Sheriff questioned the eligibility for Elected Officials to receive premium pay referencing N.M. Const. Art IV, section 27 “No law shall be enacted giving any extra compensation to any public officer, servant, agent or contractor after services are rendered or contract made; nor shall the compensation of any officer be increased or diminished during his term of office, except as otherwise provided in this constitution.”, and NMSA 4‐44‐4.1 related to County Elected Official Salary caps. Former County Manager responded premium pay should be issued to all staff including Elected Officials through the accounts payable department instead of payroll to avoid violating New Mexico Constitution and State Statute and premium pay is not considered a salary increase but “premium pay” outside of regular salary paid to “essential workers”. Former County Manager went on to explain that all law enforcement officers were eligible for premium pay because they were described as “essential” within the American Rescue Plan Act Rule. In a regular Commissioner Meeting held on 10/12/2021 Former County Manager presented to Commission and recommended approval of public safety recruitment and retention plan as well as a one‐time payment to current staff of $5,000 who worked from January 2020 through October 2021 and a prorated rate be awarded to any employee that worked a portion of that time. She also stated new information was received that confirms all County employees are eligible for the premium pay, currently 88 employees. She also stated that public health contractors are also eligible for premium pay and recommended payment be made to 2.5 full time positions to contracted health care services provider. Commission approved the request from the Former County Manager based on her recommendation. Former County Manager drafted, reviewed and approved a list of employees scheduled to receive payment including 5 contracted medical service provider including the CEO of the company. Former County Manager directed accounts payable clerk to issue payment through accounts payable. On November 8th 2021, Former County Manager presented to and recommended approval additional premium pay be awarded to Employees that had retired and worked part of the period of January 2020 though October 2021 and two full time Employees that were laid off. In January 2022 Elected Officials requested a meeting be held to discuss the issuing of 1099 forms to employees who received premium pay. Also present in the meeting was Commission Chairman. Elected Officials raised concern that staff was issued a 1099 and questioned if this was correct. Former County Manager informed staff the advice the County got was to issue a 1099‐NEC, under the circumstances. However, upon review of email communication former County Manager received an opinion from her personal Tax Accountant stating that the payments should have been run through payroll and recommended Former County Manager either correct the original error and would require several steps including corrected 941’s and corrected w‐2’s or issue a 1099 NEC. Former County Manager directed accounts payable clerk to issue a 1099 NEC. Commission Chairman questioned several expenditures from American Rescue Plan Act Fund, including the additional 2 full time positions and CEO of the company not approved by Commission, it was later determined that several expenditures were not allowable under the American Rescue Plan Act Fund Rule. Colfax County Staff submitted written report to Office of the State Auditor as required under NMSA 1978, Section 12‐6‐6 (criminal violations) an agency or auditor shall notify the state auditor immediately, in writing upon discovery of any violations of criminal statute in connection with financial affairs. Former County Manager announced her resignation February 28, 2022. It was later discovered through communication with County legal Counsel and NMC General Counsel that Former County Manager mislead the County Commission, Elected Officials, and County Staff and did not consult with County Legal Counsel or NMC General Counsel as previously stated and as directed by the Commission before making recommendations for approval of American Rescue Plan Act Funds.

Identification of federal programs 10.558 and 21.027 – Child and Adult Care Food Program (CACFP) and Child Care and Development Block Grant (ARPA) Condition The Organization did not retain eligibility documentation for each site noting the control process. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

Finding Number: 2022-002 Condition: WakeMed charged costs associated with ineligible individuals to the grant. Planned Corrective Action: WakeMed identified all HRSA patients with other documented insurance within the system. Each claim was reviewed to identify patients with active insurance coverage. Patients identified with active insurance coverage were considered ineligible for grant purposes, and the HRSA payments are in the process of being refunded. These costs were removed from the SEFA. In addition, WakeMed has written off all outstanding HRSA claims. Contact person responsible for corrective action: Terry Flynn, Director, Reimbursement Anticipated Completion Date: 06/14/2023

Finding 2022-009 Lack of Internal Control over Compliance Eligibility Type of Finding: Material weakness in internal control over compliance and material noncompliance Name of Contact: Jana Rae Koenig, Executive Director Corrective Action Plan: The Native Village of Point Hope will adhere to the grant agreement and Administrative Management System Manual Chapter III: Financial Management and Chapter VI: Records Management to ensure that all proper documentation is recorded and kept on-file and that authorized personnel are selected to receive program services. Proposed Completion Date: Before the end of the next audit cycle.

The Organization has created a process to move all documents to cloud based storage, including recipient agency contracts for USDA and proof of tax-exempt status under Internal Revenue Code 501(c)(3).