Corrective Action Plans

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

The Department of Community Affairs (DCA) has recently implemented timely reporting of required FFATA subaward data in the Federal Subaward Reporting System (FSRS). The FFATA reporting process is fully documented, and additional staff have been hired and trained on the process to further support the federal reporting functions. The FFATA reports identified by the auditors with inaccurate subaward amounts reported have also been corrected in FSRS. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

Based on the Corrective Action Plan (CAP) developed for the prior year FY 2022 audit finding cited for FFATA reporting, the Department of Health (DOH) Grants Unit, with coordination from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) fiscal staff, added a new function to the System for Administering Grants Electronically (SAGE) that pulls all subaward data for the ELC program using the program’s 93.323 federal Assistance Listing Number (ALN). Thus, the CAP implemented in September 2022 for the prior year FY 2022 audit finding includes SAGE now pulling the subaward data for the entire ELC program by the ALN number and enables the ELC fiscal staff to access all ELC subawards within the DOH. ELC fiscal staff also has a task reminder set to report at the end of each month, enter subaward information into the FFATA Subaward Reporting System (FSRS), and upload each report submitted to the SharePoint ELC Document Library at the end of each month. As per the original CAP created under the FY 2022 audit, FFATA information for ELC subawards were entered into FSRS beginning on September 1, 2022 and DOH actions and efforts have continued to ensure compliance going forward. COMPLETION DATE/ CONTACT PERSON April 10, 2024 Rina Warehall (609) 913-5300 Rina.Warehall@doh.nj.gov

The Department of Health’s (DOH) Vaccine Preventable Disease Program (VPDP) is in compliance with the Federal Funding Accountability and Transparency Act (FFATA) requirements with regard to reporting all active first-tier subawards of federal COVID-19 funds that DOH divisions have issued totaling $30,000 or greater under this Cooperative Agreement and COVID-19 Supplemental. However, it is not in compliance with regard to reporting required subaward data in FSRS by the end of the month following the month in which DOH has made the subawards totaling $30,000 or greater. The VPDP will continue to follow the DOH policy set forth in FMC 22-05 and report to FSRS all active first-tier subawards of federal COVID-19 funds DOH divisions have issued at $30,000 or greater under the COVID-19 Supplementals. The VPDP fiscal/grants leadership team will strive to ensure each of the identified subawards is entered on the FFATA Subaward Reporting System (FSRS) website by the end of the month following the month that DOH has made the subawards. VPDP will continue its efforts to bring the gap in reporting to FSRS down from five months presently to within the specified FFATA submission deadlines denoted above. VPDP also has on boarded a full-time Contract Administrator 2 who will be responsible for reporting FFATA data into FSRS for the Immunization Cooperative Agreement. COMPLETION DATE/ CONTACT PERSON April 4, 2024 Susan Barcarola (609) 943-5302 Susan.Barcarola1@doh.nj.gov

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely. This noncompliance finding is not due to a lack of controls within NJDOE but lies squarely on system issues at SAM.gov and the FFATA Subaward Reporting System (FSRS) sites and until the issues listed below are corrected on these federal system sites, NJDOE will continue to be noncompliant with timely FFATA reporting. Issues with the SAM.gov and FSRS sites: • SAM.gov has approved NJDOE’s local education agency (LEA) registrations without a ZIP+4, but FSRS reporting system for FFATA uploads requires ZIP+4 for each LEA. The two systems use the same database, which means information registered on SAM.gov feeds directly into the FSRS system. However, because FSRS batch uploads require a ZIP+4, those LEAs that were approved by SAM.gov without a ZIP+4 during the registration process, are rejected from the FFATA report batch upload. There is an option to manually load each LEA and their details into the system, but the process becomes incredibly time consuming, given the 700+ LEAs in the state, the number of federal awards granted, and the steps for identifying & removing rejected LEAs from the batch upload. • Issues NJDOE has with SAM.gov and FSRS have been shared with the federal helpdesk and a USED representative without avail, as the systematic issue remains unresolved and continues to delay our FFATA reporting process. • There are several rural LEAs in the state that do not have a ZIP+4. These LEAs will continue to be rejected from the batch upload, delaying our FFATA reporting process, if SAM.gov and FSRS do not come up with a viable solution. • There were a number of LEAs that were continuously rejected from the upload by FSRS for no obvious reasons. The error message received was the same exact error we receive for incorrect zip codes. After spending much time investigating the cause with the helpdesk support, it was identified that FSRS did not update their system to reflect the Congressional District code changes during New Jersey’s redistricting process. • The FSRS system rejects batch uploads if a single lower-case SAM UEIs is entered in the batch file. However, SAM.gov search box and the FSRS manual uploads are not case sensitive. Batch uploads are the only place where SAM UEIs are case sensitive. Further, this information is not included in any of the FSRS User Guides or manuals. I have shared this with the FSRS helpdesk, but no solution was provided. Again, this discrepancy in their system affects and delays our FFATA reporting processes. NJDOE dedicated personnel, including the director of OGM, continuously work with SAM.gov, FSRS system, and both system sites’ help desks, to bring to light the issues mentioned above in order to express the urgent need for corrective actions at the federal system sites to allow for timely FFATA reporting. In addition internal controls and procedures are in place at NJDOE related to FFATA reporting and corrective actions are constantly performed in real time to perform the below NJDOE Internal Controls and Procedures. Some of these procedures include reviewing internal SAM applications and troubleshooting with NJDOE’s local education agencies (LEAs) to correct data in the application and resubmit to the federal reporting system sites with more detail included below. NJDOE Internal Controls and Procedures: • Due to the large number of LEAs in the state (700+), each FFATA report must be submitted via batch upload, which saves an enormous amount of time it takes to input data manually for every single LEA, for every grant. To address this need and to expedite the process, our vendor has created a reporting tool that generates a FFATA batch report. • We have been contacting the federal helpdesk to address the issues on their sites and asking for support. Some of those tickets were closed without providing any support and most were not helpful. • We have created and implemented an in-house System for Award Management (SAM) application, mandatory for all of our federal grant recipients. This was done specifically for FFATA reporting purposes to ensure data in these applications are directly tied to the FFATA batch reports. • The SAM applications go through a thorough review process, where data entered by the districts is compared with the data registered with SAM.gov (applicants are required to upload a copy of their Entity Overview Record, issued by SAM.gov). • SAM applications are returned for changes whenever an applicant has entered data that is inconsistent with data on SAM.gov (i.e.. Incorrect SAM UEI, incorrect zip code, incorrect zip+4, incorrect City name). • We have asked many of our districts to contact SAM.gov and update their physical address information to include the full 9-digit zip code, which was SAM.gov reviewers’ oversight. Our school districts have commented that this process can take months. • We are communicating with our districts/applicants on a daily basis through the review summary checklist, outlining the changes that must be made, as well as by email and phone. • We have implemented an automatic messaging system, where applicants are reminded to update their SAM registration expiration date, multiple times a month leading up to their expiration date. Due to the system discrepancy in the FSRS system’s batch upload, we had to create a workaround pertaining to the district’s SAM UEIs. As stated above, SAM UEIs, in batch FFATA reports, are case sensitive while not case sensitive anywhere else in the two system sites. We have updated our instructions in NJDOE’s SAM application and have added another layer of application review, to ensure that all UEIs entered are in all capital letters. Because the federal helpdesk has ignored this discrepancy and did not resolve the issue, we are obligated to take additional steps and spend additional time on FFATA batch reports. COMPLETION DATE/ CONTACT PERSON Indeterminate – Completion based on federal implementation of fixes to SAM.gov and FSRS portal as noted in views. Martin Egan, Director NJDOE Office of Grants (609) 376-9089 Martin.Egan@doe.nj.gov

The Department of Labor and Workforce Development (DLWD) transitioned from a manual contract agreement process to a web-based grant administration system in recent years that employs the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Reporting Unit has access to these automated systems and monitors them on a monthly basis to identify when new subaward contracts/agreements are approved in order to report required data in the FFATA system timely. DLWD corrective actions regarding FFATA reporting are expected to be fully implemented as of June 30, 2024. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) will continue to review and enhance controls to ensure that BAM quality control case investigations are completed timely, that reviews are signed as required by appropriate staff, and that all required case review supporting documentation is maintained in case files. DLWD corrective actions will be completed by September 30, 2024. COMPLETION DATE/ CONTACT PERSON September 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD implemented a new process that allows staff to electronically obtain signatures through Simpligov, beginning June 2023. This process requires that staff obtain all necessary signatures before a RESEA claimant record is completed. Supervisors are assigned to monitor this process in order to mitigate the risk associated with missing information on any single RESEA customer registration. DLWD will monitor this process to ensure that all interviews are properly documented, and forms are signed and electronically uploaded to its electronic case management system of record for future reference. During the initial rollout of this process, there were records that didn’t migrate to the case management system of record. This issue has now been addressed through training. DLWD has also developed dashboards that will assist with monitoring data entry. Monthly reviews of RESEA data entry will be conducted to identify possible errors. These RESEA process changes that will be implemented by DLWD will ensure compliance with regulatory standards and assist with maintaining the integrity of its data management process. COMPLETION DATE/ CONTACT PERSON June 30, 2023 Baden Almonor (609) 777-1042 Baden.Almonor@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not. For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program. DLWD corrective actions related to FPUC and PUA payments were fully implemented as of September 2023. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

Out of over 182 compliance records requested, the organization was unable to provide 3 health assessments, all other requested documentation was provided. The missing health assessments were for high school students, who are not required to provide them to attend school and often do not have access to updated health assessments. We have been directed by the funding agency never to exclude these youth from participation for an inability to obtain a health assessment. BGCP has already taken steps to address these issues. The funding agency, PHMC has begun sending monthly compliance reports. Over the last three months, we have collected 42% of missing health assessments organization wide. Additionally, on our recent FY24 Admin review from PHMC, which included a full compliance report, all of our sites received overall scores of above 95%. We will continue to monitor compliance and follow-up with youth and families to complete needed items.

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.

March 28, 2024 Nance County, Nebraska, respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Period: July 1, 2022 through June 30, 2023 The findings from the March 28, 2024 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2023-001 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. FINDINGS – FEDERAL AWARD PROGRAM AUDIT U.S. Department of the Treasury 2023-002 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. If the U.S. Department of the Treasury has questions regarding this plan, please call Adrian Chlopek at (308) 536-2331.

Finding Reference Number: 2023-003 Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-003. Corrective Action: To ensure supporting documents are maintained to support all HUD-52722 forms, all privately managed Mixed-Finance developments will submit utility cost and consumption data to include copies of invoices to LMHA monthly. Utility cost and consumption data to include copies of invoices are already collected by LMHA managed sites. Name of Contact Person: Jeff Ralph, Director of Finance, 502-569-4372, ralph@lmha1.org Projected Completion Date: Louisville Metro Housing Authority is actively working with third party managers to ensure that LMHA receives, on a monthly basis, the utility invoices that support the HUD-52722 forms and maintaining the documentation on LMHA network servers along with a secondary review of all HUD-52723 and HUD 52722 forms prior to annual submission to HUD /Secure Systems/Public Housing Portal (PIH Operating Fund). QUESTIONED COSTS Undeterminable per Cherry Bekaert If the (Office of Policy and Management and/ or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

Finding Reference Number: 2023-002 Statement of Concurrence or N onconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-002. Corrective Action: To verify that the hours charged by maintenance staff are reasonable, Central Maintenance supervisors/coordinators will verify the accuracy of the hours recorded to work orders completed. Questionable hours will be reviewed and corrected when appropriate. The report will then be submitted to Finance to be charged to Public Housing development. The Finance Department will perform an additional review for reasonableness prior to posting. Name of Contact Person: Greg Crum, Director of Property Management, 502-569-3416, crum@lmhal.org Projected Completion Date: Louisville Metro Housing Authority implemented the corrective action measure in April 2024. LMHA will monitor the issue on a monthly basis in conjunction with its month end accounting close process to ensure compliance with the special fees charged in related party transactions. QUESTIONED COSTS All costs were corrected and fees were reversed. If the (Office of Policy and Management and/ or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

Finding Reference Number: 2023-001 Statement of Concurrence or N onconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2023-001. Corrective Action: LMHA has implemented a comprehensive plan to resolve the backlog of recertifications that necessitated the roll forward of tenant's prior year form HUD-50058 family report without updating family income and composition. First and foremost, representing the rolling forward of the tenant's HUD-50058 as a biennial recertification has been discontinued. Compliance staff has implemented training of Housing Specialists and other staff to assure biennial recertification and use of HUD-50058 Type 2 ("Annual Recertification") will now be compliant. LMHA has contracted with a vendor to assist with the recertification process. LMHA has also restructured workflows to provide efficiencies and accountability that will promote compliance. LMHA is also working with various HUD departments and personnel to assess noncompliance and how to move forward. In addition to resolving these issues with HUD, LMHA has engaged its Financial Auditor, Cherry Bekaert, to review the Housing Choice Voucher Program for process, compliance, and internal control. Name of Contact Person: Sarah Galloway, Special Assistant to the Executive Director, 502-569-3422, galloway@lmhal.org Projected Completion Date: Louisville Metro Housing Authority implemented the corrective action measure in March 2024. LMHA will monitor the issue on a monthly basis to ensure compliance with the HCV program. QUESTIONED COSTS Undeterminable per Cherry Bekaert If the (Office of Policy and Management and/or Oversight Agency) has questions regarding this Plan, please call Jeff Ralph at 502-569-4372.

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 2023-103 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

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

2023‐004 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 4 when reporting lost revenue. Key line items for reporting related to lost revenue were materially misstated. No lost revenue was claimed during the current period. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Hospital will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items 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 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

2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. b. ODEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. c. ODEM will continue to review older awards to determine what actions should be taken. Anticipated Completion Date: December 30, 2024. Contact person: Jeff Flowers, Chief Financial Officer

2023-023 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations MANAGEMENT RESPONSE: We agree with this recommendation. The authority will provide two separate training modules to enrollment staff and staff responsible for the CCO enrollment and validation regarding complete ownership and disclosure documents. We will perform the trainings on April 18, 2024, during our monthly staff meeting and a separate ownership form only training on May 30, 2024. The Office of Developmental Disability Services has implemented new contractual language for our fiscal intermediary to review I-9 for providers with stricter criteria. This was added earlier this year and is already in place in the contract and implemented. Further, upon enrollment, state staff are validating older I-9s for providers who have submitted their I-9 historically. The Office of Aging and People with Disabilities is committed to ensuring Provider Enrollment Agreements and accurate I-9 forms are on file and ensuring records are stored and retained properly for all Home Care Workers. The department will reinforce the requirements concerning the collection and storage of agreements at both the Quarterly Home Care Coordinators meeting on May 30, 2024, and at the AAA/APD Local Line Leadership meeting on May 16, 2024. The department will also create a reference guide in the new ODHS Field Business Procedure Manual implemented in February 2024. The department will make provider enrollment agreements and I-9 forms available statewide via DocuSign as an optional tool for state staff that guides them through accurately completing information on the form and capturing electronic signatures. This will ensure that all required fields in forms are filled out correctly including ensuring the presence of required documentation to mitigate human error. Additionally, we will continue to explore developing a training module for front office staff and office managers as well as a peer review process on business procedures and exploring ways that we can leverage technology such as the replacement Electronic Data Management System (EDMS) "Laserfiche" implemented by Imaging and Records Management Services (IRMS) to store provider records electronically. The questioned costs of $1,786 will be refunded to CMS and reported on the CMS 64 by 6/30/2024. Of note, the prior year finding with questioned costs of $1,843 has since been found as the provider being eligible. No corrective action is needed. Anticipated Completion Date: August 30, 2024 Contact person: Todd Howard, Business Operations Supervisor; Vanessa Richkind, Provider Administration Manager; Jennifer Stallsworth, Chief of Staff; Travis Labrum, Grant Accounting Manager

2023-029 Department of Human Services Strengthen controls over program expenditures MANAGEMENT RESPONSE: We agree with this recommendation. Questioned costs consist of facility payments totaling $139 and a separate payment which exceeded costs of client services by $10. The agency agrees with the finding and will refund those questioned costs. The agency will review the specific circumstances for each of the invoices paid to ensure staff receive the appropriate training as well as reiterate the need to review invoices carefully according to current policies and practices to avoid coding errors. Anticipated Completion Date: June 30, 2024 Contact person: Keith Ozols, Vocational Rehabilitation Services Director