Corrective Action Plans

Finding 2022-001: Material Weakness in internal controls over compliance for earmarking and material noncompliance for earmarking in the U.S. Refugee Admissions Program: Effect: The Organization may not have met earmarking requirements outlined in the underlying award agreements nor have controls to monitor that earmarking requirements were met effectively. Auditor's Recommendation: We recommend that the Organization implement a process to identify the value of direct assistance provided to each eligible refugee as recorded within the financial records. Further, we recommend that internal controls over compliance be implemented to monitor direct aid distribution and meet the earmarking requirements included within the grant terms. Management Response: We agree with the recommendation and have also submitted the following response. In accordance with the U.S. Department of State, Bureau of Population, Refugees, and Migration (PRM) FY 2019 Reception & Placement (R&P) Cooperative Agreement, all affiliates are required to have written documents available for review evidencing the following: · R&P refugee per capita disbursement policy · How refugee per capita funds beyond the $975 minimum are spent (i.e., Flex Funds policy) · Pocket money disbursement policy · Structured training plan for new and existing staff · Policy on protection from sexual exploitation and abuse (PSEA) · Grievance policy · Policy on cultural orientation (CO) delivery and assessment of refugee understanding · Implementation of accountability to affected populations (AAP) framework Jewish Family Services of Silicon Valley ( JFSSV) has adequate policies and procedures and follows the grantor's guidelines on per-capita earmark funds as stated by the Funder. JFSSV will continue to follow the funder-approved policies and procedures, which state the following: “Per capita funds can be paid by the affiliate directly to the third party, or the affiliate may reimburse U.S. ties or clients for purchases as long as receipts are provided evidencing that the purchases were for allowable material needs. If there are per capita funds remaining at the end of the R&P period and all possible material needs have been provided to the case, including paying rent and utilities forward, the affiliate may write a check to the client for the remainder of the funds. The affiliate must ensure that the situation has been thoroughly documented in the case note log and that the case has no outstanding material needs. This option should be considered an exception and used sparingly.” JFSSV makes every effort to provide the minimum amount to all referred clients as required by the funder. JFSSV meets with clients to provide the initial per capita funding and reviews program requirements for the next per capita funding. If the client follows the program, they are funded. Sometimes, clients leave the program or do not provide adequate documents to be funded, resulting in unspent per capita funds. When this occurs, JFSSV follows the Cooperative Agreement #12.9 Availability of Per Capita Funds: A written statement must be submitted on or before December 31, 20xx, as a Post Award Task through [website link] reporting the amount of per capita funds and accrued interest unexpended and available as of September 30, 20xx. This statement must confirm the amount of those funds expended and reported as a part of the quarterly financial reports for October 1, 20xx, through September 30, 20xx. Should the Recipient have any unexpended per capita funds as of the financial report due on March 31, 20xx, such funds must be returned to the Bureau no later than April 30, 20xx. In addition, JFSSV undergoes vigorous monitoring visits, monthly invoice reviews, and program/fiscal audits, which they pass. JFSSV has provided Harshwal & Company LLP with contracts, cooperative agreements, program guidelines, internal Funder-approved policies & procedures, and all testing requirements with client backup. To address the specific concerns raised regarding internal controls over compliance and earmarking requirements, JFSSV will continue to: Enhanced Monitoring Process: JFSSV will continue monitoring processes to track the value of direct assistance provided to each eligible refugee. Internal Controls Implementation: JFSSV will continue reviewing its internal controls to oversee direct aid distribution with the funder and ensure all requirements are met effectively. Documentation and Reporting: JFSSV will continue to review all disbursements to ensure they are thoroughly documented and reported. This will include maintaining receipts, case notes, and other relevant documentation to provide clear evidence of compliance with earmarking requirements.

Condition: The City did not have sufficient controls in place to ensure that the schedule of expenditures of federal awards was prepared correctly. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended at the City. A grant committee has been established with key personnel in the City that works with grants and monitoring spreadsheets have been developed to track pending grant applications and awarded grant activity. These tools will be further enhanced with key due dates to ensure that grants are applied for by the required deadlines and requests for reimbursement are completed in a timely manner. In addition, the City will research grant management software options to further enhance grant monitoring. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: March 31, 2025

A consistent and substantiated methodology for accounting for indirect costs to be allocated was implemented in FY 23 and remains in place. Anticipated Completion Date-Completed.Responsible Contact Person-Kathleen Boyce, CFAO

Our accounting system does allow for these reports to be produced for the RD Project once we have the opening balance sheet separated by program. We are working with our Net Suite consultants to correct the historical transactions on the balance sheet to insure that all balance sheet accounts are maintained by program.Anticipated Completion Date- August 31, 2024. Responsible Contact Person- Kathleen Boyce, CFAO

Finding 2022-003: Reconciliation of Accounts Federal Program: Research and Development Cluster: 47.076 Condition: The year-end schedules for federal grants receivable, for net assets, and for vacation payable were not reconciled and needed to be revised and updated. Views of Responsible Officials and Planned Corrective Actions: The outstanding liability due to NSF of $115,244 will be reimbursed when AAPT files the next drawn down request. Anticipated date of drawn down will be by July 31,2024. The senior accountant will be trained to prepare entries previously prepared by the CFO The senior accountant will reconcile accounts, and provide updated current schedules. The CFO will review and approve the entries and schedules prepared by the Senior accountant. Anticipated Completion Date: 08/01/2024 Responsible Official: Michael Brosnan, CFO

Correction action planned: When HRSA opens the portal again the numbers will be updated to estimates using the gross revenues by payor and the yearly contractual adjustments amounts. If the portal does not open again the facility will calculate net patient revenues, using estimates, in a separate file to be sent to HRSA upon request. Anticipated completion date: upon request. Contact person responsible for correction action: Tesa Anewishki, CEO.

Action Item Title 2022-004 – Reporting Compliance Requirement Reporting Status (Open: In-process) Condition: Pass-Through Entity Reporting Requirements – The Corporation submitted just two reports during the year, the first and second required submission. Single Audit Reporting Packages – The Corporation did not comply with the Single Audit Reporting Package submission requirements for the years ended June 30, 2022, and 2023. Identified root cause: Lack of understanding of reporting compliance requirements for federal awards. Fiscal year 2022 was the first year for the Corporation to be subjected to a single audit compliance requirement for receiving and expending COVID-19 public health emergency programs. Grantee resolution plan: Pass-Through Entity Reporting Requirements – On July 1, 2022, the Corporation began submitting the monthly requested reports, subject to the Puerto Rico Fiscal Agency and Financial Advisory (AAFAF, as its Spanish acronym), the pass-through entity, required guidelines when funds are obligated. Single Audit Reporting Packages – The Corporation will submit the outstanding Single Audit Reporting Packages. Completion Date: Pass-Through Entity Reporting Requirements - Corrected Single Audit Reporting Packages – August 2024 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. The new system performs an automated allowance calculation; however, a manual distribution of the allowance is required to record the adjustment in the proper period. Unbilled receivables are not adjusted by the system; therefore, a manual journal entry is required to record the allowance. The District was not familiar with the system design and the distribution was not recorded in each month. A manual journal entry must be performed at the end of each month to distribute the allowance in the proper period. The District’s monthly closing procedures have been modified to record the allowance at the end of each month. Anticipated completion date: February 17, 2023 Contact person responsible for corrective action: Kim Manus, Chief Financial Officer

Planned Corrective Action: The Town will adopt policies pertaining to federal awards, specifically ARPA, that have been effective and useful in other municipalities. Using established policies from other municipalities will expedite bringing Southampton into compliance. The new policies will establish controls setting responsibilities and deadlines for timely and accurate submissions. With ARPA funding moving towards an expiration date, these policies will be important to finalize and close-out any awards.

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all deficiencies corrected. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

The Houston Housing Authority agrees with this finding and related recommendations. During this audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In addition, we hired a firm to come in and undertake a review of the finance department. The purpose of this review was to review our existing staffing levels, workloads, experience, etc., for purposes of proposing a reorganization of the finance department to address any deficiencies. We have reviewed the recommendations from this consultant and are in the process of implementing many of the recommended changes. We are in the process of bringing in additional staff to expand the capacity of the Finance department. As we had fallen behind on our audits we anticipated the weaknesses noted in prior audits would continue to be present in future audits. We have been working very diligently to address the issues within the finance department that gave rise to this finding. We fully expect this finding or a similar finding to be present for the 2023 audit as many of the departmental improvements and changes were only recently made and would not have been in place for the majority of 2023.

Condition: The Organization’s controls in place for reporting submissions did not identify that the General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to expense amounts reported in the Organization’s period 2 portal submissions. Planned Corrective Action: The Organization will review its processes surrounding the quantification of expenses reported and will implement additional levels of review to ensure that the expense amounts are validated for future reporting periods. Contact person responsible for corrective action: Tom Garvey, Interim CFO Anticipated Completion Date: 9/30/2023

Condition: The Organization’s lacked effective controls to ensure documentation for expenses reported within the Organization’s period 2 portal submission were retained. The Organization was able to produce documentation for total expenses of $7,516,920, while the Organization had reporting to HRSA that it had incurred $8,509,978 of expenses. As a result, the Organization was unable to provide support for $993,058 of the total expenses reported. Planned Corrective Action: The Organization will review its processes surrounding the retention of documentation used to report expenses and will implement additional levels of review to ensure that the proper documentation is retained for future reporting period portal submissions. Contact person responsible for corrective action: Tom Garvey, Interim CFO Anticipated Completion Date: 9/30/2023

Finding 2022-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Material Weakness in Internal Control over Compliance of the Major Programs Criteria: Where employees work solely or partially on a single Federal program or cost objective, their salaries or wages must be supported by periodic certification that the employee worked on these programs for the period covered by the programs. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the Town was not able to provide evidence that the required certifications of time and effort for employees whose time was spent either completely or partially spent on these programs was performed as required by Uniform Guidance. Questioned Costs: Unknown Context: During our test of payroll transactions of the Education Stabilization Fund grants it was noted that the time and effort certification for a sample of employees tested was not completed. Effect: The Town was not in compliance with the time and effort certification requirements. Cause: Clerical error. Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of West Bridgewater follow procedures to ensure that semi-annual certifications and/or monthly certifications are prepared and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Responsible for Corrective Plan: Superintendent Estimated Completion Date: Complete for subsequent fiscal years. Action Taken: Reviewed and followed required procedures for subsequent fiscal years.

Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance. In addition, management will prepare information on federal awards to determine whether a Single Audit is necessary and prepare a Schedule of Expenditures of Federal Awards as part of preparation for future audits.

2022-006 – Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Immunization Cooperation Agreements Assistance Listing Number: 93.268 Federal Award Identification Number and Year: FY 21/22 and 22/23 Pass-Through Agency: Pennsylvania Department of Health Pass-Through Number(s): None Award Period: 1/1/2022 – 12/31/22 Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition and Context: While testing allowable costs relating to payroll expenditures, sixteen out of forty transactions were identified that could not be appropriately re-calculated per the amount that was charged to the grant. The County was not able to provide support for payroll expenditure amounts charged to the grant for part-time hourly employees. Recommendation: We recommend management should review the process of timekeeping for grant eligible employees for daily time input, as well as grant authorized wages. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Grant Accountant met with department staff to review the time tracking process for grant-eligible employees to ensure that all payroll expenditures charged to the grant are eligible, authorized, and charged on an individual employee basis. Project codes in Infor allow salary distribution and personnel information to be assigned to each grant. Where possible, this function is to assist in supporting the amounts charged to the grant program. The department will maintain documentation to support the amounts and allowability of the charges applied to the grant for payroll. The County is evaluating new time tracking systems to be implemented in 2025 that will allow for time tracking and reporting at a grant/program level. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Dean Dortone Planned completion date for corrective action plan: March 2025

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on health prevention, isolation and quarantine activities, and temporary shelter for homeless and other low-income, vulnerable seniors and disabled persons. We served those in need and our intake processes and recordkeeping did not keep pace. Additionally, given the time that has passed since the services in question, it is possible that records that did exist were misplaced. Staff turnover, resulting from the pandemic burden, made it challenging to go back to the work that had been done. In the time since these events Cornerstones has further emphasized the compliance and documentation needs of the case management process, and we have filled turned-over positions with experienced staff that also understand intake and documentation requirements. We have also hired a Senior Director, Finance with over 20 years of federal contracts experience that is an integral part of increased program compliance and operational oversight responsibilities within the Finance/Operations function. This Senior Director and Cornerstones’ Chief Financial & Operating Officer, Executive Vice President of Housing and Community Programs, and other program leaders and staff, will all work together to ensure that the file construction process is complete and timely for all participants. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

Finding 2022-008 Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: Management concurs with the finding and will strive to endure future audits are completed timely and reporting packages are submitted to the FAC within the required timeframes. Anticipated Completion Date: December 31, 2024

Finding 2022-002 – COVID 19 – Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Norfolk County Noncompliance and Material Weakness in Internal Control over Compliance of the Major Programs Condition: Upon review of the Town of Bellingham’s report filed with the U.S. Department of Treasury and Norfolk County it was noted that the reports did not agree with the Town’s accounting ledgers. Criteria: Per the U.S. Department of Treasury the Town was required to submit an accurate annual Recovery Plan Performance Report. Additionally, the Town was required to submit quarterly performance reports to Norfolk County. Context: The annual report submitted to the U.S. Department of Treasury indicated that the Town had no expenditures which was incorrect. The quarterly report submitted to Norfolk County for the time period of April 1, 2022 through June 30, 2022 did not agree to the accounting ledgers. Effect: The Town of Bellingham was not in compliance with the U.S. Department of Treasury and Norfolk County reporting requirements. Questioned Costs: N/A Cause: During this time period, the Grant Administrator compiled manually created records to support the reporting requirement. Those manual records were not properly reconciled with the General Ledger reports prior to submission to the required agencies. Identification as a Repeat Finding: Yes, 2021-002 Recommendation: The Town of Bellingham should complete and submit all required quarterly reporting by the due date designated by either the Federal Agency or pass through entity and ensure that it agrees with grant activity for time period reported. Responsible for Corrective Plan: Grants Administrator and CFO Estimated Completion Date: January 2024 Action Taken: The Town has trained the Grants Administrator on procedures to reconcile General Ledger reports with manually created project-based records. The Town is also implementing a procedure whereby the CFO signs each required report before submitting.

2022-006 – ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

2022-005 – REPORTING: PERFORMANCE REPORTING Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

2022-004 – REPORTING MATERIAL WEAKNESS/MATERIAL NONCOMPLIANCE Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

2022-003 – ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director