Corrective Action Plans

Finding No. 2022-002 ? Preparation of Financial Statements Jeff Cottingham, Management agent and Wes Clanton, board president of project will continue to monitor financial reports and accounting information as correction is not practical.

Finding No. 2022-001 ? Segregation of Duties Jeff Cottingham, Management agent and Wes Clanton, board president of project will be responsible for monitoring monthly financial results and accounting information as correction is not practical.

Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: Section 811 of the National Affordable Housing Act provides funding for housing for persons with disabilities. To qualify as disabled, the household must consist of at least one person who is an adult (18 years or older) with a disability, two or more persons with disabilities living together, or a surviving household member under certain circumstances (42 USC 1437a(b)(3); 24 CFR section 891.505). Residents must also qualify as very low-income households to be eligible (42USC 8013). Condition: Upon performing testing over tenant eligibility, we noted that the eligibility documentation for one of the tenants was missing and could not be located. Questioned costs: None Context: Eligibility documentation for 1 out of 5 tenants tested was missing. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over tenant eligibility documentation. Effect: There is no evidence that review of tenant's eligibility was performed. Tenant could be ineligible. Repeat Finding: No Recommendation: We recommend that management strengthen controls over review and retention of tenant eligibility files. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Property sponsor and manager reviewing and updating records currently. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Completion by 6/1/23

Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: As per 24 CFR 891.410 Selection and Admission of Tenants, the owner must reexamine the income and composition of the household at least every 12 months. Upon verification of the information, the Owner must make appropriate adjustments in the total tenant payment in accordance with federal regulations and must determine whether the household unit size is still appropriate. Condition: Upon performing testing over tenant rent and eligibility, we noted that annual recertifications were not completed timely. Questioned costs: None Context: Annual recertifications for 3 out of 5 tenants tested were not performed. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over timely completion of tenant annual recertifications. Effect: Untimely performance of required annual recertifications could affect the household?s eligibility for project rental assistance payments. Repeat Finding: Yes Recommendation: We recommend that all required annual recertifications be completed timely. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Sponsor has requested a meeting with senior property management team to discuss lack of transparency with problems in this area. We are in the process of obtaining a current list of clients and their recertification dates. We will monitor monthly and follow up with management company and help from case managers to work with tenants to provide the needed information. Property management has new hires in the pipeline that should be up and running no later than 4/1/2023 to help mitigate the issues. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Immediately

2022-002 Comprehensive Opioid, Stimulant, and Substance Abuse Program ? Assistance Listing No. 16.838 Recommendation: We recommend TASC put a process in place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. We also recommend a careful review of all terms and conditions of grant awards to ensure compliance with the grant award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will modify its? Subaward Recipient Administration and Monitoring of Federal Funds Policy (BUS 122) to include language requiring reporting of subaward and subawardee executive compensation in compliance with FFATA requirements. Name(s) of the contact person(s) responsible for corrective action: Roy Fesmire, CFO Planned completion date for corrective action plan: June 30, 2023

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has been reviewing the year end close process as soon as we learned that there was a need for a stronger year end closing procedure. With the two new key roles being implemented the organization will have a full review of the internal control process and the yearend close process. A new full year end closing check list will be set forth to help designate appropriate steps to verify that all accounts have been review and reconciled with support from general ledger. The Director of Finance will review the processes as the accounting teams works through the checklist and once the Accounting team has determined that the process has been completed, the Financial Quality and Compliance Manager will complete a full review/audit of items to ensure that each have followed the year end closing check list and that the accounts have been reviewed and reconciled with the support of the general ledger accounts. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has implemented an updated journal entry (JE) process as soon as the issues was mentioned during the audit process in July 2022. All Accounting Specialists, Accountants, and Senior Accountants have access to the accounting software and have the ability to do the journal entry. Once they complete the JE, the team member goes to another Accountant/Senior Accountant to review and sign off after making the entry. Items are reviewed for accuracy, appropriateness, and correctness. The JE is then printed (with supporting documentation attached), signed by both the individual initiating the entry as well as the person approving the entry, and then kept on file in a locked file cabinet. After the audit process concluded, the Finance department was reorganized to have two new key roles. The Director of Finance oversees all the financial functions for WPHW, and the Financial Quality and Compliance Manager will be responsible for ensuring that practices and financials are completed per policy and regulations. Starting 2nd quarter of 2023, WPHW will be using a new accounting software that will lessen the need to print JE. However, the system has a built-in monitoring and approval function that will require all JE to be reviewed and approved. This entire process will be able to be seen from start to finish within the software. In addition, the Financial Quality and Compliance Manager will conduct a monthly review all journal entries completed, starting the second quarter of 2023. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

Management is currently confident with the abilities of the accounting staff to prepare interim financial statements. The District has also accepted the additional risk associated with the auditor drafting year-end financial statements including the notes to the financial statements. Management will review, approve, and take responsibility for the financial statements.

Corrective Action Plan Finding 2022-001 Finding Summary: The County does not have an internal control system designed to provide for the timely preparation of the financial statements and related financial statement disclosures. There were material entries recorded that were detected as a result of audit procedures. Further, Eide Bailly assists in the preparation of multiple cash-to-accrual entries as an approved nonattest service. Responsible Individuals: Lucy Valero, County Auditor Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for preparation of the financial statements and accompanying notes. We requested that our auditors, Eide Bailly LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes, and we have reviewed with and agree with the adjustments proposed during the audit. Anticipated Completion Date: Ongoing Finding 2022-002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF} Assistance Listing Number: 21.027 Finding Summary: Per the U.S. Department of Treasury SLFRF Compliance and Reporting Guidance, counties with a population below $250,000 that were allocated less than $10,000,000 in SLFRF funding are required to submit annual Project and Expenditure Reports. The annual report for the period March 3, 2021 - March 31, 2022 was due during the year under audit. The County reported no expenditures for the period included in the annual report, omitting expenditures incurred in the prior fiscal year. The annual report was not reviewed by an individual other than the preparer. Responsible Individuals: Terri Stahl, County Treasurer Corrective Action Plan: Dawson County does not agree with the finding, and does not believe corrective action is required due to the following circumstances. Upon advisement from TAC, the County made a transfer from the ARPA fund to the General fund before the end of the year using the interim rules, but were told NACO still had not finalized the final rule because they were looking at additional ways to help smaller counties. No checks were written out of the ARPA fund. In March 2022, NACO finalized the regulations on the ARPA funds, which allowed the County claim revenue loss of up to 10 million or to use the interim rule provisions for allowability. The County chose to claim revenue loss of up to 10 million, rather than claim allowable costs of $400,000 under the interim rule. On April 5, 2022 the Commissioners signed a resolution to declare all funds as "Lost Revenue." The money was transferred from General fund back to the AARP fund. TAC/NACO's advisement was that since no checks had been written to any businesses, the annual report needed to show no expenses. Anticipated Completion Date: 03/09/2023

Finding ref number: 2022-003 Finding caption: The District overcharged indirect costs to the program and did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Paula Bailey, Executive Director of Business Services P.O. Box 8 Silverdale, WA 98383 (360) 662-1650 Corrective action the auditee plans to take in response to the finding: To ensure correct indirect rate charges, the District will create a grant tracking sheet that will list all information needed to fill in the SEFA. The Grant tracking sheet will include: ? Grant Title ? Grant year ? Grant number ? Grant amount ? ALN number ? Granting agency ? Federal agency name ? Approved Indirect Rate In order to ensure compliance of wage rate requirements the district will ensure: 1. Weekly collection and review of Certified Payroll Reports (CPRs) with compliance statements for all active projects will be incorporated into the Capital Projects accounts payable process. 2. The CPRs collected will be accessible to all Capital Project staff members in electronic format as well as a newly created control document verifying the date of review and reviewer of each CPR submitted. 3. Requests for CPRs will be made to all contractors or subcontracts missing reports through the period for which work has been performed. 4. Monthly invoices and pay applications will not be processed until CPRs for the billing period are collected and reviewed. 5. CPR procedures will be included in the Pre-Construction Meeting Agenda for all projects with emphasis given to weekly CPR submittals. 6. Contracts will be reviewed to ensure applicable laws and regulations are included. 7. Ongoing contracts will be amended to include required federal language as required by Title 29 CFR, Section 5.5 Anticipated date to complete the corrective action: 8/31/2023

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Paula Bailey, Executive Director of Business Services P.O. Box 8 Silverdale, WA 98383 (360) 662-1650 Corrective action the auditee plans to take in response to the finding: In order to ensure compliance of wage rate requirements the district will ensure: 1. Weekly collection and review of Certified Payroll Reports (CPRs) with compliance statements for all active projects will be incorporated into the Capital Projects accounts payable process. 2. The CPRs collected will be accessible to all Capital Project staff members in electronic format as well as a newly created control document verifying the date of review and reviewer of each CPR submitted. 3. Requests for CPRs will be made to all contractors or subcontracts missing reports through the period for which work has been performed. 4. Monthly invoices and pay applications will not be processed until CPRs for the billing period are collected and reviewed. 5. CPR procedures will be included in the Pre-Construction Meeting Agenda for all projects with emphasis given to weekly CPR submittals. 6. Contracts will be reviewed to ensure applicable laws and regulations are included. 7. Ongoing contracts will be amended to include required federal language as required by Title 29 CFR, Section 5.5 Anticipated date to complete the corrective action: 8/31/2023

Finding 2022-001 ? Reporting The District concurs with the finding 2022-001. Corrective Action: The District will implement quality control procedures that will verify and confirm that monthly meal reimbursements and counts are correct prior to submission in CNMS Contact Person: Michael Brennan, Business Manager (518) 758-7575 ext 3009 mbrennan@ichabodcrane.org

Finding Number: 2022-009 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services, HIV Emergency Relief Project Grants Condition: Original Finding Description: The City controls did not result in the reporting of program income earned by subrecipients to the funding agency and not reporting the program income and related expenditures in their general ledger and on the SEFA. Contact Person Responsible for Corrective Action: Regina Greear and Keisha Pierce Anticipated completion date: July 2023 Planned Corrective Action: The $4,800 Program Income was reported on the general ledger In FY22 and included in the final FY22 SEFA but after the notification from the auditors. The city will implement a Corrective Action Plan (AFCAP) to document the Program Income requirements, track all awards with program income to help ensure proper and accurate reporting and further training on Program Income requirements.

Finding Number: 2022-004 Condition: The billing procedures review process did not ensure charges to federal awards were incurred prior to billing the grantor. Planned Corrective Action: Management understands the importance of incurring costs that are charged to federal awards. Management will follow its existing policy to ensure that expenditures charged to grants accurately reflect the costs incurred. In addition, management will return the overage amount to the awarding agency no later than July 31, 2023. Contact person responsible for corrective action: James D. Hagestad Anticipated Completion Date: July 31, 2023

U.S. Department of Health and Human Services The Substance Abuse and Mental Health Services Administration Block Grants for Prevention and Treatment of Substance Abuse ? Recovery Community Organization Grant Assistance Listing # 93.959 Finding: 2022-004 Name of contact person: Sue Polston, Executive Director Corrective Action: Management of Sunrise Community for Recovery and Wellness, Inc. will formalize and implement written policies that comply with Uniform Guidance standards and will present the policies to the Board of Directors to be approved and adopted. Proposed Completion Date: Immediately

U.S. Department of Health and Human Services The Substance Abuse and Mental Health Services Administration Block Grants for Prevention and Treatment of Substance Abuse ? Recovery Community Organization Grant Assistance Listing # 93.959 Finding: 2022-001 Name of contact person: Sue Polston, Executive Director Corrective Action: Management of Sunrise Community for Recovery and Wellness, Inc. will continue to consider actions to further segregate incompatible job functions that will benefit the Organization. An accounting assistant has been hired and some duties will be delegated to her that will assist with segregation of incompatible job functions. In addition, review and approval processes will be formalized by documentation of review and approval. Policies and procedures will be formalized as well. Proposed Completion Date: Immediately

March 10, 2023 CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings, as noted in the Missaukee County, Michigan?s Single Audit report for the year ended September 30, 2022, and corrective actions to be completed. Finding: 2022-001 ? Material weakness over federal award ? Preparation of the Schedule of Expenditures of Federal Awards Auditor Description of Condition and Effect: Management provided an initial Schedule of Expenditure of Awards; however, material misstatements of federal expenditures recorded on the Schedule of Expenditures of Federal Awards were discovered during the audit process. This condition was primarily caused by the extreme infrequency of the County being required to prepare a Schedule of Expenditures of Federal Awards and the corresponding lack of established policies and procedures to produce an accurate Schedule. As a result of this condition, the County is not in compliance with the required written procedures under the Uniform Guidance. The schedule of expenditures of federal awards, would have been materially misstated if adjustments hadn?t been made. Auditor Recommendation: The County should develop and implement written procedures over the preparation of the schedule of expenditures of federal awards to be used as a reference for future year(s) subject to single audit reporting. Corrective Action: We agree with the finding and will develop and implement written procedures required for federal awards.

View of Responsible Officials We concur. The Department has contracted with Myers & Stauffer (M&S) to conduct the periodic audits of all three of its Managed Care plans for State Plan Rate Year 2020. We anticipate the audits will be completed by August 2023. Anticipated Completion Date: September 2023 Contact Person: Shirley Iacopino

View of Responsible Officials We concur and have developed a corrective action plan in conjunction with Conduent. See attached plan. The SOC report will include auditing the change management of the quarterly NCCI edit checks. The auditing firm will also update the control objective 5 activities to include a population of claims specifically with NCCI edits. Anticipated Completion Date: The completed 6/30/2023 SOC report. Contact Person: Roger Boissonneau, MMIS Director

View of Responsible Officials We concur with the finding. Corrective Action: Condition A The Bureau of Employment Supports has been undergoing massive programmatic changes over the past 2 to 3 years. As part of those changes, there has been an updated Work Verification Plan submitted which will help to address some areas where errors have occurred. Keeping in mind that for a period of close to 2 years, due to the COVID pandemic, NHEP was not holding participants accountable for not returning signed employment plans to NHEP staff. The focus for that time was to ensure that families were housed, fed and safe, therefore, services focused on their immediate needs. Participants who entered the NHEP program during that time were not held accountable to returning a signed employment plan therefore it did not become part of their routine with NHEP. While COVID restrictions have been lifted, participants seem to have needed some time to reintegrate into the NHEP program and the mandatory expectations. NHEP staff and leadership will continue to remind participants and become more diligent in ensuring that signed employment plans are on the forefront of their daily responsibilities. It should be noted that in a couple of instances, employment plans were created as part of a Service Determination Appointment and very quickly after the participant was deemed exempt from the Work Program (NHEP) so the employment plan was not necessary and became a moot point. A Director?s Memo will be sent out by the end of this week which will allow Employment Plans to be acknowledged and accepted by the participant in multiple ways (not just with a wet signature) thereby increasing the likelihood of participants returning accepted employment plans to NHEP staff. Making this shift will mitigate the difficulties that are causing participants to not return their signed employment plans to NHEP staff and will decrease instances where there is not an accepted employment plan on file. NHEP leadership will hold a state wide mandatory staff training where ways to prioritize the monitoring and obtainment of accepted employment plans will be outlined and discussed. Field Support Managers will continue to monitor their staff on a quarterly basis, however, will add a monthly check on having accepted employment plans to their responsibilities. Condition B Part of the changes that NHEP has implemented have included a new Activity Tracking form which has made tracking hours more efficient and easier for the participant as well as the Employment Counselor. We believe that this activity tracker as well as the decrease in mandatory forms will allow for more accuracy and fewer errors moving forward. Uploading documents into the e-folder was found to be error prone, therefore, on March 1, 2023, NHEP leadership provided guidance and training on a specific process of indexing and scanning documents to ensure that moving forward the Employment Counselors are checking their e-folder?s to ensure that documents are properly uploaded and visible. This process was initially sent out to the field as a suggestion in 9/2022, however, on 3/1/23 this process was sent out as an expected process moving forward. Also, through cursory investigations, we believe that this new process, combined with the new Activity Tracking form, has already shown to be effective in improving the accuracy of supporting and recording hours. NHEP leadership has also been working with the NEW HEIGHTS system to streamline the process of uploading documents to further decrease the potential for errors. A change request form was submitted approximately one year ago. Also during the time period of this audit, NHEP was requiring pay stubs from employed participants and completing ?overrides? of the number of work hours that a participant worked during the week if that number was different than what was auto-populating based on information obtained by and entered by eligibility. NHEP discontinued that practice. NHEP no longer requires pay stubs from participants as that is a function of eligibility. NHEP utilizes the number of hours worked per week based on the number of hours entered by eligibility. This change will ensure that employment hour errors no longer occur. In order to address issues of audit findings, within the next 90 days, NHEP leadership is holding a state wide mandatory staff training where more in-depth information on the audit process will be shared including audit ?tests?, ?questions? and ?corrective action plans?. Historically in NH, the audit process was not shared with the NHEP staff making them unaware of the expectations and/or findings of the audit. NHEP staff were trained to complete certain processes and enter particular data but were never able to connect that back to anything. While we have been introducing this process more and more to our staff, we intend to hold a training to help them more thoroughly understand why they are doing what they are doing and remind them that what they do is reviewed for accuracy as part of the federal audit process. We believe that this transparency will create buy-in from the staff to put systems in place for themselves and to self-monitor more. Anticipated Completion Date: December 31, 2023 Contact: Brigitte Bowmar, Program and Workforce Administrator III

Finding 2022-001 ? Eligibility ? Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: As part of our testing of eligibility, using a random number generator, we selected 25 days the Organization was open for food distribution during the year ended December 31, 2022. Out of the 25 days tested, the Organization did not follow intake guidelines for required eligibility and data collection prescribed by the Washington State Department of Agriculture for 12 different days. Planned Corrective Action: The organization implemented procedures to collect client intake data for one of the programs identified in testing and expects to continue making progress on the remaining program during 2023 and 2024. Responsible Division/Office and Individual: Mike Cohen, Executive Director Estimated Completion Date: 12/31/2024

FINDING 2022-0005 Contact Person Responsible for Corrective Action: Chris Richie Contact Phone Number: 219-987-4711 ext. 1113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Before submissions, grant reports will be reviewed by someone other than the preparer of the report to ensure the information submitted was accurate. Individuals will initial and date a hard copy of final the report acknowledging the accuracy and submission of the report. Anticipated Completion Date: March 31, 2023

FINDING 2022-0004 Contact Person Responsible for Corrective Action: Chris Richie Contact Phone Number: 219-987-4711 ext. 1113 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In the future, the treasurer will maintain a list of capital assets that includes serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, and the use and condition of the property. The list will be verified by a central office employee each December and June. Individuals will initial and date a hard copy of final the report. Anticipated Completion Date: June 30, 2023

Finding Number: 2022-002 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the reporting of expenses. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to submission to ensure that reports are submitted within the established guidelines. Contact person responsible for corrective action: Andrew Young, Corporate Controller Anticipated Completion Date: 3/31/2023

Finding Number: 2022-001 Condition: Covenant HealthCare's controls in place for reporting submissions did not identify that guidelines were not followed related to the inclusion of expenses that had previously been reimbursed. Planned Corrective Action: Covenant Healthcare will implement additional layers of expense review prior to submission to ensure that reports are submitted within the established guidelines. Contact person responsible for corrective action: Andrew Young, Corporate Controller Anticipated Completion Date: 3/31/2023