Corrective Action Plans

Finding Number: 2022-002 Program: 14.218 ? Community Development Block Grant Compliance Requirement: Reporting ? Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Condition: Prince George?s County (County) did not report required subaward information to FSRS for first-tier subawards of $30,000 or more. Cause: The County?s policies and procedures were not sufficient to ensure that required subaward information was reported to FSRS. Internal controls did not prevent or detect the errors. Resolution: DHCD established Policies and Procedures governing all entitlement programs, including the Community Development Block Grant Program. DHCD will provide the Office of Management of Budget (OMB) with all subawards of $30,000 or more monthly to upload into the FSRS system. Responsible Party: Aspasia Xypolia, Director, DHCD Anticipated corrective action plan completion date: The Department will coordinate with OMB to upload the required data of the sub awardees receiving $30,000 or more in entitlement funds. DHCD has the necessary sub-awardee data for current and prior years to begin updating the required data. Any questions concerning the findings or corrective action plan can be directed to Aspasia Xypolia, Director, DHCD at 301-883- 6511.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Yvonne Hoffmaster Contact Phone Number: 219 873-1404 Ext. 2004 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: To bring the City into compliance with effective internal controls to ensure requirements related to the grant agreement and the reporting compliance requirements are satisfied, the City Controller will prepare the project and expenditure reports and the Assistant Controller, or the 2nd Assistant Controller will review the project and expenditure reports before they are submitted. Anticipated Completion Date: The process will begin with the reports due April 30, 2023.

Finding: 2022-002 ? Material Weakness, Internal Control Over Compliance, Eligibility and Special Tests ? ALN 93.778 Medicaid Cluster Personnel Responsible for Corrective Action: Pam Noonan, Mesa County Finance Director Anticipated Completion Date: 09/29/2023 Cause: Internal controls over the eligibility determinations are the responsibility of management. Mesa County did not follow its formal process in place for reviews of eligibility determinations. View of Responsible Officials and Planned Corrective Action: Mesa County agrees with the finding and has put together a corrective action plan for the finding. Corrective Action Plan: Mesa County was aware that they were not meeting their internal or Health Care Policy and Financing (HCPF) and Colorado Department of Human Services (CDHS) review requirements for 2022. Mesa County created a new quality control case reviews policy and procedure effective June 2023. The new policy included internal, HCPF and CDHS review requirement for all programs. In addition, MCDHS quality assurance team will be providing oversight using a tool they create to ensure review requirements are being met for each program.

2021-001 ? Internal Control Finding over Reporting Auditor Description of Condition and Effect: Internal control procedures are required to ensure the reporting requirements for the Homeland Security Grant Program are being met. The County is required to submit standardized EMD reimbursement reports to report expenditures under Federal Awards. During our testing, we identified $11,884 of expenditures that were not included on the EMD reimbursement reports. As a result of this condition, the County is exposed to an increased risk of not being reimbursed for eligible expenses. Auditor Recommendation: The County should review and reconcile the EMD reimbursement reports to the County?s detailed accounting system records to ensure completeness of the reimbursement requests. Corrective Action: We agree with the finding and will implement this procedure going forward. Responsible Person: Anticipated Completion Date: September 30, 2023

2022-002 ? Reporting Contact Person Terry Hanson Corrective Action Plan The Program will implement procedures to ensure timely reporting for future report submissions. Planned Completion Date for CAP July 30, 2023

2022-001 ? Reserve for Replacement Contact Person Terry Hanson Corrective Action Plan The Program is aware of required monthly deposits to a reserve for replacement account in accordance with their regulatory agreement. Management will allow for cash flows in to account as allowable. Planned Completion Date for CAP Ongoing

Finding Number 2022-001 SPECIAL TESTS AND PROVISIONS- ENVIRONMENTAL CONTAMINANTS TESTING AND REMEDIATION ? MATERIAL WEAKNESS Agency Name FEDERAL AGENCY: PUBLIC AND INDIAN HOUSING, DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 ? PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Special Tests and Provisions - Environmental Contaminants Testing and Remediation As stated in the April 2022 Compliance Supplement, Public Housing must be decent, safe, sanitary, and in good repair. Public Housing Authority?s (PHA) must maintain such housing in a manner that meets the physical condition standards set forth in 24 CFR section 5.703 in order to be considered decent, safe, sanitary, and in good repair. Those standards address the major areas of the public housing: the site; the building exterior; the building systems; the dwelling units; the common areas; and health and safety considerations. Health and safety considerations require that all areas and components of the housing must be free of health and safety hazards. These areas include, but are not limited to, air quality, electrical hazards, elevators, emergency/fire exits, flammable materials, garbage and debris, handrail hazards, infestation, and lead-based paint. The housing must have no evidence of infestation by rats, mice, or other vermin, or of garbage and debris. The housing must have no evidence of electrical hazards, natural hazards, or fire hazards. The dwelling units and common areas must have proper ventilation and be free of mold, odor (e.g., propane, natural gas, methane gas), or other indoor air hazards such as radon. The housing must comply with all requirements related to the evaluation and reduction of lead-based paint hazards and have available proper certifications of such (see 24 CFR Part 35). For the period under audit, the PHA is required to test for and remediate environmental contaminates including but not limited to lead-based paint, radon gas, and mold to ensure that public housing met the physical condition standards for health and safety considerations set forth in 24 CFR section 5.703. Condition/Context The New York City Housing Authority (the ?Authority?) performs environmental contaminates testing and remediation including but not limited to Lead-based paint, Mold, Pest Control, Elevators, Heating and Annual Apartment Inspections. To track compliance with the Agreement executed on January 31, 2019 by and among the Authority, the U.S. Department of Housing and Urban Development (?HUD?) and the U.S. Attorney?s Office for the Southern District of New York (SDNY) and The City Of New York (the ?HUD Agreement?), the Authority maintains monthly inspection reports for the various inspections performed and provides that information to HUD, the SDNY and the Federal Monitor appointed under the HUD Agreement. Deloitte obtained the bi-annual lead-based paint compliance reports from the Authority and for the Period from February 2022 through July 2022 and August 2022 through December, 2022, we read extermination, heat outage, mold inspections, annual apartment inspections, and elevator outage reports for the months of February 2022; April 2022; July 2022; September 2022 and November 2022. During our audit, we noted that the Authority did not complete all corrective actions in the 2022 audit period and is in the process of addressing these issues Recommendation We recommend that the Authority continue to ensure that all environmental contaminates are properly remediated during the audit period through the HUD Agreement. Corrective Action Plan In January 2019, the Authority entered into the HUD Agreement to address building conditions, including conditions related to lead-based paint, mold, pests, elevators, and heating. Among other things, the HUD Agreement appointed a federal Monitor and established three new Departments ? Compliance, Environmental Health & Safety, and Quality Assurance. It also required the promulgation of action plans around these health and safety issues and other items. These action plans are publicly available at https://www1.nyc.gov/site/nycha/about/reports.page, along with other reports on health and safety issues, which detail the Authority?s efforts to inspect for and correct deficiencies associated with environmental contaminants like lead-based paint and mold. The Authority plans to continue to work to address these health and safety issues, and to work towards meeting the multi-year obligations laid out in the HUD agreement in addition to the action plans. NYCHA has recorded $3,808,843,000 of pollution remediation obligations as of December 31, 2022 which relates to costs to inspect for and correct deficiencies associated with environmental contaminants. Action Date Ongoing milestones through January 31, 2039 Final Implementation The latest in time obligation under the HUD Agreement is the Authority?s obligation to abate 100% of the apartment units that contain lead-based paint, and the interior common areas that contain lead-based paint in the same building as those units, by January 31, 2039 Name And Phone Number Of Person Responsible For Implementation Brad Greenburg Chief Compliance Officer 212-306-4240

2022-002 Internal Controls over Schedule of Expenditures of Federal Awards Preparation (Material Weakness) Federal Agency: Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing Number: 21.027 Recommendation: The Organization should develop written policies for the internal control over compliance of federal awards. Action Taken (Unaudited): Management plans to develop proper written policies and procedures for the internal control over compliance to ensure accuracy and completeness in the preparation of the schedule as required by Uniform Guidance. This policy includes adding another control by a third-party accountant to review federal award financial management. Contact Name ? Rebecca Buford Expected Completion Date ?12.31.23

Finding reference number: 2022-001 Corrective action planned: We agree with the finding noted above. Prior to the issuance of these financials, we began a project to implement system based controls over changes to the vendor master file. Additionally, we are in the process of designing manual controls/review process which would further strengthen our control environment.

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review of wage rates for eight employees selected for testing. There was no formal documented review for the calculation of indirect costs submitted for reimbursement for four months selected for testing. There was no formal documented review for seven reimbursements requests selected for testing. Washburn Center has designed internal controls over these areas; however, the controls were not formally documented. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: Management will review the current active review process and implement a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: December 2023

Finding Number: 2022-003 Condition: The Organization did not submit audited financial statements to REAC within the required time frame after the fiscal year end for the year ended December 31, 2022. Planned Corrective Action: No further corrective action will be taken. The Section 232 HUD insured mortgage is in default. The Mortgage Servicer made claim on the HUD insurance and has been paid. HUD is working through the process to bring the note/mortgage to sale later in 2023 or early 2024. Contact person responsible for corrective action: Daren Lee, Chief Operating Officer Anticipated Completion Date: March 31, 2024

Finding Number: 2022-002 Condition: As of December 31, 2022, principal and interest payments on the mortgage are delinquent by $53,154. In addition, the various escrows are underfunded by $13,635. Planned Corrective Action: No further corrective action will be taken. The Section 232 HUD insured mortgage is in default. The Mortgage Servicer made claim on the HUD insurance and has been paid. HUD is working through the process to bring the note/mortgage to sale later in 2023 or early 2024. Contact person responsible for corrective action: Daren Lee, Chief Operating Officer Anticipated Completion Date: March 31, 2024

2022-001 Income Certifications Name of contact person ? Angela Riley, CFO Corrective action ? The Corporation agrees with the finding, and has continued to implement strategies to address these issues throughout 2021 and 2022, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date ? Management has begun the corrective action and is expected to have additional internal controls and training done by December 31, 2023.

View of Responsible Officials The Department does not concur. The Department notes extensions are in place related to COVID-19 and the Tydings Amendment through the Department of Education mitigating the condition noted. The Department will confer with the US DE to clarify the extensions in place and resolve any disparities identified within the finding. Anticipated Completion Date: Completed as of the date of this report Contact Person: Lindsey Labonville, Melissa White Rejoinder Based on the supporting documentation provided by the Department, it did not appear that the expenses identified within the condition found were charged to the correct period of performance during the liquidation period. Subsequently management adjusted the CAN the expenses related to which would correct the condition found.

View of Responsible Officials The Department acknowledges the misinterpretation of the agreement as a subaward has led to a failure to comply with 2 CFR 170. Underlying this misinterpretation was the Department?s failure to differentiate between entering into agreements with other state agencies and entities recognized as component units of state government such as the NH Business Finance Authority; noting FFATA reporting would not apply to agreements between state agencies. Accordingly, the Department will review existing policies and procedures related to FFATA reporting to ensure agreements with component units of state government are properly considered and reported. Anticipated Completion Date: June 30, 2023 Contact Person: Taylor Caswell

Quarterly Reporting The State concurs in part with the condition and recommendation. A unique challenge with ERA reporting has been changes in the U.S. Treasury portal for that program, which have impacted the State?s ability to download and provide copies of past reports that have been submitted. In addition, this issue in the reporting portal has been inconsistent, as some previously submitted reports were made accessible by Treasury, while others were not, which resulted in the State being able to access some requisite materials but not others. The State did not have documented procedures to ?pull down? copies of reports it had submitted to Treasury because the State has otherwise been able to rely on access to its previously submitted reports within reporting portals in order to enable the testing required during audit for the relevant periods. Meaning, in the State?s experience with COVID-19 related federal funds reporting, it has been able to access and download past reports for purposes of audit. However, also noted above is that the Treasury portal was recently revised and updated to allow for accessing previously submitted ERA reports that were not otherwise available (the communication from Treasury acknowledging this change was provided by the State). However, the reporting portal change did not take place in time for the State?s auditors to reasonably conduct the necessary testing. The State did provide the data and materials it reported to Treasury for the relevant periods, but auditors were unable to test and validate that data because the State could not access and provide a copy of what was actually uploaded into the portal. Nevertheless, to avoid any such potential issues in the future, the State has already implemented a procedure that involves downloading copies of reports as soon as they are submitted and taking screenshots of portions of the portal where perceived necessary to support what the State has submitted to Treasury. This updated procedure will be memorialized in the program?s transaction processing memo during its next update. Monthly Reporting The State concurs in part but has already implemented related corrective action in line with the recommendation above. The State would also like to note that as part of the ERA reallocation process U.S. Treasury has relied on both quarterly and monthly reporting, and that the State has continued to engage in thorough monitoring of its subrecipient and receives regular reports from that subrecipient, including weekly, biweekly, and quarterly data, which also includes quality control reports. This is inclusive of the monthly reports that were required by U.S. Treasury at one time but no longer are. The State reviews and then discusses reports received at standing, calendared, weekly meetings with the subrecipient and often engages in e-mail correspondence concerning those reports, especially if any questions concerning the data provided arise. However, the State has acknowledged that its documentation of those weekly conversations needed to be more formally memorialized. During the current fiscal year, the State began providing agendas and summaries of topics discussed during the weekly check-ins and will ensure that the program?s transaction processing memo adequately documents this requirement and procedure. The very nature of this program and U.S. Treasury?s facilitation of it has required the State and its subrecipient to stay in close contact, make regular decisions on strategies and policies within the program, and closely consider data relative to it. Anticipated Completion Date Quarterly reporting - Corrective action relative to acquisition of submitted federal reports has already been implemented and this revised procedure will be memorialized in the transaction processing memo for the program during its next update in Q1 2023. Monthly Repotting - Corrective action relative to documentation of weekly meetings was already complete as of the State?s response to this finding, and the State will ensure that the transaction processing memo for the program reflects these measures during its next update in Q1 2023. Contact Person Chase Hagaman, Lisa Cota-Robles, and Emily Larson

FINDING 2022-003 Contact Person Responsible for Corrective Action: Robert Glover Jr. Contact Phone Number: (219) 945-0250 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: COVID-19 ? Education Stabilization Fund ? Equipment and Real Property Accounts Payable will track purchases of equipment over the capitalization threshold and notify the Business Manager of qualifying expenditures. The Business Manager will confirm that the items have been barcoded with the appropriate fund administrator.

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There has been turnover in the finance department and the past employees who would have been responsible for this are no longer here. There are already internal controls in place to ensure that the monthly sponsor claims submitted match the school?s meal count reports. The Treasurer will continue to ensure that everything is correctly entered before submission. Anticipated Completion Date: March 2023

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Spokane Housing Authority January 1, 2022 through December 31, 2022 This schedule presents the corrective action planned by the Housing Authority for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-01 Finding caption: The Housing Authority had inadequate internal controls for ensuring compliance with Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Housing Authority contact person: Kathy Clark, Finance Director 25 W. Nora Avenue Spokane, WA 99205 (509) 252-7109 Corrective action the auditee plans to take in response to the finding: Spokane Housing Authority acknowledges the above reference finding. Although personnel responsible for conducting the HQS inspections and ensuring owners corrected the cited life-threatening deficiencies were trained on policy and procedure, SHA did not establish the internal controls to ensure proper follow-up was made. In September 2022, SHA, established a Housing Support Specialist position, which will log life-threatening HQS deficiencies as documented on the HQS inspector?s reports daily and follow-up with the landlord within the 24-hour timeframe to ensure that repairs have been addressed and completed. If repairs have been made pursuant to the directive given by the inspector, then a letter will be sent to the landlord and tenant indicating that the 24-hour hazards have been fixed. If the landlord fails to comply within the 24-hour timeframe, then the unit fails, and a Notice of Termination of HAP letter will be sent to the landlord and tenant. SHA will work with the tenant to start the process of locating a new unit that passes HQS. The log of deficiencies will be reviewed by the Inspections Coordinator regularly as an additional internal control. Anticipated date to complete the corrective action: January 1, 2023

Finding 2022-002: Internal Controls (Material Weakness) The Chief Executive Officer will ensure that the Accounting Officer makes adjustments to record all grants ahead of time in Quickbooks and deduct funding as we spend from these areas to directly show grant balances and that the restricted funding is spent in compliance with the funding received. We will also provide these findings to a certified public accountant to make sure they are adhered to correctly and meet the requirements of both state and federal funding. To address these findings and ensure compliance with Title 2 requirements, Habitat for Humanity Yuba/Sutter will implement the following corrective action plan: 1. Operationalize the Grants Management Standards ? Habitat for Humanity Yuba/Sutter will conduct a comprehensive review of its current grants management policies and procedures to identify any gaps or deficiencies in compliance with Title 2 requirements. ? The organization will update its grants management policies and procedures to align with Title 2 regulations, including documentation requirements, financial management, reporting, and record keeping. ? Habitat for Humanity Yuba/Sutter will provide training and resources to its staff involved in grants management to ensure they are knowledgeable about the updated policies and procedures. ? The organization will establish a system for ongoing monitoring and internal audits to ensure compliance with grants management standards, and make necessary adjustments as needed. 2. Establish a Robust Marketplace of Modern Solutions ? Habitat for Humanity Yuba/Sutter will conduct a thorough review of its current marketplace of solutions, including vendors, software, and technologies used in its operations. ? The organization will identify opportunities to modernize its systems and processes to enhance efficiency, streamline operations, and ensure compliance with Title 2 requirements. ? Habitat for Humanity Yuba/Sutter will develop a plan to implement modern solutions, including budgeting, procurement, and implementation timelines. ? The organization will establish a process for ongoing evaluation and monitoring of the effectiveness of the modern solutions implemented, and make necessary adjustments as needed. 3. Manage Risk ? Habitat for Humanity Yuba/Sutter will conduct a comprehensive risk assessment to identify potential risks associated with grants management and compliance with Title 2 requirements. ? The organization will develop and implement risk mitigation strategies, including internal controls, monitoring mechanisms, and contingency plans. ? Habitat for Humanity Yuba/Sutter will establish a system for ongoing risk management, including regular risk assessments and reviews, and updates to risk mitigation strategies as needed. ? The organization will ensure that all staff involved in grants management are aware of the risk mitigation strategies and trained on how to implement them effectively. 4. Achieve Program Goals and Objectives ? Habitat for Humanity Yuba/Sutter will review and align its program goals and objectives with the requirements of Title 2. ? The organization will develop a comprehensive plan to ensure that its programs are designed, implemented, and evaluated in accordance with Title 2 guidelines, including outcome measurement, data collection, and reporting. ? Habitat for Humanity Yuba/Sutter will establish regular monitoring and reporting mechanisms to track progress towards program goals and ensure compliance with Title 2 requirements. ? The organization will provide training and resources to its staff involved in program management to ensure they are knowledgeable about the updated program goals and objectives and the requirements of Title 2.

Finding 2022-003 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster CFDA #: 84.063, 84.007, 84.268, 84.033 Finding Summary: Due to the changeover in software in the current year, the College did not have an internal control process in place to provide for an independent review over the return of Title IV calculations. Responsible Individuals: Frankie Everett, Director of Financial Aid Corrective Action Plan: The department will assign an individual to randomly sample 30% of the R2T4?s each term, documenting the results and ensuring the system is calculating and reporting these accurately throughout the year. Anticipated Completion Date: January 15, 2022

Recommendation: Recommend management review their policies to ensure distributions are made based on the biannual surplus cash calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and update their policies and procedures to ensure distributions are made based on the biannual surplus cash calculations based on the dates in the regulatory agreement. Name of the contact person responsible for corrective action: Connie Bednarek, Controller Planned completion date for corrective action plan: June 30, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Donya Jordan Contact Phone Number: 219-866-4654 Views of Responsible Officer: We concur with the finding Description of Corrective Action Plan: We will have the Interim Report and Project and Expenditure Reports be reviewed by one of the deputies in the office which would ensure accurate and timely reporting. Anticipated Completion Date: 07-01-23

Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve funds for the federal program. Responsible Individuals: Nina Hollingsworth, CFO and Marcus Lewis, CEO Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the Health Center?s reserve fund is completed with formal documentation noting the review. Anticipated Completion Date: 10/31/2023

2022-005 Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Activities Allowed or Unallowed and Allowable Costs/Costs Principles Material Weakness in Internal Control Over Compliance Finding Summary: There was no review and approval by a separate individual outside of the preparer over the lost revenue calculation utilized to claim expenditures under the federal program. Responsible Individuals: Kelly Johnston, Interim CFO; Larin Jones, Controller Corrective Action Plan: There will be a secondary review and approval by a separate individual outside of the preparer over future lost revenue calculations, if applicable. The secondary review and approval will be documented and recorded. Anticipated Completion Date: December 31, 2023