Corrective Action Plans

2022-001 ? SPECIAL TESTS & PROVISIONS: RENT REASONABLENESS Material Weakness/Material Noncompliance U.S. Department of Housing and Urban Development ALN #: 14.871 ? Housing Voucher Cluster Auditee?s Response and Planned Corrective Action The Westerly Housing Organization hired the public accounting firm, MARCUM to perform and file the organizations 2022 annual required audit and financial statements required by HUD. We do not expect any further issues with performing an assessment to determine if the rent requested by the landlord is reasonable for new admissions. Due to a turnover in administration in the Housing Choice Voucher program, the new Housing Choice Voucher Coordinator was still in training when the audit was conducted. The coordinator had started reviewing the files and realized the rent reasonableness was not listed in all files and was informed by the auditor the files contained an outdated rent reasonableness form. At that time, the auditor forwarded an updated rent reasonableness form. The organization has since implemented a new written policy and submitted a new form provided by our auditor to enable assessing rent reasonableness for new admissions. The organization can ensure that HAP payments to landlords are reasonable by surveying several listings of available comparable unassisted units for rent throughout the local area on websites such as Apartments.com, Zillow.com, Turelia.com and reached out to area Real Estate companies. The organization will secure training for all housing authority program employees with necessary updates and HUD changes regarding rent reasonableness on an ongoing basis. The organization will consistently review the information for rent reasonableness standards required from HUD and make any necessary changes immediately. Planned Implementation Date of Corrective Action: May 2023 Person Responsible for Corrective Action: Lucienne Andrew, Executive Director

2022-003 Subrecipient Monitoring The Organization has created a subrecipient monitoring schedule that follows the grant cycle of each of its federal grants and has also created a template document to collect the information required by 2 CFR Part 200, Subpart D, Section 200.332. Staff time has been allocated to collecting the required information from each subrecipient during 2023, which will continue annually to complete this requirement from this point forward.

2022-002 Procurement While the Organization has a procurement policy in place, it is noncompliant with the requirements of Title 2, Subtitle A, Chapter 2 Part 200, Subpart D, section 200.318 of the Code of Federal Regulations. The Organization has experienced substantial growth in recent years and in support of this expansion, hired an experienced CFO in early 2022. The new CFO identified the need for a compliant procurement policy that includes certain requirements as it relates to procuring goods and services using federal dollars. To facilitate the adherence to the new procurement policy, the Organization has purchased new ERP software and both contracted with an outside organization and hired new internal staff to oversee the implementation of this software during 2023. The new procurement policy was reviewed by the auditors during the 2022 audit and a determination was made that had the new policy been in effect and followed, the Organization?s practices would have met the requirements of Title 2, Subtitle A, Chapter 2 Part 200, Subpart D, section 200.318 of the Code of Federal Regulations. This policy will become effective on the go-live date of the new ERP software. A staff member has already been selected to oversee the procurement function and has completed a number of training courses specific to federal procurement requirements.

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District?s contact person: Daniel Yorton 214 W Laurel Rd Bellingham, WA 98226 360-988-3840 Corrective action the auditee plans to take in response to the finding: The district would like to thank the auditors for their work and recommendations regarding Davis-Bacon requirements. The district has implemented internal controls to ensure that contract language meets Davis-Bacon requirements. The district has also implemented internal controls to ensure that contractors submit weekly certified payroll and Davis-Bacon requirements are met. Anticipated date to complete the corrective action: 7/31/23

Finding Number: 2022-003 Condition: ProMedica Health System's controls in place for reporting submissions did not identify that guidelines were not followed related to the reporting of infection control expenses in the correct period. Planned Corrective Action: Management fully understands and acknowledges the importance of identifying and complying with the reporting guidelines of federal awards, including the reporting of infection control expenses in the correct period. The receipt of Provider Relief Funds has broadened the scope of individuals that are responsible for reporting of Federal awards to those outside of the Grants and Research departments. Expenses for the Provider Relief Funds were correctly captured by period incurred and appropriately tracked for allowability. ProMedica has implemented a review procedure of the Provider Relief Funds consistent with other grant reporting so that the HRSA reports will be reviewed by a Grants Advisor or Grants Analyst prior to submission to ensure that eligible expenses are entered into the correct period in accordance with the guidelines established by HHS. Contact person responsible for corrective action: Kyle Kickbusch, Interim Corporate Controller and AVP Anticipated Completion Date: 09/21/2023

Finding 2022-005 ?Medicaid ? Eligibility Contact Person Responsible for Corrective Action: Scott Miller, Heather Lawson Contact Phone Number: 765-659-1339 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corp switched Medicaid providers in FY23, and will monitor the new provide to ensure compliance with the federal requirements. Anticipated Completion Date: June 30, 2023

Finding 2022-004 ? Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Scott Miller, Heather Lawson Contact Phone Number: 765-659-1339 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Finding 2022-004 ESSER - we do not have GEER grants - We have reviewed all files of previous Treasurer and Superintendent and did not find documentation. We will make sure going forward that documentation stays with the Grant file at all times in case of staffing changes. Anticipated Completion Date: June 30, 2023

Finding Number: 2022-012 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of financial management in the School, Academica Nevada, the School?s management company, has filled all the open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. The grant manager will reconcile all grants to ensure proper cutoff, with a secondary review performed by a member of management. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

Finding 2022-04 ? Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following. Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: During the audit of Umpqua Public Transportation District for Fiscal Year 2021-2022, the district provided auditor with Separate and Identifiable General Ledger reports that showed a clear division between Federal, State and Local expenditures and revenues. However, the separation was done retroactivity and was not been completed for the entire fiscal year or life of grants. This deficiency was instrumental in causing the general ledger to be inadequate for financial and Federal Award Reporting. Cause: The District had originally relied on unskilled individuals for structuring and recording activities in their general ledger. District management did not have sufficient staff or monitoring policies to recognize and correct the deficiency. While trained staff have been hired at Umpqua Public Transportation District, and improvements made to the general ledger and recording of Federal grants, improvements are still necessary to meet the full requirements of CFR Part 200.302.b Auditee Responsibilities. Effect or Potential Effect: Potential for incorrect financial reporting, and untimely results, with the inability to rely on the general ledger for correct and timely information. Questioned Cost: No Context: While federal grant revenues and expenditures are now tracked using the general ledger ?jobs? indicators, additional recording is needed to track the matching portions of the costs and revenues of those federal grants. The lack of completed effort at separating revenues or expenditures by grant may lead to errors in reporting expenditures for Federal Awards. Repeat of a Prior-Year Finding: Yes, Findings and Questioned Costs 2021-11 Recommendation: We recommend that Umpqua Public Transportation District improve their general ledger structure to meet the requirement for separate accounts for Federal awards for program revenues and program expenditures. We also recommend that the district establish policies and procedures to ensure that all program revenues and expenditures are reported in the correct fiscal year. In addition, we recommend that the district establish a training program and policies and procedures for staff and management to receive appropriate training for administering and recording Federal Grant revenues and expenditures. District's Response: The District concurs with the recommendation. General ledger accounts separating Federal, State, and Local revenues and related expenditures will be designed and implemented. Corrective Action Plan: The District has hired a Finance Manager to oversee the day-to-day financial operations of the district. The Finance Manager has developed an accounting system for separating Federal, State, and Local revenues and related expenditures. This will allow the activities of the district to be recorded in a manner that allows for reporting in compliance with federal requirements. Planned Implementation Date: July 1, 2022 Responsible Person: General Manager, Umpqua Public Transit District

Finding 2022-02 ? Fiscal Management System, Ensure Compliance with Federal Regulations Over Accounting Systems (Material Weakness) Criteria: Management is responsible for establishing and maintaining effective internal control over financial reporting. Internal controls should allow management or employees in the normal course of performing their assigned functions to prevent or detect material misstatements in the financial reporting of all district funds. The Internal Control ? Integrated Framework, published by the Committee of Sponsoring Organizations of the Treadway Commission (COSO) and the U.S. Government Accountability Office Standards for Internal Control in the Federal Government specify that a satisfactory control environment is only effective when there are adequate control activities in place. Effective control activities dictate that a review is performed to verify the accuracy and completeness of financial information reported. The Federal Grant Activity Schedule captures amounts that must be accurate and complete in order to ensure the accuracy of the financial and federal information reported on such schedule to verify the accuracy and completeness of financial information reported. CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following. Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: During the audit of Umpqua Public Transportation District for Fiscal Year 2021-2022, the district provided auditor with Separate and Identifiable General Ledger reports using QuickBooks Jobs feature, that showed identification between individual grant expenditures and revenues. Entries were prepared or recorded using the jobs feature, but not on a timely basis throughout the year, as portions were completed retroactively, and general ledger restated for the entire fiscal year. This deficiency was instrumental in causing the general ledger to be inadequate for financial and Federal Award Reporting for a large portion of the year. Cause: The District had relied on inadequately trained individuals to record activities and setup of their general ledger. The accounting records were retroactively constructed to meet Federal award reporting purposes, but late in the fiscal year. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Failure to record transactions timely into the general ledger for Umpqua Public Transportation District, and lack of proper accounting structure separating revenues and expenditures into each Federal and State or Local grant may result in transactions not being properly included in the district?s financial statements. The potential for incorrect financial reporting, and untimely results, with the inability to rely on the general ledger for correct and timely information, may also cause misstatement of financial statements, and inappropriate reporting of federal awards. Questioned Cost: No Context: Restatement of the general ledger was necessary for proper reporting of grants for the Schedule of Federal Awards. Tracking of matching local and state grants remains ineffective. Repeat of a Prior-Year Finding: Yes, Financial Statement Findings 2021-4 Recommendation: We recommend that Umpqua Public Transportation District improve their general ledger structure to meet the requirement for separate accounts for Federal awards for program revenues and program expenditures. In addition, we recommend that the district establish policies and procedures to ensure that all required matching of grant expenditures be recorded in sufficient detail tracking to ensure that all matching program revenues and expenditures are reported correctly in the fiscal year. We also recommend that the district continue training program, policies and procedures for staff and management for administering and recording Federal Grant revenues and expenditures. District's Response: The District concurs with the recommendation. General ledger accounts separating Federal, State, and Local revenues and related expenditures will be adhered to and further training implemented. Corrective Action Plan: The District hired a Finance Manager to oversee the day-to-day financial operations of the district. The Finance Manager retroactively created accounting records to separate grant revenues and related expenditures, for both Federal grant records as well as State grant records. The Finance Manager will improve the general ledger to allow the recording of the matching identification for each federal grant. This will allow the activities of the district to be recorded in a manner that allows for reporting in compliance with federal requirements. Planned Implementation Date: July 1, 2022 Responsible Person: General Manager, Umpqua Public Transit District

Federal Program: ALN 93.224, Department of Health and Human Services, Health Center Cluster Condition per Auditor: The County has a sliding fee discount policy that is based on income and family size and schedule in place; however, it was not followed for all patients during the year. Planned Corrective Action: Management will implement and follow a process of reviewing accuracy of intake data and application of sliding fee calculations performed by co-applicant employees by internal County representative. Anticipated Completion Date: 9/30/2024 Responsible Contact Person: Ka?leef Morse

Federal Program: ALN 21.023, Department of the Treasury, COVID-19 Emergency Rental Assistance Program Condition per Auditor: The County did not have adequate controls in place to ensure that payments to beneficiaries were calculated correctly. Planned Corrective Action: Management will implement and follow a process of reviewing of consultant administered activity for accuracy by internal County representative. Anticipated Completion Date: 9/30/2024 Responsible Contact Person: Hassan Sheikh

Federal Program: ALN 14.218 ? U.S. Department of Housing and Urban Development (HUD) ? Community Development Block Grant (CDBG) ? Entitlement Grants Cluster, CFDA 14.239 - U.S. Department of Housing and Urban Development (HUD) ? HOME Investment Partnership (HOME), CFDA 93.563 ? Title IV-D, U.S. Department of Health, and Human Service - Child Support Enforcement (CSE) Condition per Auditor: Controls in place were not adequate to ensure compliance with 2 CFR 200 Appendix V submission requirements for its self-insurance cost allocation process and annual chargeback plan. Planned Corrective Action: Management agrees and will submit subsequent plans to federal cognizant agency as required by 2 CFR 200. Anticipated Completion Date: 4/30/2023 Responsible Contact Person: Jake Bower and Shauntika Bullard

Federal Program: ALN 10.557, U.S. Department of Agriculture (? WIC Special Supplemental Nutrition Program for Women, Infants, and Children) Condition per Auditor: Controls in place were not adequate to ensure the County maintained responsibility for compliance with eligibility standards when eligibility determinations are made by the contractor. Planned Corrective Action: Management will implement and follow a process of reviewing of eligibility intake and certification performed by contractor employees by internal County representative. This will be completed by the internal county WIC Compliance Manager or designee and will utilize the audit tools provided by the state that includes monitoring of eligibility intake and certification. The WIC Compliance Manager will request contractors to complete audit reporting templates monthly and flag any items in need of further investigation with the contractor. Anticipated Completion Date: 9/30/2024 Responsible Contact Person: Natalie Dean Wood and Dr. Avani Sheth

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Warden School District No. 146-161 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District 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: 2022-002 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: Kassandria Rouleau, Director of Finance 101 W. Beck Way Warden, WA 98857-9401 Corrective action the auditee plans to take in response to the finding: All parties contracting services will receive training on prevailing wage compliance. The business manager will review and ensure the requirements are being met. Anticipated date to complete the corrective action: April 2023

Finding 2022-002 - Accounting Controls - Timeliness of Financial Statement Preparation ALN 14.182, Noncompliance & Material Weakness Corrective Action Plan: The unaudited FDS and the OC FASSUB entries will be completed timely and the CPA Firm that prepares these for the Authority has agreed to the prescribed deadlines as detailed by HUD.t- Person Responsible: Connie Stewart - Executive Director Anticipated Completion Date: This has been implemented effective June 1, 2023. The next FASSUB is due by December 31, 2023 for the year ended September 30, 2023 and the next FASPHA is due by November 30, 2023 (it should be noted that there is a 15 day grace period until December 15, 2023 for this submission).

Finding 2022-001 - Allowable Costs/Costs Principles - Ineligible Wire Transfer ALN - 14.182, Noncompliance & Material Weakness Corrective Action Plan: ALL subsequent requests for wire transfers will be immediately verified with the person(s) or company that has requested the wire transfer. In addition, the Authority will strongly discourage the use of wire transfers. Person Responsible: Connie Stewart - Executive Director Anticipated Completion Date: This has already been completed as soon as the issue was discovered.

Contact Person Responsible for Corrective Action: Kelsi Hall Contact Phone Number: 765-641-2096 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Meal counts are gathered and printed off of NutriKids by the food service Bookkeeper and given to the Director. The Director reviews the information and enters the numbers in CNPweb for each school individually. Before submitting the claims, the Director cross references the combined totals from NutriKids with the totals on the CNPweb Sponsor Claims page to ensure they match. If they do not match, this would alert the Director if there were any typos or errors in CNPweb. The meal count papers are then returned to the Bookkeeper to double check that the numbers entered in CNPweb match the numbers that were printed off from NutriKids. Anticipated Completion Date: July 1, 2023

Finding Number: 2022-002 Planned Corrective Action: In the future, the Treasurer will ensure that prevailing wage rate requirements are included on all applicable contracts. Anticipated Completion Date: 6/30/2023 Responsible Contact Person: Roxane Harding, Treasurer

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 City 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 City 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 City 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.

Corrective Action Plan Finding 2022-001 Provider Relief Fund (Assistance Listing #93.498) Activities Allowed or Unallowed and Allowable Costs At the beginning of the pandemic, Eisenhower Medical Center created a COVID-19 response team to evaluate the requirements for the COVID-19 funding received and ensure the funds were only used for allowable purposes. The response team continuously monitored the FAQs and other guidance on the reporting requirements as they continued to evolve as additional funds were received. As part of the Uniform Guidance audit, Eisenhower Medical Center provided documentation of the Provider Relief Fund review process, including response team meeting agendas, email correspondence, as well as management sign-off on the lost revenue calculations and expenses submitted as part of the Provider Relief Fund Period 2 report. Through the audit testing, we were asked to provide copies of approval documents for some of the supply requisitions for expenses reported as part of the Provider Relief Fund period 2 report. The documents in question were paper approval forms for some of the supplies purchased in July through December of 2020. Historically these documents were only retained for two years and thus they were not available for the audit procedures. In November 2021, we implemented a new automated supply requisition process that is integrated with our financial software (Workday). This new implementation will help to correct this issue in the future with the ability to provide electronic documentation of date/time stamped approvals. In addition to the new requisition process we wanted to improve the process for documenting the review of the expenses and lost revenue to be reported in the Provider Relief Fund reports. To ensure our internal controls are documented to level necessary under current audit standards, Eisenhower has developed a review checklist to document the review and approval of supporting documentation of the revenue and expense information to be reported in the Provider Relief Fund reports. The checklist will be retained with our existing support of Provider Relief Fund federal expenditures. The new checklist had not been developed when the Provider Relief Fund Period 2 Report was submitted, and thus not used. The new checklist however, will be used for any future Provider Relief Fund Report submissions. Responsible Official: Melanie Long, VP Finance Anticipated Completion Date: March 31, 2023

Corrective Action Plan and Views of Responsible Officials The District strives to maintain adequate and accurate inventory records for assets and services purchased with all funds, regardless of source. Staff works hard to ensure that inventory records are regularly updated to reflect when and to whom all purchased items and services are provided, reflecting compliance with all program requirements. For the fiscal year under review, the District prioritized providing students and staff with technology needed to meet the otherwise unmet connectivity needs of students and school staff during the COVID-19 pandemic and recognizes the need for improved inventory tracking practices by all staff. The District believes that ECF Program support was not used to fund more than one connected device and more than one Wi-Fi hotspot per student or school staff member during the COVID-19 emergency period.

Corrective Action Plan and Views of Responsible Officials The District strives to maintain adequate and accurate inventory records for assets and services purchased with all funds, regardless of source. Staff works hard to ensure that inventory records are regularly updated to reflect when and to whom all purchased items and services are provided, reflecting compliance with all program requirements. For the fiscal year under review, the District prioritized providing students and staff with Chromebooks and other technology needed to access instruction and recognizes the need for improved inventory tracking practices by all staff.

Finding 2022-003:COVID-19 Education Stabilization Fund, CFDA 84.425U U.S. Department of Education Passed through the Colorado Department of Education Compliance Requirements: Activities Allowed and Unallowed, Allowable Costs/Cost Principles Grant No.: 4414 Type of Finding: Internal Control Over Compliance (material weakness) and Compliance (material noncompliance) Recommendation: The District should strengthen its internal controls with adopted policies and procedures to include a review of reimbursement requests to ensure indirect costs are allowable and adequate source documentation is maintained for federally-funded activities. Action Taken: Adequate documentation will be maintained to support the calculations of the indirect costs and any other costs associated with ESSER funding. If the U.S. Department of Education has questions regarding this plan, please call the responsible party listed below. Sincerely yours, Jeff Bollinger Superintendent Mountain Valley School District RE-1 Lisa DuPont Co-Business Manager Mountain Valley School District RE-1 Rebecca Quintana Co-Business Manager Mountain Valley School District RE-1

Views of Responsible Officials and Planned Corrective Actions: Staffing turnover limited ability for portfolio property managers to effectively manage tenant files at each building location. Inglis has contracted with an external expert regarding implementation and process training for Yardi, the new property management system. Once fully implemented there are several key internal controls within the system that will alert property management team to tenant issues regarding rent and recertifications. All of the itemized items listed as findings are part the tenant life cycle record in the property management system Inglis is implementing.