Corrective Action Plans

The City will use the contract start date (7/1) as the Obligation date, and will submit the FFATA report accordingly.

Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement     Contact: Chris Holmes   Title: Controller  Phone Number: 202-235-1938  Estimated Completion Date – done  Corrective Action  The results of the 2023 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on the allowability of trailing costs and the unallowability of newly incurred costs. During 2023, PSI resumed delivering in person training to its global finance and program staff and will continue to offer training during 2024.

Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles   Contact: Chris Holmes   Title: Controller  Phone Number: 202-235-1938  Estimated Completion Date – ongoing  Corrective Action  The results of the 2023 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on recording expenses within the correct accounting period. During 2023, PSI resumed delivering in person training to its global finance and program staff and will continue to offer training during 2024 to address such issues.

2023-002 – Internal Control over Compliance and Compliance with Period of Performance Contact Name – Jeff Kaufman Position – Global Controller Contact – jkaufman@corusinternational.org Estimated date of completion: September 30, 2024 Corrective Action Plan – Corus management concurs with this finding and reaffirms its commitment to responsible stewardship of funding awarded to Corus by the United States Government and other donors. There are occasions when Corus may anticipate successfully negotiating a program extension with the USG or other donors. In the event there are immediate needs of the program’s potential beneficiaries, Corus may decide to utilize its own unrestricted funds in expectation that if the extension is obtained, these funds will be reimbursable under the terms of the extension. Corus recognizes that there is no guarantee that the program will be extended; thus, it understands that it incurs the expenses at its own risk. As a point of emphasis, while the expenses referenced in this finding were incorrectly coded such that this spending was erroneously included on the SEFA, Corus did not draw on USG funding to recover these expenses, the expenses were funded by Corus’ own unrestricted resources. Action steps to be implemented during the Corus 2024 fiscal year include: • The steps outlined in response to 2023-01 should also ensure proper account coding of expenses and timely monitoring of program spending against available obligated funds as well as program expiration dates.

Kid Power, Inc. agrees with the finding. The Organization will implement effective and written procedures for the review of cost allocation journal entries, allowable costs and activities, period of performance, matching, and reporting. The written procedures will explicitly lay out the processes for review and approval of each of these compliance components per each federal Assistance Listing that the Organization receives. Curtis Leitch, Deputy Director, will use the most up to date 2 CFR Part 200, Appendix XI - Compliance Supplement to identify the specific compliance requirements for each of the Assistance Listings and create the written procedures. Procedures for internal controls include monthly expense reports completed through Brex by the Operations Manager, Charles Thomas, and stored in Kid Power, Inc.’s Google Drive; allowability and expense allocations will be reported in Google Drive on monthly basis and completed by the Deputy Director, Curtis Leitch; cost allocation journal entries will be inputted into QuickBooks on monthly basis by the Deputy Director, Curtis Leitch. Federal allocation and reimbursement reporting will be prepared by the Deputy Director, Curtis Leitch; reviewed by the Executive Director, Andria Tobin; and submitted by the Deputy Director, Curtis Leitch, on a quarterly basis.All reviews and approvals will be documented henceforth in Kid Power, Inc.’s Google Drive. Curtis Leitch, Deputy Director, will oversee the implementation of this corrective action.

Finding 2023-002: Overcharge of Indirect Costs Federal Grant – ALN 93.959 Condition – During testing it was noted that indirect costs were overcharged for ALN 93.959 by an immaterial amount. Corrective Action – The HealthWest grants policies and procedures have been updated and will follow the de minimis indirect rate. All HealthWest staff will be required to review the policy annually. Contact Person – Brandy Carlson, Chief Financial Officer Anticipated Completion Date – June 30, 2024

Finding 2023-001: Overcharge of FICA Expenses Federal Grant – ALN 93.958 and ALN 93.959 Condition – During testing it was noted that FICA costs were overcharged for ALN 93.958 by $6,663 and for ALN 93.959 by $458. Corrective Action – HealthWest is implementing Attendance on Demand (AOD). AOD is a timekeeping system that will allow staff to account for times worked under grant funding. HealthWest will update the grants policies and procedures accordingly and will review expenses monthly for accuracy and compliance. HealthWest will also create a Timekeeping policy and procedure for AOD. All HealthWest staff will be required to review the policy annually. Contract Person – Brandy Carlson, Chief Financial Officer Anticipated Completion Date – October 1, 2024

Finding 2023-003 – Reporting Cluster: Student Financial Assistance Federal Agency: Department of Education Assistance Listing Title and Number: 84.268 - Federal Direct Loan Program Award Year: Fiscal year 2023 Management concurs with the auditors’ finding. The academic year end date was reported incorrectly for Direct Loan borrowers enrolled in Law School. All affected records have been identified and were limited to students seeking professional degrees. All incorrectly reported dates have been corrected in the COD system as of June 13, 2024. Though the University had procedures in place to monitor the correctness of information submitted to the COD system, this error in one of our smallest student groups was overlooked during our office’s transition back to normal operations from COVID-19 procedures. To prevent a recurrence of this error, a separate review process will be added to our office workflow to annually ensure the accuracy of academic dates entered into the Banner student information system. Ronald Price, Associate Director, Student Financial Aid, Fiscal Operations and Loans of the University of Alabama (ronald.price@ua.edu), is responsible for implementing the corrective action planned. The University expects to complete this corrective action plan by July 31, 2024.

2023-003 Compliance of Special Tests and Provisions – National Service Criminal History Checks: Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper and documented prior to a member’s start date. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ending August 31, 2024

2023-003 – Period of Performance Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that expenditures are not charged to federal awards during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and Related services and the Portsmouth Finance department will monitor expenditures on an ongoing basis to ensure the funds are spent in accordance with the period of performance of the grant. The Finance department will review all purchases and notify the Office of Special Education if purchases are unallowable and do not follow the period of performance and have alternate suggestions on how the purchase can be made. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

Views of Responsible Officials: Beginning with the FY2023, Hope for Prisoners’ CEO reviews and approves all RFR forms in writing prior to submission. Oversight by specific board members will be provided through a review of the submitted RFR to compare it to the monthly financial reports already being provided.

Planned Corrective Action: To ensure grant funds are not utilized prior to final approval, grant application documents will be submitted to DESE by August 15th to ensure approval is given prior to costs being incurred. Additionally, we will identify alternative funding sources in the event grant approval is delayed and costs must be incurred.

We understand the auditor’s comments and the following action has been taken to resolve the situation. Procedures have been developed and implemented to ensure that grant draw requests are prepared, reviewed and submitted on a timely basis in accordance with the grant agreements.

Management concurs. The City will strengthen its policies and procedures related to federal award reporting to comply with reporting requirements.

Condition: A duplicate expense was recorded to the program and expenses were recorded to the program prior to the period of performance. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has instituted procedures to provide a review of journal entries to reclass expenses to grant funded programs and promptly record. As well, Finance staff have been added to oversee the accounting function for the grant. Contact person responsible for corrective action: Mary Lawrence, Director of Financial Analysis and Special Initiatives Anticipated Completion Date: 5/15/2024

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the allowable indirect costs reimbursed to the University from the NASA federal grant funds was not calculated correctly for fiscal year 2023. In recent years the University has applied for a quarterly no cost extension of the previously used indirect cost rate for federal grant purposes. In March of 2024 the University actively pursued a contract with a firm known as Point Consulting to help reevaluate the currently used in direct cost rate for the University. Pont consulting has been contracted by the university in past years, but the percentage has been simply rolled forward and not adjusted. Going forward the University plans to reevaluate the indirect cost percentage in accordance with federal guidelines. The accounting department will work directly with the Challenger Learning center to make sure that indirect funds are calculated correctly and drawn down in timely and accurate manner. Anticipated Completion Date: July 2024

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period of Performance: January 20, 2020 – May 11, 2023 Finding: Management did not consistently retain documentation evidencing the performance of controls to ensure allowable COVID-19 expenses were charged to the program. Corrective Action Plan: All of these deficiencies were related to the selections being more than 36 months old, which is past the current documentation retention policy of PVHMC for non-controlled substances and non-patient records. In order to ensure that documentation is retained for future audits, all FEMA related documentation that is still retained will be kept indefinitely to ensure compliance in future years. Person Responsible: Juli Hester, Chief Financial Officer Estimated Completion Date: May 31, 2024

The Northeast Texas Public Health District (NET Health) will take steps to ensure overall effective grant monitoring and to increase communications between NET Health Grant Managers and the Chief Financial Officer and Chief Executive Officer. The NET Health Leadership Team will discuss any issues during our weekly Leadership Team meetings to ensure compliance. These weekly meetings will address costs expended within the grant parameters and ensure grant funds will be more evenly expended during the year as appropriate. NET Heatlh will continue to develop effective methods of grant oversight as it finds weaknesses in its processes. To ensure compliance with the period of performance requirements, NET Health will change its processes effectively immediately. Going forward checks will only be prepared, dated, signed, and mailed to vendors after work is completed or items are received. There will be enhanced internal controls by establishing procedures to monitor and ensure timely payment of accrued expenditures, such as regularly accounting for any outstanding checks and actively communicating with vendors on performance requirements. In addition, we will enhance communication and coordination among relevant departments to expedite the payment process while maintaining compliance with grant regulations. George T. Roberts, CEO, and Lawanda Owens, CFO, are the persons responsible for this action plan going forward. NET Health is expected to have this action plan implemented by May 1, 2024.

As of January 2, 2024 CAL, hired a staff account (Melanie Richards) to ensure all expenses are recorded in compliance with performance periods. The Associate Director of Finance will review all postings monthly and consult with the Vice President of Finance on any corrections or recommendations.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: Corrective action in progress Corrective Action: The Department is strongly committed to ensuring the health, safety, and well-being of all children in care. The Department concurs with the finding and has taken the following actions: • In the fall of 2022, the Department began recruiting new staff to address staff turnover issues and providing training on child care licensing rules and regulations. • In November 2022, added new positions to assist supervisors with onboarding and training new staff and focused training on monitoring visits, caseload management, and health and safety requirements. • Implemented a data driven, phased in approach, to return staff to in-person field work after the COVID-19 pandemic: o In July 2022, implemented return to in-person field work by reducing pandemic level requirements and authorizing staff to visit providers on-site to assist with meeting health and safety requirements. o In February 2023, developed and implemented a field practice onboarding process to streamline training for newly hired staff on practices to support the annual monitoring of all licensed child care providers. o In the spring of 2023, prioritized monitoring visits to return to compliance with Child Care and Development Fund program health and safety requirements. • Conducted a root cause analysis to determine other underlying causes for missed monitoring visits and untimely follow-ups, and how to address them. • For license-exempt family, friend, and neighbor (FFN) providers, the Department: o Received approval from the Office of Child Care for a hybrid monitoring approach (in-person and virtual visits). o Dedicated staff resources to update the WA Compass system to include all health and safety requirements for FFNs and address data format issues. Completion Date: Agency Contact: The Department will continue to strengthen internal controls as follows: For licensed providers: • Create in-training licensing positions to assist with staff recruitment efforts. • Continue to track and monitor health and safety requirements with available tools until all WA Compass system development is completed. • Examine ways to secure resources to add additional full-time staff to support caseload needs. For FFN providers: • Continue to track and monitor FFN health and safety requirements with available tools until all WA Compass system development is completed. The conditions noted in this finding were previously reported in findings 2022-045, 2021-039, 2020-042, 2019-039, 2018-035, 2017-025, 2016-022 and 2015-024. Estimated July 2025 Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Health Care Authority did not have adequate internal controls to ensure payments to providers for the Block Grants for Prevention and Treatment of Substance Abuse program were allowable and met period of performance requirements. Questioned Costs: Assistance Listing # 93.959 93.959 COVID-19 Amount $3,447,346 Status: Corrective action not taken Corrective Action: The Authority does not concur with the finding. The Authority maintains that its internal controls are effective, and procedures are compliant with grant requirements. No corrective action will be implemented. The costs questioned by the auditor do not reflect funds that have been paid or drawn from the grantor. As a result, there are no funds to return to the grantor. The conditions noted in this finding were previously reported in findings 2022-067, 2021-057, and 2020-059. Completion Date: Not applicable Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

Finding: The Department of Social and Health Services did not have adequate internal controls to ensure individuals are eligible to receive benefits for the Money Follows the Person program. Questioned Costs: Assistance Listing # 93.791 Amount $0 Status: Corrective action complete Corrective Action: The Department partially agrees with the finding. The Department agrees that the Financial and Social Services Communication (14-443) forms were not provided to terminate the enrollment of the four exceptions identified in the finding. However, in those exceptions, the Roads to Community Living (RCL) disenrollment communication was made in accordance with the existing Nursing Facility Case Management policy as defined in Chapter 10 of the Long-Term Care (LTC) Manual. In addition, all clients met eligibility criteria for RCL services or were converted to another Home and Community Based program within the 365-day RCL demonstration year limitation. In these cases, the client was converted to a state plan or waiver with the new program start date noted on the 14-443 forms. The 14-443 form is a communication tool used by the Department’s public benefit specialists. For Modified Adjusted Gross Income (MAGI) enrolled Medicaid participants, benefits are managed by the Washington State Health Care Authority and the 14-443 form is not required or used by the Department’s public benefit specialists. This MAGI beneficiary communication detail was not articulated in the RCL chapter of the LTC Manual. As of May 2024, the Department updated Chapter 29 of the LTC Manual to clarify instructions related to when the 14-443 form must be completed for MAGI participants and what needs to be included on the form when it is required. Completion Date: May 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal provider eligibility requirements for the Medicaid and Children’s Health Insurance Program. Questioned Costs: Assistance Listing # 93.767 93.767 COVID 93.775 93.777 93.777 COVID 93.778 93.778 COVID Amount $0 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the finding. The Authority does not concur that four providers did not receive a proper license check, nor that the backdated provider was noncompliant with regulations prior to receiving a National Provider Identifier (NPI). When a provider’s license expires, the Authority enters an end date for the provider taxonomy to prevent future payments. The Authority does not pay claims without an NPI and this is compliant with federal requirements. Corrective action has been in process to address revalidation issues. As of January 1, 2024, the Authority implemented a system change moving the revalidation date to 90 days before the end of the five-year period. The Authority is developing additional procedures to strengthen internal controls over provider enrollment. The conditions noted in this finding were previously reported in findings 2022-055, 2021-047, 2020-046, 2019-048, 2018-042, 2017-033, and 2016-035. Completion Date: Estimated December 2024 Agency Contact: William Sogge, CPA, CIA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to providers were allowable and properly supported for the Social Services Block Grant. Questioned Costs: Assistance Listing # 93.667 Amount $8,518,020 Status: Corrective action in progress Corrective Action: The Department maintains that funds were not improperly charged to the Social Services Block Grant (SSBG) program. The Department utilizes grant-level management for all federal funds, including the SSBG program. This process consists of making grant-level adjustments between allowable grant sources to properly spend grant funds within the allowable period of performance and ensure level of effort and matching requirements are met. The Department allocated the SSBG funds to eligible clients and allowable activities in compliance with 45 CFR 98.67 but did not include the level of data recommended by the State Auditor’s Office (SAO) for some transfers. Cost objectives within the accounting system are used to track SSBG funding. Expenditures eligible for the SSBG program are transferred at the cost objective level and not the transaction level. The SAO tested a sample of 16,006 payments which totaled 94% of total provider payments charged to the grant. SAO found that all payments were for activities that were supported, allowable, authorized, and accurate. SAO is questioning the costs of the remaining payments because the transfer of expenditures was not completed at the transaction level. Those remaining payments were transferred from eligible and allowable expenditures for the SSBG program. The Department is committed to collaborating with SAO to determine an appropriate methodology which identifies a sampling unit that can be used to accurately test compliance. In response to the auditor’s recommendations, the Department will develop and maintain a business process that would allow adjustments to include transaction level data. Completion Date: Agency Contact: Estimated December 2025 Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure group care facility employees and adults residing in prospective caregivers’ households had cleared background checks before having unsupervised access to children. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department partially concurs with the finding. The auditors identified two exceptions where fingerprint checks for two family foster home adults were completed two days later than the required timeline of 15 calendar days. The delay was due to the misspelling of one applicant’s last name in the system. Upon correction, the applicants subsequently completed the fingerprint checks and were determined eligible. As stated in the finding’s Cause of Condition, the Department developed a corrective action plan to address the internal control deficiencies in response to the prior year’s finding which had not been fully implemented within the current audit period. The Department is confident that all staff who work with children and youth have cleared background checks. As of April 1, 2023, the Department implemented a new process for processing background checks for group care facilities to strengthen internal controls, documentation, and clarification on the “effective date.” The updated process is outlined below: • A new form was created with clear instructions for the group care facilities to provide the applicant/employee information, including the background check confirmation code, directly to the Department’s Background Check Unit (BCU). • The BCU works with the applicant/employee through the fingerprint background check process. • The results are sent directly to the BCU, at which time they complete a child abuse/neglect history check and if needed a suitability assessment. The BCU documents the results in FamLink with the date the background check is completed. • The BCU emails the results to the group care facility and the Department’s Licensing Division (LD) group. If the applicant/employee is cleared and is not a renewal, LD staff adds the applicant/employee to the group care facility in FamLink with the clearance information attached. The conditions noted in this finding were previously reported in finding 2022-050. Completion Date: April 2023 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov