Corrective Action Plans

Action taken in response to finding: The new CFO reviews and approves federal grant draw requests prior to the submission to the granting agency. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: August 31, 2024

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are incurred, charged appropriately and supporting documentation is maintained on file. Additionally, AP and Finance team review supporting documentation and ensure completeness. Name(s) of the contact person(s) responsible for corrective action: Floral Reed Planned completion date for corrective action plan: June 30, 2024

Action taken in response to finding: The Finance team corrected their processes to ensure proper recording of payroll costs during the time of the FY22 Audit procedures; however, the changes were made to subsequent months and previously submitted months were not retroactively corrected. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: Sep 2023 & New rates: Sep 30, 2024

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.

The subaward will be updated to include elements required by Uniform Guidance, Part 200.332.

1. Cleveland UMADAOP will obtain written prior approval for any expenditure deviations from the originally approved budget. This topic will be covered when training occurs during the quarterly review of grant guidelines. 2. As part of its updated financial policies and procedures, Cleveland UMADAOP will seek to document all financial activity to ensure compliance with grant and federal guidelines. 3. As part of the updated financial policies and procedures, Cleveland UMADAOP will seek written confirmation from funders whenever there is a deviation from the terms outlined in the original award documentation. 4. As part of the updated financial policies Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

Finding ref number: 2023-002 Finding caption: The Housing Authority had inadequate internal controls for ensuring compliance with the Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Housing Authority contact person: Joanna Tepley, Finance Director 1555 S. Methow Street Wenatchee, WA 98801 (509) 663-7421 Corrective action the auditee plans to take in response to the finding: The HCV department will be creating an Excel spreadsheet for the inspector to complete and utilize to better manage compliance dates. It will include the failed inspection date, compliance due date, tenant and landlord names, passed date, abatement start date, and memos. In addition, the supervisor will be monitoring this spreadsheet and auditing inspection compliance more frequently. Anticipated date to complete the corrective action: Immediately

We appreciate the auditor's identification of the material weakness in our internal controls over the review of payroll registers for allowable costs and activities and period of performance related to our federal award. We understand the importance of maintaining effective internal controls to provide reasonable assurance that we are managing federal awards in compliance with statutes, regulations, and the terms and conditions of the award. Documentation Process: We will implement a documentation process to ensure that payroll registers are reviewed for accuracy by management on a timely basis and that the review is properly documented. Specifically, we will: 1. Assign responsibility for reviewing payroll registers for accuracy by management to a specific staff member. 2. Establish a process for reviewing payroll registers for accuracy by management, including the use of a standardized form. 3. Ensure that all payroll registers related to our federal award are reviewed for accuracy by management on a timely basis and that the review is properly documented. 4. Investigate and resolve any discrepancies identified during the review process related to our federal award. 5. Document the review process related to our federal award and ensure that all documentation is properly maintained. Person Responsible: Anthony Jayesingha Date Corrected: 7/31/2023

2023-003 Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Sam Kimball Title:  Corporate Controller Phone Number: 202-296-9165 Estimated Completion Date – October 2024 Corrective Action: Management acknowledges the finding and notes that the costs identified related to a project that ended in March 2023. On October 1, 2023, the Foundation implemented a new ERP system that includes better controls around the period of performance, preventing transactions from being entered after the award end date and/or close out date, reducing the risk of recording transactions to projects outside of the stated period of performance. Therefore, management does not anticipate similar issues around period of performance going forward, as the risks are additionally addressed with the new system design.

The corrective action to be taken will be to created formal policies and procedures to ensure there is a second person involved in the reporting process. Expected Completion Date: December 31, 2024. Contact Person: Nicole McGee, Finance Director

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County review its procedures relative to allocating costs to Federal programs, and ensure only cost within the grant period are included. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements regarding period of performance. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

Corrective Action Plan: The Methodist College Registrar has been working with NSC to get the college relinked to the correct college in their system, which was fixed 11/2023. The registrar redeveloped database query to pull the old data that had been deleted by NSC due to FERPA and began sending accurate file submissions to NSC in June 2024. Files generated and submitted under the College’s new processes are taking roughly one week to process from initial submission, through error correction, and finalization. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: End of 2024

Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal control process to verify all requisition slips get signed. Anticipated Completion Date Fiscal Year 2024

We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have implemented a process that all grant claims/payment vouchers are formerly reviewed and initialed by our Executive Director.

Finding Reference Number: 2023-001 Identification of the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing No.: 10.557 Name of responsible official: James Geraghty Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: September 12, 2024 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Management was unable to provide evidence of a control being consistently performed to address the risk that the Health System may seek reimbursement for expenditures that are either out of contract period or are for non-permissible costs under the applicable contracts. Status Management concurred with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures, and that all expenditures were incurred in the proper period. Evidence of the monthly review and approval will be retained.

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to the Director of Finance. The Director of Finance reviews time and effort reports and compiles the data to allocate personnel expenditures, however, the time stamp of approvals was not effectively documented during 2023. The Foundation has implemented procedures to effectively time stamp the review and approval process, each month. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024

For Federal grants we will make it standard practice to request 1-2 months extension so that we get reimbursed for the work required to close out the grant after the grant end date. We have had federal employee's contact us as much as 4 months past the close date with erronious time consumming issues. Lynn Ketch, Executive Director, is the person responsible for the plan.

Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal audits. Person(s) Responsible: Sandi Weiss, AVP Finance Expected Completion Date: November 15, 2024

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID‐19 pandemic to support the receipt of the various allocations of the herein described COVID‐19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID‐19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID‐19 pandemic. The term “COVID‐19 Funds” means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020, through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021, through December 31, 2024. To provide further assurance that the COVID‐19 Funds were properly applied by the nursing home beneficiaries receiving COVID‐19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look‐back review plan. The framework of the lookback review plan will be for each nursing home beneficiary that received COVID‐19 Funds to submit during the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID‐19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in‐depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID‐19 Funds through the Foundation, plus another 10 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID‐19 Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID‐19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID‐19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID‐19 Funds to an unmet need for a qualifying purpose, those COVID‐19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID‐19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

FINDING 2023-005 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: Description of Corrective Action Plan: The Town of Upland will implement an oversight system to review the P&E Report before submission to the Federal Government. Anticipated Completion Date: Upon the submission of our next report due April 30, 2025

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.

Views of Responsible Officials: Management acknowledges that prior approval must be received before allocating any cost to an award that is incurred outside of the period of performance. While in this case approval was ultimately not granted, the cost was returned to the original project and removed from the affected project and subsequent drawdowns adjusted accordingly. To avoid incurring costs outside the period of performance, the following actions will be implemented:  Update the Global Center procurement guidelines to explicitly emphasize period of performance requirements when incurring expenses on grants and contracts.  Systematically confirm all purchase requests, vendor contracts, consulting agreements and subawards fall within the period of performance by including the start and end date of the grant or contract on all associated documentation. Responsible Officials: Daniel Grimshaw, Director of Finance Anticipated Completion Date: December 31, 2024

FINDING 2023-004 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Humphrey Nagila Contact Phone Number: 317-542-4554 Views of Responsible Official: We agree with this finding. The City will create a policy and procedure to ensure appropriate segregation of duties and reviews, approvals, and oversight are in place for reporting. This policy will require that two staff members from the Controller's Office prepare the quarterly Project and Expenditure report (P&E report). One staff member shall be responsible for preparing the report and the other will complete a review and submission of the report. Anticipated Completion Date: 12/31/2024