Corrective Action Plans

Housing Choice Voucher Program ? Assistance Listing No. 14.871 We recommend that the City review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA staff will review its current procedures for completing rent reasonableness requirements. As noted above, they will pursue options available under their contract with McCright, data feeds that could work within their existing software, and any other options in use at peer agencies to determine the best specific path forward to ensuring compliance with rent reasonableness requirements. PHA Supervisory Staff have also requested more detailed information on the audit results to help them further analyze the specific rent reasonableness cases where documentation and performance errors were made which led to this finding. This will help supervisory staff conduct a more thorough review and consider additional procedural changes. Also, as noted above the Finance Department suggests the PHA engage its software vendor or a peer agency to review functionality in the software to determine whether additional features could be employed in the software to prevent a HAP payment on a unit where rent reasonableness has not been completed yet. Name(s) of the contact person(s) responsible for corrective action: Steve Schaer Planned completion date for corrective action plan: 3/31/2024

KCHD will implement internal controls to review outstanding items and ongoing projects monthly, particularly those charged to grants, for proper reporting to ensure compliance with the terms of the award. Specifically, the Business Manager and Administrator will identify any hidden issues that could violate Uniform Guidance reporting requirements. The Health Department expects to have this procedure in effect no later than July 1, 2023. Additionally, the KCHD plans to obtain adequate resources to assist the financial and grant reporting function to ensure compliance.

2022-001: Reporting Corrective Action: Due to ever-evolving processes, LCCC did not fully comprehend all reporting nuances for the HEER program. The Comptroller and Director of Sponsored Awards will continue to perform in-depth reviews of all reporting guidance and requirements to ensure accurate reporting. Anticipated Completion Date: June 30, 2023 Contact Persons: Nola Rocha, Comptroller and Jennifer McCartney, Director of Sponsored Awards and Compliance

Finding 2022-003: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Plan to Correct: If we are to receive federal funding of this kind in the future we will insure the validity of any expense chosen after verifying against the standards set by the fund guidelines before expenditures are made or any reporting is completed. Internal staff will also review work papers in detail to double check data integrity to ensure reporting is accurate. We will work with our CPA firm or other appropriate consultant if we have any questions surrounding expenses chosen. Responsible Party: Denise Doucette, CFO/VP Estimated Completion: Ongoing.

2022-006 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 2022 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. From 2023, PSI will resume delivering in person training to its global finance and program staff.

Reference Number: 2022-003 Description: Lack of Written Procedures for Federal Awards Corrective Action Plan: The Society will develop written procedures for federal awards received. Anticipated Corrective Action Plan Completion Date: ongoing Contact Information: For additional information regarding this finding, please contact Larry Gaffey, General manager at 262-723-3228.

Identifying Number: 2022-001 Finding: The Center did not file a FFATA sub-award report for sub-grants greater than or equal to $30,000. The Center did not have a policy and procedures in place to ensure compliance with the FFATA reporting requirement. Corrective Actions Taken or Planned: On June 28, 2023, the Vice President of Finance of the Center filed the FFATA sub-award report for sub-grants greater than or equal to $30,000.

Corrective Action Plan: The Department will continue its work to ensure the data provided to the USED and other entities is timely and accurate. This includes communication to subrecipients through CCIP notes, reminder emails, reporting dashboard information and guidance documents on the time period for reporting and expectations. Going forward, the Department will also include a training webinar and open office hours. In addition, the Department will revise its process for annual reporting ESSER expenditures to the USED to ensure the Department?s survey to collect ESSER expenditure data from subrecipients has a validation/error test against OAKS payments for a given reporting period. If the data does not align with the expenditure data in OAKS, the subrecipient will have to undergo data correction to ensure accurate reporting. Data correction will vary depending on the organization and any previous expenditures reported to USED. Anticipated Completion Date for Corrective Action: July 2023 Contact Person Responsible for Corrective Action: Corey Fronk, Director of Audits and Risk Management, Ohio Department of Education 25 South Front Street, 7th floor, Columbus, Ohio, 43215 Phone Number: 614-644-7812, E-Mail Address: Corey.Fronk@education.ohio.gov

Contact Person - Jeremy Tammi, Superintendent. Corrective Action Plan - The District will implement procedures to ensure the budget and expenditures are reported in the correct year. Completion Date - December 31, 2022.

Finding 2022-001 Federal Agency Name: Department of Homeland Security, State of Idaho Office of Emergency Management Program Name: Disaster Grants ? Public Assistance CFDA # 97.036 Finding Summary: Administrative labor costs were claimed for reimbursement that fell outside the period of performance of the federal award in two instances. In addition, one instance in which the Cooperative submitted a material cost for reimbursement that was not used in the project. Responsible Individuals: Reed Christensen Corrective Action Plan: Management revised its procedures to ensure a review of labor hours submitted in the future for FEMA-reimbursed projects in order to ensure the labor hours submitted fall more precisely within the Federally specified timeframe of the disaster declaration. As it concerns material cost reimbursements, in the future the work order will be reviewed and reconciled to the ?pick list? quantities. This has also been added to our FEMA-related work procedure. Anticipated Completion Date: March 30, 2023

2022 ? 008 Reporting (Significant Deficiency and Noncompliance) Management Response: The City agrees with the finding. The City will implement controls to ensure compliance with federal financial management regulations. The City recognizes that it needs to improve its procedures for preparing quarterly report for Treasury funds. Going forward, the Family and Community Services Department will work with the Grants Section to develop and implement standardized procedures for identifying and documenting expenditures, and for reviewing quarterly reports prior to submission. Timeline and Responsible Position: June 2023 ? City Controller/DFAS Deputy Director and Director of Family & Community Services

Finding 2022-002 Please see management?s action plan below in response to EY?s Federal Award Finding and Questions Costs, 2022-002 ? ?Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls.? Management?s Response and Action Plan: Management has had in place internal controls to ensure that the calculation of lost revenues is correct and accurate. Management recognizes the need to document internal controls over lost revenue for PRF funds. Management will ensure that documentation for compliance with internal controls is maintained to substantiate lost revenue related to PRF funds. Responsible party: Jordan Urban, AVP Finance, FP&S Expected Completion Date: December 31, 2022 with Period 4 portal submission

Finding 2022-001 Please see management?s action plan below in response to EY?s Federal Award Finding and Questions Costs, 2022-001 ? ?During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and conditions of the award and the calculation of expenses attributable to Coronavirus reported during July 1, 2021 to June 30, 2022?. Management?s Response and Action Plan: Management has had in place internal controls to ensure that the calculation of expenses attributable to Coronavirus is correct and accurate. Management recognizes the need to document internal controls over terms and conditions and expenses attributable to Coronavirus. Management will ensure that documentation for compliance with internal controls is maintained to substantiate review of terms and conditions and expenses attributable to Coronavirus. Responsible party: Dessy Chi, Director of Finance-LLUHC, FP&S Expected Completion Date: December 31, 2022 with Period 4 portal submission

2022-058 Department of Human Services Perform timely reconciliations of refinanced OR-Kids transactions Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.667 Social Services Block Grant Federal Award Numbers and Years: 2101ORSOSR, 2021; 2201ORSOSR, 2022 Compliance Requirement: Period of Performance Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: $1,308,457 (likely) Criteria: 42 USC 1397a(c); 45 CFR 75.386a(2); 45 CFR 96.30b(2) According to federal requirements, to be eligible for federal funding, expenditures must be expended in the fiscal year allotted or in the succeeding fiscal year (period of performance). Additionally, federal post-closeout requirements stipulate the return of any funds due because of later refunds, corrections, or other transactions. As part of the grant closeout process, block grants also require the grantees to report the total funds expended and the date of the last expenditure. Grant closeout is the process by which the federal awarding agency determines that all applicable administrative actions and all required work have been completed. Social Services Block Grant (SSBG) has expenditures originating from the child welfare system, OR-Kids. OR-Kids is used to manage placements, eligibility, payments, and other case information. When various corrections are initiated, OR-Kids can re-process transactions as far back as January 1, 2008. For some placement corrections, OR-Kids processed the recovery of the funds in a state grant (Miscellaneous Other Fund grant), instead of the federal grant. To date, the department has not completed permanent fixes to the OR-Kids system to prevent these re-processing errors from occurring. During fiscal year 2022, the department was reconciling the Miscellaneous Other Fund grant and identified refunds related to SSBG. The refinanced expenditures reduced the amount of SSBG expenditures originally reported in closed grant awards. Instead of submitting a refund, the department identified expenditures recorded in subsequent grants that could have been used to backfill the reduction of expenditures. Allowable expenditures, that met the period of performance, were subsequently moved. To illustrate, a total of $1.3 million of expenditures were moved in the accounting system from grant award 21 (federal fiscal year 2021) to grant award 20. The department then moved expenditures totaling $1.2 million from grant award 20 to grant award 19. This process continued for all grant awards going back to grant award 11 (federal fiscal year 2011). The table below illustrates the movement of expenditures between grant awards. ?See Corrective Action Plan for Table? Although the department only moved expenditures that qualified for each respective period of performance, we question whether the federal awarding agency would allow the department to backfill the $1.3 million of expenditures in question after grant closeout had been completed. We recommend department management conduct more timely reconciliations of OR-Kids refinancing adjustments to ensure adjustments are made during the related periods of performance. We further recommend management work with its federal awarding agency to determine if it is appropriate to backfill program expenditures between grants to account for the reduction in expenditures created by the reconciliation process. If not appropriate, the questioned costs should be repaid to the federal awarding agency. MANAGEMENT RESPONSE: The agency disagrees with this finding. SFMA grant phase is an internal tracking mechanism only and is not mandated by ACF. None of the expenditures observed were moved into or out of the period of performance for which they originally qualified for. SSBG awards have a two-year period of performance for claiming. As a result, there is an overlap between internal phases where expenditures qualify for two at any given time. Assignment of phase in SFMA is based on internal balancing needs to ensure claiming is not over or under the award for that period. Prior period adjustments occur periodically and are debited or credited to the phase they were originally recorded under. Should those adjustments cause a phase to become under or over reported, the assigned phase in SFMA is adjusted to maintain consistency between SFMA expenditures and the SF-425 report provided to ACF. If a prior period increasing expenditure is outside the period of performance, it is moved to non-reportable and state only funding. Anticipated Completion Date: N/A Contact: Fariborz Pakseresht, Oregon Department of Human Services Director

FINDING 2022-009 Contact Person Responsible for Corrective Action: Melissa Hinds, Director of Special Education Contact Phone Number: 812-279-3521 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: As of July 2022, internal controls were put into place to ensure supporting documentation was attached to all reimbursements. Anticipated Completion Date: July 2022

Item: 2022-004 Assistance Listing Number: 14.241 Programs: Housing Opportunities for Persons with Aids Federal Agency: U.S. Department of Housing and Urban Development Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 144347 Award Year: July 1, 2021 ? June 30, 2022 and July 1, 2022 ? June 30, 2023 Compliance Requirement: Allowable Activities and Costs Criteria: Under cost principles established by 2 CFR 200.430, compensation for personal services includes all remuneration, paid currently or accrued, for services of employees rendered during the period of performance under the Federal award, including but not necessarily limited to wages and salaries. Condition: In our sampling of payroll expenditures charged to the program, we noted one employee's wage rate charged to the grant was not updated consistent with the employee's wage rate increase paid in their payroll. As a result, the incorrect amount of payroll costs was charged to the program (undercharged). Name of Contact Person: Mike Fett, CFO Phone Number: (602) 265-8338 Anticipated Completion Date: September 30, 2023 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will implement controls to ensure payroll costs charged to the grant properly reflected payroll changes and that amounts charged to the grant were properly supported by current wage rates.

Finding 2022-001 Planned Corrective Action: The District?s management will evaluate the grant monitoring process and ensure all documentation for federal grant requirements are maintained, with a planned implementation date by the Financial Officer of January 23, 2023.

Finding Number: 2022-002 Finding Title: Activities Allowed and Unallowed, Allowable Costs/Cost Principles, and Period of Performance Program: 21.023 COVID-19 ? Emergency Rental Assistance Program Name of Contact Person Responsible for Corrective Action: Jamie Radel, Senior Project Coordinator, Community Planning and Economic Development Corrective Action Planned: City staff will review invoices in conjunction with itemized documentation to support the expenditure prior to payment. Anticipated Completion Date: December 31, 2023

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-004 Community Development Block Grant ? Assistance Listing number: 14.218 Recommendation: We recommend the City establish cutoff procedures for the accrual of grant related reimbursements to ensure expenditures are invoiced within the appropriate contract dates as specified by the agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that grant expenditures processed after the end of the fiscal year are thoroughly reviewed to ensure they are recorded in the correct fiscal year. Name(s) of the contact person(s) responsible for corrective action: Mark C. Mason, CPA, Financial Services Director; Juan G. Guerra, ICMA-CM, CPA, Controller Planned completion date for corrective action plan: December 31, 2023

2022-001 Revenue Recognition Views of Responsible Officials and Corrective Action Plan: Responsible Officials: Maggie Boland, Managing Director Valerie Bunns, Director of Finance and Administration Corrective Action Plan: Signature will incorporate training on ASU 2018-08, Not-for-Profit Entities (Topic 958) related to revenue recognition of pledges and contributions for the appropriate personnel.

Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures for allocating expenses to grants to ensure only expenses incurred during the grant period are charged to grants. Completion Date: Immediately

DEPARTMENT OF TREASURY 2022-005 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) ? Assistance Listing No. 21.027 Recommendation: We recommend the County design controls to ensure review and approval of reports are maintained in the County's grant files. Also, we recommend the County design controls to ensure reports agree to the documentation used to prepare them. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has revised internal controls to ensure reports are prepared accurately and consistently with the back-up used to prepare them. Within these internal control procedures, an appropriate review and approval process will be utilized and documented to ensure report is accurate with underlying support documentation and clearly documents this review and approval control. As a primary function of this review and approval control process, the reviewer/approver will provide assurance that the federal award is reasonably being managed and complies with all applicable statues, regulations, and terms and conditions. Evidence of review and approval will be maintained within the grant file support documentation for future reference and to be provided in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Barry Anderson Planned completion date for corrective action plan: June 30, 2023

Finding 2022-001 Activities Allowed or Unallowed and Eligibility Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (HRSA COVID-19 Uninsured Program) Mercy Community: Various Award Number: Various Award Period of Performance: 07/01/2021?March 2022 Condition: Mercy Health did not retain supporting documentation over the HRSA COVID-19 Uninsured Program report query logic (the Report) that was developed to identify patients that meet the allowability and eligibility requirements of the HRSA COVID-19 Uninsured Program. In addition, supporting documentation was not retained to validate who had access to modify and run the script, what changes were made to the script, and how any changes to the script were tested and implemented during the fiscal year based on changes to Health Resources and Services Administration (HRSA) guidance. Further, management did not maintain supporting documentation to demonstrate how it validated the completeness and accuracy of the data extracted by the script. In addition, Mercy Health did not retain supporting documentation over its approval of HRSA COVID-19 Program claims, determination of a patient's uninsured/self-pay status, and review of credit balances. While management had a process to identify and review claims for allowability under the HRSA COVID-19 Uninsured Program, determine a patient's uninsured/self-pay status through third-party insurance discovery, and review of credit balances, sufficient supporting documentation was not retained to support internal controls over the process. Cause: Development of the Report occurred outside of the Information Technology (IT) department that would require a formal process for the development of IT reports, access and program changes; the report resided in the Revenue Cycle department. The Revenue Cycle department did not develop internal control over report writing, program changes and user access. In addition, while management represented that the Report?s logic and subsequent changes to the Report?s logic were reviewed, no audit evidence was retained to support internal controls over that process. Management represented it performed a review of claims charged to the HRSA COVID-19 Uninsured Program for allowability; however, supporting documentation to evidence that the internal controls were sufficiently designed and operating effectively was not maintained. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Views of Responsible Officials and Planned Corrective Actions: In March 2022, HRSA announced that the HRSA COVID-19 Uninsured Program was ending. Therefore, remediation of internal controls is no longer applicable. If this program is reinstated, Mercy will take the necessary steps to ensure proper documentation is retained to provide evidence of our internal control processes. Responsible Parties: Mercy?s Revenue Management Department Date of Completion: Not applicable since program has ended.

FINDING 2022-006 Contact Person Responsible for Corrective Action: Mindy Byers Contact Phone Number: 765-364-6401 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: ALN changed during middle of audit period. Will inquire mid-year with departments managing grants to see if any ALN changes. If so, new grant fund will be created. Anticipated Completion Date: 08/2023

2022-003 Child Nutrition Cluster Recommendation: School Corporation management should establish a system of internal controls to ensure compliance with the grant agreement and program income requirements. Documentation should be retained to support the existence and accuracy of all program income earned. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation with review existing control processes surrounding program income and strengthen procedures to ensure documentation to support program income is adequate and reviewed. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately