Corrective Action Plans

Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certified enrollment workers across California are consistently adhering to eligibility and documentation requirements. However, due to staffing challenges caused by the redirection of staff during the state of emergency declared for the COVID-19 pandemic, ADAP faced significant workforce shortages from March 2020 through much of 2023. This caused a backlog in SR processing, which delayed tasks, including the review of this client’s application. The client’s eligibility lapsed after 130 days, before SR could be conducted. The Eligibility Operations Section (EOS) of ADAP which conducts SR, is now fully staffed and has successfully addressed the backlog. As of early 2024, SR processing has returned to normal operations and is current. Estimated Implementation Date: Already implemented as of April 2024 Contact: Joseph Lagrama, ADAP Branch Chief California Department of Public Health

Condition: The Organization did not have appropriate segregation of duties surrounding the preparation and review of the monthly NIST schedules which accumulate the information necessary to calculate allowable costs and matching for drawdown requests. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Action: Subsequent to year end, the reorganized finance team put new controls and procedures in place. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/24

Condition: A process was not in place during the year to ensure program income was reported accurately on the SF-425 reports submitted during the year. Planned Corrective Action: Subsequent to year end, the reorganized finance team performed a recalculation and resubmitted corrected SF-425 reports. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/2024

Instructions were given to the Program staff to ensure that the program income funds will be used for CDBG activities before the withdrawal of CDBG funds.

Condition: The City did not submit the required annual report related to use of program income. Planned Corrective Action: The City will work with the EPA to determine how to report the use of program income. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

U.S. Department of Housing and Urban Development AUDIT FINDINGS: Finding Reference Number: 2023-001 Description of Finding: Homes with Hope, Inc. and Affiliate provides supportive housing via HUD Project Number 017-HD015, which requires the establishment and maintenance of a replacement reserve fund in accordance with its HUD Regulatory Agreement. The Project did not make the monthly deposits in a timely manner during the year ended December 31, 2023 as specified in the agreement, and seven months’ worth of deposits were delinquent as of December 31, 2023. This was due, at least in part, to cash flow issues that resulted from delays in the process that the Project’s property manager utilized during the period for invoicing HUD via a third-party vendor for the related rental subsidy funds. Statement of Concurrence or Nonconcurrence: Homes with Hope, Inc. and Affiliate concurs with this audit finding. Corrective Action: A new in-house billing process that does not rely on a third-party vendor has been implemented since year-end, which should eliminate the cash-flow issue, Additionally, all delinquent deposits that were due as of December 31, 2023, were deposited in March 2024. Name of Contact Person: Helen McAlinden President & Chief Executive Director 203-226-3426x14 hmcalinden@hwhct.org Projected Completion Date: Immediately

Finding No.: 2023-022 Program Income Responding Agency: Guam Environmental Protection Agency (GEPA) Responsible Personnel: Michelle Lastimoza (GEPA) Agency disagrees with the findings. The program income is not tied to assist or supplement the federal awards. The program income is used to supplement the special revenue funds handle by the department.

Federal program title – Community Development Block Grant – CDBG – CFDA 14.228 Recommendation: CLA recommends the County develop procedures, such as reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training with employees to ensure that knowledge is shared among the team members. Action taken in response to finding: The Grants department had two employees in FY 22/23. The Grant coordinator and assistant both terminated county employment in fiscal year 22/23 and left virtually no records. Information and materials, they did leave behind were stuffed in boxes and tracking in the electronic workbook was not fully completed. Admin staff trained the Grant employees but was unaware they were not following the process and procedures, and only saving information to their personal computer. Current admin staff requested the documents from prior staff members and they were received, though we are unsure if all were sent. Staff is doing their due diligence and working diligently to get back on track in monitoring activities, and train the newly hired staff. There is insufficient budget to hire the staff needed to fully monitor the CDBG efforts. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for correcting action plan: Undetermined at this time as the staff continues their current minimal CDBG efforts while still maintaining all other duties, and being short staffed. Existing CDBG workload is being closed out as fast as possible.

Financial Reporting and Review Process Description of the Finding: BSEDC did not have a secondary review process over the required financial reporting to Federal EDA. The lack of a secondary review process allowed for errors and omissions to go undetected, thus resulting in omission of $3,614 of loan origination fee income and interest income from federal program income calculations. Planned Corrective Actions: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director have implemented processes for the Senior Director of Finance to perform a secondary review of the required reporting to Federal EDA before it is submitted. Timeline for Completion: BSEDC implemented the secondary review process in October 2024 with the completion and submission of the FY24 annual report to Federal EDA. Responsible Person or Party: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director are both responsible for ensuring that the secondary review is complete before submitting reporting to Federal EDA.

Finding 2023-003 Finding Summary: In connection with the audit performed, it was noted that there was an instance where a patient received more federal assistance and another patient received less federal assistance than allowed based on federal poverty guidelines. Responsible Individuals: Kathryn Boyd, President and CEO Corrective Action Plan: The use of applying slides automatically, without reviewing the account first, has been prohibited by billing staff. In addition, clinic staff are not to apply any payments until the slide has been applied. If there are any issues with the slide, the clinic staff has been instructed to contact the billing staff for review and resolution. The Director of Revenue Cycle will randomly audit staff throughout the year to ensure additional slides are not applied and report out to the Chief Executive Officer. Anticipated Completion Date: 12/02/2024 (disallowing application of slides was previously implemented in 2023)

Finding Reference Number: 2023-003 Name of Responsible Person: Amy Reigel, Executive Director Reporting Views of Responsible Officials: We concur that there is no process in place to track that program income is expended prior to drawing on the federal grants. Concur or Do Not Concur with this Finding: Concur Agree or Disagree with Auditor Recommendations: Agree Completion Date or Proposed Completion Date: December 31, 2024 Actions Taken or Planned on this Finding: COHHIO's chart of accounts / financial management system will be updated to track the expenditure of program income in separate accounts.

2023-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corporation has conducted several staff trainings and has revised its review procedures for checking compliance to improve monitoring of the process by the Corporation. Completion Date: Estimated December 2024. Contact Person: Rajuan Sherman - Chief Financial Officer - 2731 M.L. King, Jr. Blvd, Tuscaloosa, AL 35403 - (205) 614-6070 - rsherman@whatleyhealth.org.

In 2023 there was a change in management within ACED’s financial staff. The current supervisor was unaware that there was program income that had not been recorded. ACED has contracted with an outside auditing firm. All accounts are being reviewed and reconciled and program income is being receipted. ACED will receipt all program income as it comes in and it will be immediately allocated to eligible projects.

Management’s response and corrective action is as follows: The Office of Community Development utilizes a loan service agency to manage, administer and oversee the funds for the loan program. Requests for loan forgiveness are submitted to the OCD by the loan service agency monthly for staff approval. The OCD staff then reconciles this income monthly and submits the monthly report to the Finance Department for processing. Loan balances are not only altered by program income but also through loan forgiveness offered to low-to-moderate income residents. All loans are reviewed for forgiveness in compliance with the Code of Federal Regulations and are approved by the OCD before being executed by the Parish Attorney’s Office to provide multiple layers of review. Case files are maintained at the OCD and documentation of monthly reconciling has been provided along with an accounting ledger. The OCD is working to improve monthly reconciling templates to include incurred fees from the loan servicing agency as well as forgiveness events to provide an accurate gross revenue. Expected Implementation Date: June 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development

Material Weakness in Internal Controls over Compliance Condition: As of the March 31, 2023 reporting date, the Town’s Project and Expenditure report had reported cumulative expenditures that were approximately $134,000 more than what was recorded in the grant fund on the general ledger. In addition, obligations were overstated by approximately $85,000. Corrective Action Planned: ARPA funds were tracked on a spreadsheet by the DPW Director. Reporting was done using the spreadsheet. Later, it was found the expenses didn’t match up to GL. We will use the GL for reporting purposes in the future. Anticipated Completion Date: Next submitted reporting Contact: Katie Medina, Town Accountant

Condition: The City did not prepare and file the four required quarterly Project and Expenditure reports for fiscal year 2023. Corrective Action Planned: The City has prepared and filed the Project and Expenditure reports for fiscal years 2023 and 2024. The City has implemented procedures to prepare and file the four required quarterly Project and Expenditure reports by the required deadline. We feel the finding has been resolved going forward. Anticipated Completion Date: June 30, 2024 Contact: Conor MacCorkle, City Chief Financial Officer

Finding 2023-002 Federal Agency: U.S. Department of Health and Human Services, ALN#93.224/93.527 Health Centers Cluster Response: Management acknowledges the finding of the auditors and recognizes the need for improving its Sliding Fee Discount Program systems, processes, and monitoring. In the latter half of 2024, the Billing Department leadership and front desk training team will renew its staff training and oversight efforts to improve compliance. Training on San Ysidro Health’s Sliding Fee Discount Program policies and procedures will be planned, scheduled, and provided for all front desk leaders and staff to ensure that the policies and procedures are followed to mitigate the risk of repetitive findings in following years. In addition, the Billing Department will expand the number of sliding fee encounters sampled and tested for compliance monthly. Noncompliance will serve as the basis for additional follow-up training of staff when noted. Monthly compliance reporting will be provided to senior finance and operational leaders to ensure ongoing monitoring of performance and timely resolution of noncompliance. Responsible Party: Charles Nubia, Director of Revenue Cycle; Brian Wallace, CFO Estimated Completion Date: July 22, 2024

In 2024, all required interest refunds were remitted. Additionally, management established a policy to remit annual calculated interest refunds by March 31st of the subsequent year.

CORRECTIVE ACTION PLAN 2023-001 Item 2023-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement Reporting Criteria The U.S. Department of Treasury SLFRF Compliance and Reporting Guidance requires the County prepare quarterly submissions of the Project and Expenditure Report. The 2023 Compliance Supplement identifies multiple Key Line Items in the report, including cumulative expenditures and current period expenditures. Internal control should be established and maintained to provide reasonable assurance that these requirements are complied with by submitting the reports accurately. Condition For the fiscal year under audit, the Project and Expenditure Report reported cumulative expenditures as program income, and the total obligation was reported as cumulative expenditures before the amounts had actually been spent. This was noted on the first two quarterly reports, but the last two quarterly reports were corrected. Cause The County followed a process for reviewing the reports and understanding program requirements; however, the new and emerging nature of the program and related guidance limited the internal knowledge necessary to identify the errors. Effect Required reports submitted to the Federal Agency contained inaccuracies to identified key elements. Recommendation We recommend that the County expand its review process for key reports to consider if new or emerging funding merits additional staff training or the engagement of outside assistance. PERSON RESPONSIBLE FOR CORRECTION ACTION: Becky Haynes, County Auditor CORRECTIVE ACTION PLANNED: We agree with the finding and have initiated discussions to provide training and implement procedures to ensure compliance. We have made these changes during the fiscal year, where the last two quarterly reports were properly stated . ANTICIPATED COMPLETION DATE: September 30, 2023. See prior year finding 2022-001.

Transitional Living for homeless Youth – Assistance Listing No. 93.550 Recommendation: It is recommended that the Organization implement controls to monitor program income and ensure that the funds are being properly used before requesting additional federal funds. This could include regular reporting on the use of program income and conducting periodic reviews to ensure compliance with program requirements. Additionally, the Organization should review its policies and procedures to ensure they are in compliance with program requirements and make any necessary updates. Finally, the Organization should ensure that all staff members responsible for monitoring program income are properly trained and have a clear understanding of program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During each Payment Management System Draw process, the Finance Director will verify the draw amounts and run a program income and expense report to verify that the amount of miscellaneous expenses for the Transitional Living Program are more than the program income received. A copy of the income and expense statement will be saved in each draw file with the other verification documents. A column for verification initials of this process was added to the ACF Grant Balances Spreadsheet used for recording the draw amounts and dates of the draws. Name(s) of the contact person(s) responsible for corrective action: Julia Montebello, Finance Director Planned completion date for corrective action plan: 4/26/2024

2) Finding 2023-002 a. Program Information: 14.267 Continuum of Care Program b. Criteria: In accordance with 2 CFR 200.307, program income (in this case, tenant rent) must be correctly determined and properly recorded in the accounting records. Eligibility and rent determination evaluations are performed for new tenants before move-in and annually for existing tenants to determine their portion of rent to pay via the Tenant Income Certification or Re-certification or Permanent Supportive Housing – Eligibility and Rent Determination forms which are approved by the San Diego Housing Commission. Housing program tenants are required to pay up to 30% of their income for rent. c. Condition: For one out of 12 transactions tested, The Center collected $344.40 which could not be directly traced to an individual tenant. Because it could not be directly traced, the Tenant Income Certification or Re-certification or Permanent supportive Housing – Eligibility and Rent Determination forms could not be identified and tested for accuracy or completeness and compliance with the tenant’s share of the rental payment could not be determined.

Corrective Action: As part of DRW’s internal control revision, we will enhance policies and practices associated with reporting including the semi-annual SF-425. Steps: 1. DRW will review current systems and tools in use for reporting and complying with Federal award reporting requirements and modify or implement systems or tools that are more reliably accurate than current systems and tools. 2. DRW will implement internal controls that require the preparation and review of federal reporting requirements by two distinct people at DRW. 3. DRW will implement a reporting calendar and review regularly to ensure activities including preparation and review are being performed regularly and consistently. Anticipated completion September 30, 2024.

2023-003 Finding - Federal Award - Significant Deficiency - Reporting US Department ofCommerceAL#11.611 Context and Cause - The Organization was not made aware by grants, CMTC or prior auditors that the final upload package of the federal reports and requests for reimbursement should have internal control oversight procedures and did not exercise such oversight. Only one individual was responsible for preparing and filing these final documents after such details were reviewed individually throughout the month by other individuals responsible for that review. The payroll time sheet review process was consistently followed, however, and there is not a process for the final processed payroll rep01ts to be reviewed by a second individual.Recommendation: We recommend management implement procedures to ensure the Uniform Grant Guidance and the Compliance Supplement requirements for controls over Reporting, Allowable Costs, and Cash Management are designed and performed. The month­ end checklist currently being used is a good start, and this could be enhanced by adding sections for the above items, and having specific individuals' initial and date on the checklist when the procedures are completed. A fiscal policy and procedure manual would also be a good tool. Action Taken: Manex will update fiscal Policy to include oversight on reporting to funders

CORRECTIVE ACTION PLAN 2023-001 Item 2023-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement Reporting Criteria The U.S. Department of Treasury SLFRF Compliance and Reporting Guidance requires the County prepare quarterly submissions of the Project and Expenditure Report. The 2023 Compliance Supplement identifies multiple Key Line Items in the report, including cumulative expenditures and current period expenditures. Internal control should be established and maintained to provide reasonable assurance that these requirements are complied with by submitting the reports accurately. Condition For the fiscal year under audit, the Project and Expenditure Report reported cumulative expenditures as program income, and the total obligation was reported as cumulative expenditures before the amounts had actually been spent. This was noted on the first two quarterly reports, but the last two quarterly reports were corrected. Cause The County followed a process for reviewing the reports and understanding program requirements; however, the new and emerging nature of the program and related guidance limited the internal knowledge necessary to identify the errors. Effect Required reports submitted to the Federal Agency contained inaccuracies to identified key elements. Recommendation We recommend that the County expand its review process for key reports to consider if new or emerging funding merits additional staff training or the engagement of outside assistance. PERSON RESPONSIBLE FOR CORRECTION ACTION: Becky Haynes, County Auditor CORRECTIVE ACTION PLANNED: We agree with the finding and have initiated discussions to provide training and implement procedures to ensure compliance. We have made these changes during the fiscal year, where the last two quarterly reports were properly stated . ANTICIPATED COMPLETION DATE: September 30, 2023. See prior year finding 2022-001.

Finding 2023-001 Condition: As of the March 31, 2023, reporting date, the Town understated its expenditures by approximately $1,132,000 and did not report any obligations for contracted amounts not spent. Corrective Action Planned: Update the expenditures to reflect the inclusion of prior reported expenditures for an accurate cumulative spending. Existing obligations will also be updated accordingly. A review of all obligations will be completed to ensure all necessary contracts are in place prior to 12/31/2024. Anticipated Completion Date: Expenditure and obligation reporting corrected with submission due by 4/30/2024. Contracted obligations to be in place prior to October 31, 2024. Contact: Kristine Russell, Town Accountant