Corrective Action Plans

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

2023-044 Oregon Housing and Community Services Ensure that the nature of program applicants' financial hardship is documented MANAGEMENT RESPONSE: The agency agrees with this finding. OHCS completed research to better isolate the problem and verified the nature of hardship fields are required to submit an application in the homeowner application portal. Review of the hardship fields are now required, and program underwriters and housing counselors will request hardship statements where none exist in an application. The HAF team will review funded applications to determine if any deficiencies exist related to attestations of the nature of financial hardship. OHCS will request that those applicants supplement any missing information to adhere to regulatory standards. OHCS will also implement sampling quality assurance, compliance, and data report reviews to check for attestations of the nature of financial hardships. Anticipated completion date: September 30, 2024 Contact person: Ryan Vanden Brink, Grants, Loans, and Program Manager

Condition: As of the June 30, 2023 reporting date, the City’s Project and Expenditure Reports understated expenditures by $629,040. Also, obligations were overstated by approximately $15,000,000. Corrective Action Planned: The City has implemented reconciliation procedures with the City Auditor and the City ARPA Director to reconcile the general ledger with the US Treasury portal prior to submission on a quarterly basis. The ARPA Director reached out to the US Treasury and communicated concerns that obligations cannot be edited on the portal and received guidance on remedies to edit obligations. Anticipated Completion Date: April 30, 2024 Contact: Bridget Almon, Director of Financial Services Kara Humm, ARPA Director Sedryk Sousa, City Auditor

2023-001 Title X – Assistance Listing No. 93.217 Recommendation: We recommend management develop procedures to ensure the required reporting submitted to the funder is complete and accurate. Additionally, systems should be put in place to both track and report its progress on the non-federal share requirement and any program income. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has initiated a review process to ensure the reporting is complete and accurate per the Federal Financial Report Instructions prior to submission. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: April 1, 2024

Corrective Action Plan: Due to staff turnover of key personnel in the Housing Division, the Finance Department has partnered with the Community Development Department to ensure that CDBG reporting is timely and accurate. In March 2024, a new consultant was contracted to assist the Housing Division staff with training and oversight for entering data to HUD's Integrated Disbursement and Information System (IDIS) which includes the Cash on Hand reports. Responsible Individual: Kimberly Cole-Muck, Director of Community Development Anticipated Completion Date: September 2024

Finding No. 2023-003: Period of Performance (Significant Deficiency - Internal Control Over Compliance) Federal Award: 14.218 - CDBG – Entitlement Grants Cluster Audit Recommendation: We recommend that the City establish procedures to ensure that it complies with the CDBG timeliness standard specified in 24 CFR Section 570.902. In addition, we recommend that the City ensures that it adheres to the workout plan it submitted to HUD. Administration’s Comment: The City will adhere to procedures to comply with the CDBG timeliness standard specified in 24 CFR 570.902. Anticipated Completion Date: May 2024 Contact Person(s): Holly Kawano, Department of Budget and Fiscal Services, Federal Grants Coordinator

Finding Number: 2023‐003, 2022‐003, 2021‐003 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Faron Logan, Business Manager Anticipated Completion Date: March 31, 2024 Planned Corrective Action: Since April 2023 the Business Manager has corrected the dates for the SF‐425 reporting. SF‐425 reports are turned in on time and all current SF‐425 reports have correct dates.

We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: Given the strain on resource available among City staff, the City is working to hire an outside consulting firm to assure a consisten loan monitoring program is in place. Anticipated Completion Date: June 2024

We recommend that the City develop procedures to ensure that the CDBG Annual Performance Report is filed by the required due date. Management's Response: The City concurs with the finding. Responsible Individual: Marti Brown, City Manager. Corrective Action Plan: The City has recently brought on staff to complete the periodic reports required by HCD. It is the intent of the City to have this finding resolved by the end of FY 2023-24. Anticipated Completion Date: June 2024.

Condition: Obligations were overstated by $144,923 on the March 31, 2023 Project and Expenditure report. Corrective Action Planned: All of the grant funds have been obligated and will be reflected as such in the next U.S. Treasury report. Anticipated Completion Date: April 2024 Contact: Victoria Rose, Town Accountant

The City was not aware of the CDBG quarterly PR29 (SF-425) reporting errors. The City has trained staff and implemented revised policies and procedures when preparing the CDBG PR29 (SF-425) quarterly reports to ensure proper reporting of program income on hand and the appropriate federal expenditures utilizing both federal grant and program income.

In response to Finding 2023-001 Prgram Income: Internal Control Identified is the fisal year2023 audit, the University of Kansas School of Medicine-Wichita Medical Practice Association has modified program income procedures to include a review and posting by the Senior Accountant in the financial close process. Patient payments received less refunds are allocated. The patient payments less refunds amount is an export of the speciality services facility group from the electronic medical record system, eClinicalworks as generated from a Ryan White procvider's clean claim submission. The patients included in the monthly allocation are vetted by Ryan White grant staff during the claim process. Sheila Norris, Director of Finance, will serve as the contact person for this corrective action plan. We hope these charges will sufficiently address Finding 2023-001 Program Income: Internal Control

Finding 2023-003 - Documentation of Costs and Vendor Invoices - Financial Reporting and Internal Controls ALN 14.850 & 14.871- Noncompliance & Material Weakness Corrective Action Plan: Vendor invoice backup supplied to HUD for questionable expense s. Executive Director must approve all expenses going forward and keep sufficient backup for audit. Person Responsible: John Sales, Interim Executive Director Anticipated Completion Date: January 31, 2024

Finding Number: 2023‐004 Program Names/Assistance Listing Titles: Assistance Listing Numbers: Indian School Equalization Program 15.042 Administrative Cost Grants for Indian Schools 15.046 COVID‐19 Education Stabilization Fund 84.425 Contact Person: Jim Mosley, Superintendent Anticipated Completion Date: June 30, 2024 Planned Corrective Action: The School reported incorrect expenditures for one of four quarterly reports reviewed. Acknowledged that one of the quarterly SF‐425 reports did contain an error with the additional revenue and expenses of non‐federal monies included in the report. Future reports will be reviewed more closely to prevent such errors.

L&I: A request has been made to RSA for the correction of the report. A correction will be made by OB-OCO once the report is open. To avoid typographical errors in the future, the CFO and the Division Chief of Budget and Admin will review the report after submission by OB-OCO to ensure the submission is correct. Anticipated Completion Date: 04/15/2024 Contact Name: Zulqarnain Nasir, Chief Financial Officer, OVR, L&I OB-OCO: • General Accounting revised our procedures to include having both the reviewer and preparer match the PDF output to the final Excel spreadsheet. • General Accounting discussed this finding and procedure change with the applicable staff on February 28, 2024 and February 29, 2024. • OVR has requested that the USDE unlock the RSA-17 Report for editing. General Accounting will submit a revised RSA-17 report to USDE once the report is unlocked. Anticipated Completion Date: 04/15/2024 Contact Names: Carson Buck, Commw. Accountant Manager; Kathleen Bolick, Accountant 3

Federal Award Findings and Questioned Costs Reference Number: 2023‐001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Continuum of Care Program Federal Financial Assistance Listing: 14.267 Finding Summary: Program Income Significant Deficiency in Internal Control over Compliance Contact: Jillian Patterson, Deputy Director 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: There was not a documented review by a separate individual outside of the preparer of the program income calculations. The Housing Authority had a review process in place over program income calculations. However, the review process was not documented. Corrective Action Plan: It is important to note that while we do have a process in place for program income calculations, we recognize that it was not adequately documented. To remedy this and ensure compliance with federal regulations, we have developed the following corrective action plan: Implementation of Controls Configure Yardi Voyager PHA software to enforce controls and workflows that ensure consistency and documentation of the review process. This may include setting up automated notifications for review assignments, establishing approval hierarchies, and creating standardized templates for documentation. Designation of Reviewer Utilize Yardi Voyager PHA software to assign designated reviewers for program income calculations, ensuring separation from the preparer. The software will facilitate clear identification of reviewers, their roles, and responsibilities within the review process. Documentation of Review Process Utilize Yardi Voyager PHA software to streamline and document the review process for program income calculations. The software will be configured to include a dedicated workflow specifically for documenting and tracking reviews conducted by separate individuals outside of the preparer. Periodic Monitoring and Evaluation Utilize the reporting and analytics features to monitor and evaluate the effectiveness of the review process. Generate regular reports to assess compliance with established procedures and identify any areas for improvement. Ongoing Compliance Monitoring Utilize Yardi Voyager PHA software to conduct ongoing compliance monitoring of internal controls and processes related to program income calculations. Set up automated alerts and notifications to flag any potential non‐compliance issues for timely resolution. By leveraging the capabilities of Yardi Voyager PHA software, the Housing Authority will enhance its ability to document, track, and monitor the review process for program income calculations, thereby strengthening internal controls and ensuring compliance with 2 CFR 200.303(a).

Specific Steps to Correct: Management has already corrected how it records interest earned on CDBG cash on-hand. Management will review program income on-hand throughout the year to assess its responsibility to return funds to the line of credit. Anticipated Completion Date: Will incorporate the auditor's recommendation into year end processing for fiscal year 2024, which will occur around June 30, 2024. Name(s) and Title(s) of Responsible Person(s): James Wood, Finance Director