Corrective Action Plans

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

Finding Number: 2023-001 Anticipated Completion Date: May 2024 Responsible Contact Person: David Tatro, CEO Planned Corrective Action: The Organization provided 2,682 self-pay encounters to be audited for the year ended May 31, 2023. Out of the 2,682 self-pay encounters, 20 were identified for further review. Two self-pay accounts were identified with issues which resulted in this finding. The first issue was attributed to a patient inaccurately placed on a slide level, and the other patient account did not have an updated sliding fee scale application completed on file. This issue has been resolved as of November 2023 by reviewing all sliding fee scale applications for accuracy. The Organization will continue to monitor the sliding fee scale amounts applied to ensure ongoing compliance with the requirements. The Organization will review five sliding fee scale applications each week to ensure eligibility determination, billing and collection follows the Sliding Fee Discount Program. This will go through May 2024 with a reassessment at that point, based on the results of the internal review.

The Organization will enhance its procedures to ensure verification of tenant assets is performed during recertification.

The Organization will enhance its controls to ensure all tenant files are maintained in accordance with the HUD Handbook.

Name of Contact Person: Darlene Asher, Transit Director Corrective Action: NCDOT Connect has an IMD calendar that has all dates of when reports are due to IMD including Program Income. The Transit Director will sync the IMD calendar to her Outlook calendar where reminders will pop up. Proposed Completion Date: Immediately

Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that revenue is recognized in the correct period.

Schedule of Corrective Action Plan (Auditee Prepared) Year Ended August 31, 2023 Finding 2023-001 Planned Corrective Action: Beginning in March 2023, the Corporation alerted Capital Magnet Fund of a potential issue committing the required amount of funds by August 31, 2023. The Corporation asked for an extension, but it was not granted. As of August 31, 2023, the Corporation was under committed by $700,000 and is working diligently to commit the funds to a qualified development as soon as possible. For Questions: Katie Claflin, Senior Director of Communications and Development Estimated Completion Date: March 26, 2024

Finding and Recommendation - Finding: 2023‐001 (repeat finding 2022-002, 2021‐001 & 2020‐002) Finding Type: Noncompliance with laws and regulations. Condition: The Academy NSFSA’s fund balance exceeded the allowable three months’ average expenditures balance as of June 30, 2023. The Academy had approximately 4.96 months of expenditures as fund balance as of June 30, 2023. Recommendation: The Academy should ensure it has proper internal controls in place to comply with its annual external reporting requirements in accordance with state law. Corrective Action Plan - The management company for the Academy will work with the Academy leadership to increase expenditures in a manner necessary to spend down the excess fund balance in an allowable and timely fashion. The spend down plan will include improvements to the food service program, including adding an additional food service support position. The number of salad bar offerings and daily hot breakfast options will be increased for all grade levels. The Academy will also explore allowable options for spending funds on supplies, equipment and initiatives that will create sustainable improvements to the food service program for future years. Responsible Department - Finance department and Food Service department Responsible Persons - Melinda Benkovsky, VP of Finance Gwen Hovey, Food Service Coordinator Planned Completion Date (TBD or Date) - June 30, 2024

Program Income of $310,165 was recognized during FY 2022‐2023 through a substantial amendment to the Annual Action Plan adopted by the Mayor and City Council in January 2023. The Community Assistance Office followed the recommended guidelines of the Citizen Participation Plan to complete a substantial amendment as mandated. All program income was receipted correctly into the Integrated and Information Disbursement System (IDIS) for HUD. All program income funds have been reconciled through the Consolidated Action Plan 2020‐2025 and accurate PR26 have been completed and submitted through weekly meetings with the assigned representative since June of 2023.

Complete all PR26 and PR29 for CDBG and CV by November 17, 2023. The Community Assistance Office met with Housing and Urban Development on a weekly basis to reconcile grant funds within the 2020‐2025 Five‐Year Consolidated Action Plan beginning June 9, 2023. Training was provided to Community Assistance Office staff through Housing and Urban Development and through Cloudburst Consulting to ensure key staff positions responsible for the completion of these reports is full trained. Develop a Master Calendar for the Community Assistance Office with re‐occurring reports to include the PR26, PR29 and including FFATA to ensure they are completed accurately and timely. PR26 for CDBG and PR29 for CDBG and CDBG‐CV have been submitted as of October 25, 2023, and the HUD concluded weekly meetings with the Scottsdale Community Assistance Office on October 20, 2023. PR26 for CDBG‐CV will be completed and submitted by November 17, 2023. Policies will be updated to reflect 2 CFR 170 requiring the City to submit subaward information through the Federal Funding Accountability and Transparency Act by the end of the month subsequent to an award.

Again started before I got here. I did what I was told by DLZ our Consultant.

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

Finding 2022-001 Responsible Perseon(s): April Samuels, VP of Finance No month-end close, no four-eye review process and no account reconiliations PHDC acknowledges the issue noted above and is in the process and or will correct the deficienes by: -Implemented a month-end close cycle which significantly helps in establising team expectations, timely recording, reconcilling both of the balance sheet and income statement items, and improves financial reporting. -Defined staff roles/responsibilities and trained team members to understand the business, as well as their end-to-end process to help ensure accuracy and accountability. -Made great strides with maintaining monthly reconciliations; however their biggest opportunity has been reconciling the program activity/invoices submitted to DHCD in which they most recently implemented a DHCD reconcilliation that ties to the general ledger for the reviewer to verify before approving/submitting the invoice to DHCD.

During the audit period through 2022, there was a transition of fiscal and administrative personnel at the City of Williamsport. Due to findings of an internal financial investigation, the City communicated with appropriate parties and a grand jury was convened. The City has been and continues to be under state and federal criminal investigations since February of 2020. Numerous financial records, extending over a 10-year period, have been provided to investigators. In June of 2022, the City hired a consultant to provide fiscal oversight on an ongoing basis and reconcile, to the extent possible prior financial records. Since that time, the City has enhanced internal control and implemented policies to assure accurate financial reporting and compliance. The City anticipates a similar finding for the December 31, 2020, 2021, and 2022 audits, but with the exception of the results of the criminal investigations, expects to resolve this finding for the December 31, 2023 audit.

PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Condition/Cause The Authority did not properly report program income in IDIS during the year, and therefore could not support that program income was applied prior to drawing down entitlement funding. In some instances, program income received was not reported in IDIS, and one receipt was entered into IDIS twice. When received, program income is reported in a separate general ledger account in the financial reporting software. The Fiscal Officer then enters the program income into IDIS on a regular basis. No control exists to ensure completeness or accuracy of information entered into IDIS related to program income. Recommendation We recommend the Authority develop a procedure/internal control to ensure program income is entered accurately and completely within IDIS. This will allow for documentation to support that program income is being utilized prior to drawing down entitlement funding. This will also ensure compliance with reporting requirements for reports generated within IDIS on an annual basis. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval.

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

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025