Corrective Action Plans

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

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