Corrective Action Plans

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.

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.

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

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provided by senior management to ensure proper compliance and effective implementation.

Deficiencies in controls surrounding the cash management and program income. A. Name of contact person responsible for corrective action: Name: Courtney Bershell Title: Business Manager B. Corrective action planned: The district will implement changes to ensure child nutrition management software be used to document and support the daily meal counts that will be used for claim reimbursements. C. Anticipated completion date: June 30, 2024.

Our financial staff has offered additional training for staff one the proper procedure, discussed the importance of the control of program income and used disciplinary procedures as appropriate to reach better compliance.

FINDING 2022-004 Finding Subject: CDBG – Entitlement Grants Cluster—Reporting Summary of Finding: Condition and Context: The County did not have internal control procedures over the Quarterly Reports (PR29), IDIS Section 3 Performance Report, and NSP Quarterly Reports. One individual prepared or generated the report without a review or oversight process. Additionally, the County’s internal controls were not consistently documented over the draw down requests for the CDBG grant during the audit period. The draw down requests were entered into IDIS, which then becomes the basis for several of the reports. The control presented by the County was that one individual prepared and entered the request, which would then be printed, and another individual would review and sign the printed request to document the review. Of the thirteen reimbursement requests tested, control documentation for eight of the requests were printed and signed during current period, after the documentation was requested. The creation of documentation of the control procedure did not support that internal controls were effective during the audit period. Recommendation: We recommended that the County's management design and implement a proper system of internal controls, and retain documentation of its system of internal controls, to ensure compliance with reporting requirements. Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 and brownta@lakecountyin.org Views of Responsible Officials: LCCEDD concurs with the audit finding. Concurrence: The Fiscal Officer from the Audit Period was new to the position and her training was focused on the changes to the financial systems at the county over the DRGR quarterly reporting of NSP actions. Further, Finding 2022-003 also caused some of the reporting issues with CDBG of having two CDBG funds and posting errors to these funds. The current LCCEDD Fiscal Officer found the problems during the audit and corrective actions were done retroactively to address this part of the finding with the drawdown requests. The CDBG drawdowns were submitted into IDIS by the Fiscal Officer who printed out the drawdown request. These printouts were then given to the Executive Director or the Deputy Director who then went into IDIS and approved the drawdown request, then print out the IDIS drawdown approval and return the request and the signed approval back to the Fiscal Officer. LAKE COUNTY COMMUNITY ECONOMIC DEVELOPMENT DEPARTMENT 2293 N. Main Street - Crown Point, In 46307 Tel. (219) 755-3225 www.lakecountyin.org INDIANA STATE BOARD OF ACCOUNTS 38 Description of Corrective Action Plan: LCCEDD staff have already adopted changes in internal controls to correct the CDBG reporting deficiencies as described in Finding 2022-003. Further, management will oversee compliance with current policies and the new quarterly reconciliations. LCCEDD policies will be updated to make the following changes: General Management and Oversight: On an on-going basis, the Director will meet with Department staff to determine if training or technical assistance is needed to complete HUD reporting requirements in a timely and accurate manner. NSP Quarterly Reports: To be followed until the HUD field office indicates QPR reports are no longer needed due to grant closeout: 1. Before the close of each month, the Fiscal Officer will create receipts and draws as needed in HUD’s DRGR system to reflect funds receipted or expended by the County. 2. At the close of each quarter, the Fiscal Officer will prepare and submit the quarterly report in DRGR for the NSP1 and NSP3 grant allocation. To prepare the report, the Fiscal Officer will reconcile all expenses and receipts posted in the County’s general ledger system for the NSP programs with the receipts and drawdown requests recorded in in HUD’s DRGR reporting system. 3. Before submitting the NSP QPR Report in the DRGR system, the Deputy Director will review and approve the prepared reconciliation and QPR Report. Any discrepancies between the two systems will be reported to the Auditor and the Department Director to determine corrective actions. 4. Within 30 days of the close of each calendar quarter, the Fiscal Officer will submit the NSP QPR Report via DRGR. The Fiscal Officer will maintain a copy of the NSP QPR and the corresponding reconciliation in their program files. Cash on Hand Reports: 1. At the close of each quarter, the Fiscal Officer will prepare and submit the Cash on Hand Report within thirty days of the close of the quarter. The Fiscal Officer will reconcile all expenses and receipts posted in the County’s general ledger system with the receipts (report PR09) and drawdown requests (report PR07) in HUD’s IDIS Online reporting system. 2. Before submitting the Cash on Hand Report in the IDIS Online system, the Deputy Director will review and approve the prepared reconciliation and Cash on Hand Report. Any discrepancies between the two systems will be reported to the Auditor and the Department Director to determine corrective actions. 3. Within 30 days of the close of each calendar quarter, the Fiscal Officer will submit the Cash on Hand Report via IDIS Online. The Fiscal Officer will maintain a copy of the Cash on Hand report and the corresponding reconciliation in their program files. INDIANA STATE BOARD OF ACCOUNTS 39 Section 3 Reporting: 1. As part of the application review, the Deputy Director will determine the applicability of the Section 3 requirements for each proposed project. 2. For projects where Section 3 is applicable, the Deputy Director will ensure that staff administering the project are familiar with the Section 3 requirements and understand the forms and reporting required to properly report Section 3, including the determination of total labor hours worked, labors hours worked by Section 3 and Targeted Section 3 workers, and corresponding certifications. 3. The County will collect Section 3 reports from subrecipients administering projects throughout the period of performance. If the project meets Section 3 benchmarks, the County will consider the activity to be in full compliance with Section 3. If the project does not meet one of the Section 3 benchmarks, the County will require reporting on the qualitative efforts that the subrecipient made to try to reach the benchmarks. 4. Section 3 information collected for each project will be reported in IDIS Online. The Section 3 information must be reported annually before the submission of the annual report (CAPER) to HUD. Anticipated Completion Date: Part of the corrections have already been put into place and the Policy and Procedure Manual will be amended in April of 2025 after the Lake County Redevelopment Commission adopts appropriate changes.

FINDING 2022-003 Finding Subject: CDBG – Entitlement Grants Cluster—Program Income Summary of Finding: Condition and Context: The County received program income through various loan programs it offered to qualifying individuals. Once the County received a loan payment, the receipt was posted into the financial accounting system of the County and recorded in a grant fund. The amount received was also to be recorded in the Department of Housing and Urban Development’s (HUD) Integrated Disbursement & Information System (IDIS) website. The recorded program income in IDIS would then appear on the Drawdown Report by Voucher Number report (PR07). No internal control process had been established over the program income compliance requirement. One individual was responsible for notifying the Auditor's office when program income money was received, in order for it to be receipted in the County’s financial accounting system. The same individual was also responsible for reporting the same on IDIS site. No controls were established to ensure the program income that was recorded in the financial accounting system was also reported on IDIS site and the PR07 report. Additionally, four receipts totaling $38,960 were selected for testing from the County’s receipt ledger. These four receipts were unable to be located on the PR07 report provided for audit. One of the four receipts was recorded in the IDIS system after information regarding the receipt was requested. The receipt was not in the PR07 report that had been provided for audit when we were provided information documenting it being recorded in IDIS. Furthermore, we were unable to verify the total amount recorded in receipt ledger to the total reported on PR07 report. The County’s ledger was greater than the PR07 report by $30,324 and is primarily attributed to under reporting of program income in IDIS as identified above. Recommendation: We recommended that the management of the County establish a system of internal controls to ensure that all program income received is properly reported in the IDIS system and expended prior to drawing down federal awards. Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 and brownta@lakecountyin.org Views of Responsible Officials: LCCEDD concurs with the audit finding. LAKE COUNTY COMMUNITY ECONOMIC DEVELOPMENT DEPARTMENT 2293 N. Main Street - Crown Point, In 46307 Tel. (219) 755-3225 www.lakecountyin.org INDIANA STATE BOARD OF ACCOUNTS 36 Description of Corrective Action Plan: LCCEDD staff have already adopted changes in internal controls to correct the Program Income reporting deficiencies. The process is as follows: 1. All incoming checks into the department are first reviewed by the Deputy Director. The Deputy Director determines the source of income (i.e. CDBG, HOME, NSP) and the correct receipt type (program income, repayment, homebuyer). The Deputy Director records the IDIS number of the project on the check before giving it to the Fiscal Officer. 2. The Fiscal Officer records the receipt on an internal schedule of receipts and submits the check to the County Auditor with the check deposit form with the IDIS number and correct fund and account number for deposit. 3. Once the County Auditor posts the receipt to the County’s general ledger, the Fiscal Officer records the Auditor’s receipt into HUD’s IDIS Online reporting system. 4. At the close of each quarter, the Fiscal Officer will prepare and submit the Cash on Hand Report within thirty days of the close of the quarter. The Fiscal Officer will reconcile all expenses and receipts posted in the County’s general ledger system with the receipts (report PR09) and drawdown requests (report PR07) in HUD’s IDIS Online reporting system. Before submitting the Cash on Hand Report in the IDIS Online system, the Deputy Director will review and approve the prepared reconciliation and Cash on Hand Report. Any discrepancies between the two systems will be reported to the Auditor and the Department Director to determine corrective actions. 5. Within 30 days of the close of each calendar quarter, the Fiscal Officer will submit the Cash on Hand Report via IDIS Online. The Fiscal Officer will maintain a copy of the Cash on Hand report and the corresponding reconciliation in their program files. 6. On an on-going basis, the Director will meet with Department staff to determine if training or technical assistance is needed to complete HUD reporting requirements in a timely and accurate manner. Anticipated Completion Date: A policy and procedure amendment will be written by the end of this year and presented to the Lake County Redevelopment Commission for their March 2025 meeting for adoption.

The County will review internal policies and procedures to ensure consistent documentation retention policy. Training will occur with staff involved all income verification within this program. Additional oversight protocols will be put into place to review and verify documentation is retained for each applicant. The time period and funds for this program have been exhausted. New funds will not be available until next SFY 2023-2024. We have a plan to this program under the supervision of the Economics Services Division and repurpose and existing position. We will complete the training once the position has been filled.

Finding ref number: 2022-001Finding caption:The City charged payroll-related expenditures that lacked support to the Community Development Block Grants/Entitlement Grants program.Name, address, and telephone of City contact person:Debra Rhinehart, HSD Interim Federal Grants Mgt Unit Manager, 206.684.0574Theresa George, HSD Accounting Manager, 206.798.3360Corrective action the auditee plans to take in response to the finding:HSD Response:HSD as the CDBG administrator, in collaboration with its contracted consultant support TDA consulting, will complete the following steps to support the resolution of this finding associated with the pre-approval of timesheets within the Office of Housing, and the Department of Parks and Recreation.HSD will conduct a thorough review of all existing MOAs with our recipients to ensure that the language pertaining to pre-approved timesheets is clear, consistent, and aligned with federal and state regulations. HSD will also assure staff responsible for administering CBDG funds and other federal funds are oriented to federal requirements regarding the pre-approval of timesheets and will emphasize the importance of adhering to the requirements outlined in the MOAs. HSD will encourage its city partners receiving these funds to work with the City-Wide Accounting team to adopt standardized procedures for the approval, documentation, and tracking of timesheets.Office of Housing Response:The Office of Housing will change its timesheet review procedures in order to ensure manager sign-off happens no sooner than the close of business on the final day of the pay period. Current procedure is for the Office Housing Accountant to send an email reminding all managers to sign-off on timesheets; effective 10/1/23 this message will add the specific reminder that all employees funded by federal grant revenues should not have their timesheets approved until after all hours have been worked.Parks and Recreation Response:Moving forward, Seattle Parks and Recreation (SPR) will follow the City-Wide Accounting guidance provided on June 6th, 2023 which requires employees to not submit timesheets earlier than the federally grant-funded work is performed.SPR department leadership have immediately notified the CDBG management team to re-emphasize the requirement. In addition, the SPR payroll team will also provide a reminder of the requirement for all SPR staff for each payroll cycle. The SPR executive team will continue to monitor compliance relating to this recommendation.Anticipated date to complete the corrective action:Human Services Department: 12/31/2023Seattle Parks and Recreation: 9/15/2023Office of Housing:10/01/2023

Public Health’s Office of Aids (OA) agrees with the finding and recommendation. OA developed and implemented additional internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. Prior to this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life-saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, the Health Resources and Services Administration, which encouraged ADAP to reassess its organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help mitigate future findings in ADAP applications. Estimated Implementation Date: Implemented as of April 2022 Contact: Joseph Lagrama, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health