Corrective Action Plans

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

Instructions were given to the Program staff to strengthening existing internal controls and procedures to ensure that the reexamination and HAP determination processes are performed according to program requirements and guidelines, and to obtain in a timely manner all of the required documentation for each reexamination executed.

Instructions were given to the Program staff to ensure timely registration of program income transactions in the Integrated Disbursement and Information System (IDIS). During the fiscal year 2021-2022, changes occurred in the program's management staff, which may have led to the situation mentioned in the finding.

The City’s Community Development Department is in the process of rewriting its Policies to include the CDBG-CV provisions. Those policies should be completed within the next couple of months.

Finding Number: 2022-009 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services, HIV Emergency Relief Project Grants Condition: Original Finding Description: The City controls did not result in the reporting of program income earned by subrecipients to the funding agency and not reporting the program income and related expenditures in their general ledger and on the SEFA. Contact Person Responsible for Corrective Action: Regina Greear and Keisha Pierce Anticipated completion date: July 2023 Planned Corrective Action: The $4,800 Program Income was reported on the general ledger In FY22 and included in the final FY22 SEFA but after the notification from the auditors. The city will implement a Corrective Action Plan (AFCAP) to document the Program Income requirements, track all awards with program income to help ensure proper and accurate reporting and further training on Program Income requirements.

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, 2023

2022-001 Community Development Block Grants/State?s Program and Non-Entitlement in Hawaii We recommend that the County develop a program to monitor compliance with the loan provisions in accordance with the County Loan Servicing Policies and Procedures. Management?s Response: The County concurs with the recommendation. Responsible Individual: Diane Olson, Auditor-Controller Corrective Action Plan: We will implement a process to review loan documents. Anticipated Completion Date: June 30, 2023

Findings and Recommendations - 2022 ? 001: Finding Type: Noncompliance with Laws and Regulations. Condition: The Academy?s NSFSA?s fund balance exceeded the allowable three months? average expenditures at June 30, 2022. The Academy had approximately 5.81 months of expenditures as fund balance at June 30, 2022. Recommendation: The Academy should submit a spend down plan and obtain Michigan Department of Education?s prior approval to improve the food quality or take other action to improve the program in accordance with 7 CFR 210.19(a)(2). Corrective Action Plan - The Academy is aware of the finding and is implementing procedures in order to prevent further noncompliance in the future. The Academy will be creating and implementing a spend down plan once approval of the plan is received by Michigan Department of Education. Responsible Department - Business department and Food Service department. Responsible Person - Tammy Visger (Director of Food Service). Planned Completion Date (TBD or Date) - Spend-down plan to be implemented and expected completion prior to June 30, 2023.

Program: Community Development Block Grants/Entitlement Grants Compliance: J-Program Income Finding Type: Compliance and Internal Control Agency: Department of Housing and Urban Development (HUD) Internal Control Impact: Material Weakness Finding: The City hired a third party to service single family home loans made with federal funds from this grant. The City did not maintain a listing or monitor the loans originated under this grant. Accordingly, the City cannot reconcile the loan servicer?s accounting reports to City records. Although the City indicated that they have other sources of program income, the City does not have a system which identifies other sources of program income. Status: Corrective action plan in progress Corrective Action Plan: The City has obtained information from the third-party loan servicer which will allow for the tracking and confirmation of existing loans with the goal of taking a more active role in the management of the portfolio including making decisions for write-off of non-performing balances and those where the cost of servicing the loan exceeds the loan payments. Person(s) Responsible for Implementation: Pearline McFall, Housing Department Fiscal Officer, Telephone: (816) 513-8432; Email: Pearline.McFall@kcmo.org Implementation Date: Ongoing

Ms. Lehmer, In response to Finding 2022-001 Program Income: Control, Tracking, and Allocation Method as identified with the fiscal year 2022 audit, the University of Kansas School of Medicine-Wichita Medical Practice Association has implemented the following as of July 1, 2022, to remedy the finding. 1. Established a program income department/fund to track program income and expense for each Ryan White Grant C and D: Program Income Ryan White Part C-620204, Program Income Ryan White Part D-620205. 2. 340B Program Income recorded 100% as Program Income Ryan White Part C, per requirement for HHS Awards, 45 CFR part 75.307. Sheila Norris, Director of Finance, will serve as the contact person in regard to this corrective action plan. We hope these changes will sufficiently address Finding 2022-001 Program Income: Control, Tracking, and Allocation Method. Please let me know if additional action is required. Sincerely, L. Aaron Ryan, RN, MBA, FACMPE Executive Director University of Kansas School of Medicine - Wichita Medical Practice Association

Name of Auditee: City of Niagara Falls, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2022 CAP Prepared by: Daniel Morello, City Controller Phone: (716) 286-4346 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2022-002 Management's Response The City is in agreement with this audit finding. Due in part to delays in finalizing both the 2021-2022 annual action plan and the 2022-2023 annual action plan, the City was delayed in being able to utilize those funds until approval was provided by HUD. The City continues to direct funds to projects that have the ability to be completed in a timely manner in order to be consistent with the CDBG regulation related to timeliness. The City is aware of the timeliness requirements and will continue to select projects that better allow the City to operate in accordance with these regulations. Estimated Completion Date - Next HUD verification date of May 1, 2024

Finding 2022-001 Contact Person responsible for corrective action: ? Alex Cheung ? Director of Finance and Accounting ? Lynna Magnuson ? Director of Supported Housing Anticipated completion date: 6/30/23 Corrective Action Plan: 1. All rents that were able to be recalculated for June 2022, were recalculated and have been provided 2. The SO Rent Worksheet will be updated with the correct rent calculations reflecting for June 2022 and submitted as evidence of corrective action 3. Going forward, rents will be calculated initially upon program entry and at least annually, in addition to any time income changes for a client, in accordance with HUD guidelines 4. Rent calculations and supporting documentation will be uploaded to a Shared file with Caminar?s Finance Department to allow for audit, cross-referencing, reporting, and security of information 5. Records will be audited and quality assured internally at least quarterly 6. An annual rent calculation checklist will ensure that all documents are gathered within the 120 days prior to the annual certification and rent calculation. a. The annual checklist should be prepared by the staff and approved by the Program Director on an annual basis. b. The same annual checklist will be reviewed by Accounting Department.

2022-011) Program Income Management?s response and corrective action is as follows: The OCD 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 monthly for staff approval. All loans are reviewed for forgiveness in compliance with the Code of Federal Regulations and are approved by the OCD and the Office of the Mayor-President before being executed by the Parish Attorney?s Office to provide multiple layers of review. Case files are maintained at the OCD. Documentation of monthly reconciling has been provided along with an accounting ledger on the change in the loan balance in 2022 as caused by escrow support and loan forgiveness activities for low to moderate income residents, but we acknowledge that this process could be improved. The OCD is working to develop additional internal controls and will evaluate the current loan service agency?s effectiveness at managing, reconciling, and providing reports on the portfolio. Expected Implementation Date: October 2023 Contact person: Marlee Pittman, Interim Director, Office of Community Development

2022-010) Program Income Management?s response and corrective action is as follows: The Office of Community Development (OCD) provides funding to affordable housing developers using Federal funds. Since 2021, the OCD has worked alongside dozens of developers, the State, and private investors to add over 800 units of affordable housing to our housing market. These affordable housing funds are often provided to nonprofits and local developers by means of a forgivable loan. This loan is intended to generate no income, but instead allows the parish to place a lien on the property to enforce the long-term affordability requirements required by the Federal government. The outsourced loan servicing agency provides administrative support for the HOME mortgage program and interest generating activities; however, the affordable housing support is not a part of that scope. Instead, the City-Parish Parish Attorney?s Office works alongside the Office of Community Development and the Clerk of Courts to record the forgivable loans as liens on the property. The lien ensures that developers are unable to sell the home for market rate activities or otherwise dispense of the property or manage the property in a way that is incompliant with the Code of Federal Regulations. Expected Implementation Date: December 2024 Contact person: Marlee Pittman, Interim Director, Office of Community Development

2022-009) Program Income Management?s response and corrective action is as follows: The OCD 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. All loans are reviewed for forgiveness in compliance with the Code of Federal Regulations and are approved by the OCD and the Office of the Mayor-President before being executed by the Parish Attorney?s Office to provide multiple layers of review. Case files are maintained at the OCD. Documentation of monthly reconciling has been provided along with an accounting ledger, but we acknowledge that this process could be improved. The OCD is working to develop additional internal controls and will evaluate the current loan service agency?s effectiveness at managing the portfolio. Expected Implementation Date: October 2023 Contact person: Marlee Pittman, Interim Director, Office of Community Development

We have been and are budgeting to spend more money in 2023 than we have collected or will collect in revenues. We are anticipating a deficit in 2023 for the Child Nutrition Program. This will cause our Net Cash Resources to decrease.

Finding 2022-001 PROGRAM INCOME ? CFD #93.224 (Significant Deficiency in Internal Control over Compliance) Response: Corrective Action Plan The Operation Department will conduct a verification of the sliding fee scale. In their internal monthly Sliding Fee Discount audit process, the Site Manager is to review and verify each patient application, to the current Federal Poverty Level, to ensure patient is receiving the correct discount. Attached is a copy of policy and procedure for this corrective action plan.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over Program Income for the Child Nutrition Cluster. After this review, we will implement a system to ensure that compliance with the federal program income requirements is met. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.