Corrective Action Plans

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.

Financial Statements On identification of the issue, management began reporting program income within 30 days as appropriate. All program income has been receipted appropriately. Management will continue to enter the required program income within 30 days. Management has a process for tracking program income and reflecting it properly in their accounts. This process was in place and functioning for all of 2022. Corrective Action Plan Pages Finding Number: 2022-001 Federal Assistance Listing Number: 14.239 HOME Investment Partnerships Program Year Ended: December 31, 2022 Responsible Individual: Mark Opalka Fiscal Consultant Management?s Response and Corrective Action Plan: The Agency agrees with the finding and recommendation. For part of 2022, the Agency did not report all program income timely in IDIS. On identification of the issue, management began reporting program income within 30 days as appropriate. All program income has been receipted appropriately. Management will continue to enter the required program income within 30 days. Management has a process for tracking program income and reflecting it properly in their accounts. This process was in place and functioning for all of 2022. The above procedures have already been implemented.

Corrective Action Plan and Status of Prior Year Findings Management?s Corrective Action Plan: Individual(s) Responsible for Corrective Action Plan Tysha Dixon Director, Financial Reporting (215) 496-8168 Anticipated Completion Date Completed March 2023 Management?s Corrective Action Plan Management will continue to rely on its existing controls in place; however, noting that Management will closely monitor loans and loan disbursements where the funding source has changed closely to ensure that disbursements are in accordance with funding terms and approval limits. Management will continue to rely on its existing controls that are in place, including the ongoing communication with the City for any changes in transactions that require their approval. In the circumstances where management is pending a contract amendment from the City for loans requiring additional funding, management will determine if there are unrestricted funding sources to support the change in the approved amount of the loan until the amended contract is finalized. Questioned Program: CFDA #14.218 Community Development Block Grants (CDBG)

WSIN concurs on finding 2022-002. To prevent further incidences, WSIN plans to revise its written accounting procedures to strengthen internal control policies on reporting program income. Greater emphasis will be taken to ensure the general ledger is updated in a timely manner, so program income is reported on the federal financial quarterly reports based off the WSIN general ledger rather than a secondary tracking spreadsheet. WSIN management will ensure financial reporting has been through a secondary review prior to submission to US DOJ/OJP/BJA.

Condition: As of the March 31, 2022, reporting date, the Town reported obligations of $5,044,950 while actual obligations were only $1,134,400. Corrective Action Planned: With the reporting due on 4/30/23 the method of reporting on the obligated funds will be utilized when submitting the report. Anticipated Completion Date: 4/30/23 Contact: Kristine Russell, Town Accountant

2022-004 Assistance to Tribally Controlled Community Colleges and Universities ? Assistance Listing No. 15.027 Recommendation: We recommend that the College implement a process for tracking program income and returning the funds in accordance with the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has taken corrective action by seeking guidance and preferred treatment of advance draws. The College has implemented a process to track interest earned on advance draws and plans to utilize such earnings in accordance with the guidance obtained from the granting agency. Name of the contact person responsible for corrective action: Shona Campbell, Business Office Director Planned completion date for corrective action plan: June 30, 2023

Item 2022-001 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 2022 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. 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. ANTICIPATED COMPLETION DATE: September 30, 2023

2022-003 Child Nutrition Cluster Recommendation: School Corporation management should establish a system of internal controls to ensure compliance with the grant agreement and program income requirements. Documentation should be retained to support the existence and accuracy of all program income earned. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation with review existing control processes surrounding program income and strengthen procedures to ensure documentation to support program income is adequate and reviewed. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

Finding 2022-003 Federal Transit Cluster - SEFA Management?s or Department?s Response: Management agrees. Views of Responsible Officials and Corrective Action: SCRRA will document the process to review the SEFA from prior year. Compare the SEFA to the final Single Audit Report to ensure the ending balances tie back to the Single Audit Report, before starting the current year?s SEFA. Name of Responsible Person: Thelma Bloes Implementation Date: June 30, 2023