Corrective Action Plans

Finding No. 2022-003 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure program income is reviewed by those familiar with both the program and specifically the program income allocation methodology prior to submission and that evidence of review is maintained. 3. Completion date April 15, 2023 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-003 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-003

Finding No.: 2022-_ 004__ Condition: The District prepared analysis of the profitability of the food service program was not clerically accurate by a material amount. Plan: The profitability analysis will be reviewed by someone independent of the preparer to ensure that all food service receipts and disbursements are included in the profitability analysis. Anticipated Date of Completion: 06/30/2023 Name of Contact Person: Adam Clapp Management Response: Management will implement the corrective action plan for the year ended June 30, 2023.

Contact Person ? Kenneth Azure, Executive Director Corrective Action Plan ? Management will review its policies and procedures for grant reporting. Completion Date ? 12/31/2022

2022-001 Community Development Block Grants/State?s Program and Non-Entitlement Grants in Hawaii We recommend that the City only report actual program income expended during the fiscal year instead of amounts authorized to be expended. Management?s Response: We concur with the finding. The City currently has a large grant from CDBG related to the upgrade of the Memorial Park Pool Facility. The City inadvertently reported a use of program income towards the project (which is required). However, it was determined that the grant funds were first used as the project was still ongoing. Responsible Individual: Andy Heath, Finance Director Corrective Action Plan: The City will work to assure the proper amounts of grant and program income are reported to the auditors. Anticipated Completion Date: FY 2022-23

2022-02: Significant Deficiency ? Program income compliance and controls Federal Agency: Department of Health and Human Services Program: Certified Community Behavioral Health Clinic Demonstration Grant Assistance Listing Number: 93.829 Management agrees that during the year ended December 31, 2022, Flushing did not have a formal control in place to identify, monitor and report program income collected from providing mental health counseling services to patients under the grant. Management has contacted The Department of Health and Human Services to inform them of this finding. Medisys Health Network, which includes Jamaica Hospital and Flushing, is the recipient of various federal grants, including another grant with program income requirements which was identified as a result of management?s review of the awards and for which controls have been designed and implemented to ensure compliance with the requirement. We believe our oversight of this compliance requirement was an isolated situation because the NoA only included one brief sentence regarding program income. Flushing will implement the following process to formalize controls related to the program income compliance requirement for the grant. 1) Management will review monthly charge/income reports for each clinician hired under the grant to keep track of the program income related to the grant. Management has started reviewing the program revenue and will set up quarterly reviews with the program director. 2) Management will keep track of all program income related to the grant and compare the income to the current expenses, and retain documentation supporting how the program income was used to further eligible project objectives prior to requesting reimbursement from the agency under the grant. 3) These controls and procedures will be implemented by the end of the 3rd quarter of 2023. Management responsible for corrective action plan: Gina Aharonoff, Program Director (gaharono@jhmc.org) Manzar Sassani, Vice President of Finance (msassani@jhmc.org)

The income verification process has been reviewed the Director of Food Service. She understands that the verification must be an official document of earnings (i.e. paystub).

2022-016 Finding: Program Income - ALN 14.239 ? Home Investment Partnerships Program / Department of Housing and Urban Development / Award Number: M22-MC080204 / Award Year: 2022 Status: Corrective action in progress Corrective Action: The City agrees with the finding as this was a simple oversight for the finance team due to the extreme staff shortages we?ve encountered over the last year. HOST has a process of reviewing and approving program income in Workday and associated grantor entries. We are filling vacancies to support the general ledger transactions and currently onboarding a new staff accountant to support this effort. Del Norte Loan # 34-36-01 had cash flow in 2021, and a subsequent payment due in 2022. An interest payment of $48,500 was completed credited correctly. The interest was booked in the General Ledger (GL) under HOME/GR2437 instead of NSP2/GR98, causing the NR to be inaccurately overstated in HOME/GR2437 and understated NSP2/GR98. This has been remediated going forward by practicing a process of reconciling each fund with each revenue category. Person(s) Responsible for Implementing: HOST ? Ami Webb Implementation Date: August 2023

ACED will make all necessary adjustments in its next Cash on Hand submission which occur in October 2023. Going forward the Cash on Hand report will be reviewed by Senior Staff for accuracy and completeness.

B. Corrective Action Plan: Any corrections that have not already been made will be made in a timely manner. ACED typically waits to receipt certain Program Income in order to be in compliance with CDBG program regulations. ACED will develop a schedule for receipting Program Income that will result in all Program Income being receipted in a timely manner.

Home Investment Partnership Program 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: Responsible Individual: Corrective Action Plan: Anticipated Completion Date:

Community Development Block Grants/State?s Program and Non-Entitlement Grants in Hawaii 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: Responsible Individual: Corrective Action Plan: Anticipated Completion Date:

Finding 2022-002 Condition: As of the March 31, 2022, reporting date, the Town underreported federal expenditures by $211,064. Corrective Action Plan: The Emergency Management Director will confirm with the Finance Director the ARPA expenditures being submitted to Treasury on the annual Project and Expenditure Report, and reconcile with expenses listed in all applicable MUNIS accounts. Anticipated Completion Date: 4/30/2023 Contact Information: Chief Michael Cassidy, Emergency Management Director cassidym@holliston.k12.ma.us Chris Heymanns, Finance Director ? Treasurer/Collector heymannsc@holliston.k12.ma.us

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Service Fund Balance Management Assessment - We concur with the audit assessment regarding this matter. Planned Corrective Action - The District is aware of the USDA fund balance requirements. The District operated under the Seamless Summer Option during fiscal year 2021-22 which allowed all of our students to eat both breakfast and lunch for free. The District received a large amount of federal funding which in turn resulted in more fund balance than allowed by USDA at 6/30/2022 ($5,466). The Food Service Director and Business Manager are in the process of creating a spenddown plan to be submitted to MDE which will move fund balance within an allowable range. Responsible Party - Business Manager Date of Planned Corrective Action - June 2023

Finding No. 2022-001 Criteria Per Uniform Guidance, the required reports for federal awards should include all activity for the reporting period, are supported by applicable accounting or performance records, and are fairly presented in accordance with governing requirements. Additionally, per HUD guidance, the Quarterly Cash on Hand report must be submitted to the respective field office within 30 days after the end of the reporting period. Condition For the seven Community Development Block Grants/Entitlement Grant reports sampled, disbursement and program income data reported on the report submissions did not directly tie to the general ledger. For four of seven reports sampled, the Quarterly Cash on Hand Reports were submitted after the federal report due dates. Corrective Action The Township will implement review procedures to ensure the IDIS system grant program reports are completed timely and are reconciled to the Township general ledger schedules monthly. Responsible Party Township Chief Financial Officer Anticipated Completion Date Corrective action procedures are already in place and operating.

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Condition: As of the June 30, 2022 reporting date, the City’s Project and Expenditure Reports overstated expenditures by $274,713 and overstated obligations by $14,045,059. Corrective Action Planned: ARPA Director reviews all expenditures for the quarter with City Auditor to reconcile cumulative expenditures and obligations for entry into portal. Anticipated Completion Date: October 31, 2023 Contact: Bridget Almon, Director of Financial Services Kara Humm, ARPA Director Sedryk Sousa, City Auditor

The Organization and the grantor will work to ensure that final financial reports will be accurate and tie to the underlying financial records in all respects at the end of the year. The grantor noted that they are not concerned about the accuracy of interim reports since the incorrectly reported information does not affect the funds reimbursement amount.Recommendation: We recommend that the Organization implements a review process to tie the monthly, quarterly, and annual financial reports to the underlying financial records as the reports are prepared. Planned Action: The Organization and the grantor will work to ensure that final financial reports will be accurate and tie to the underlying financial records in all respects at the end of the year. The Recommendation: We recommend that the Organization implements a review process to tie the monthly, quarterly, and annual financial reports to the underlying financial records as the reports are prepared. Planned Action: The Organization and the grantor will work to ensure that final financial reports will be accurate and tie to the underlying financial records in all respects at the end of the year. The grantor noted that they are not concerned about the accuracy of interim reports since the incorrectly reported information does not affect the funds reimbursement amount.

Finding 2022-002 a. Program Information: 14.267 Continuum of Care Program b. Criteria: Housing program tenants are required to pay up to 30% of their income for rent. Eligibility and rent determination evaluations are performed for new tenants before move-in and annually for existing tenants to determine their portion of rent to pay. In accordance with 2 CFR 200.307, program income (in this case, tenant rent) must be correctly determined and properly recorded in the accounting records. c. Condition: For two out of 10 transactions tested, the amount of rent collected by The Center from the tenant was more than the amount determined on the Eligibility and Rent Determination form. Response: a. The Director of Housing and Youth Homeless Services is working with the housing complex property manager to memorialize the practice of either having the tenant reduce a future payment by the overpayment amount or refunding the overpayment amount to the tenant. In addition, they are working together to implement an actively level control whereby the Director of Housing and Youth Homeless Services’ team and the housing complex property manager are performing a more detailed review on a monthly basis to ensure overpayments, in particular, are detected and corrected timely. Contact persons responsible for corrective action: a. Victor Esquivel, Director of Housing and Youth Homeless Services b. Angela Reyes, Chief Financial Officer Anticipated completion date: a. November 1, 2023

Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2021 program income. CUAHSI staff missed the NSF filing deadline for declaring federal fiscal year 2021 program income by one day (submitted November 16th, 2021). 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 beginning in 2023 and appropriate staff and policies are in place to ensure 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

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 an 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.

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.

The 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. During 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, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their 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 to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

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 reference number: SA 2021-002 Accurate Financial Reporting in the Annual PR26 Report Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: Since FY 2021, the City has reviewed its organizational structure and processes for management of the CDBG grant program. At the end of FY 2023, the City brought the program back in-house to the newly-created Department of Social Services and Housing (SSH). In FY 2024, staff developed a process to ensure timely and consistent draws, with reconciliation to the general ledger at the point of each draw. SSH staff have developed a timeline of required actions for the program to ensure compliance with deadlines. • Anticipated Completion Date: June 30, 2024

Finding 2021-012 Program Income Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director, Program Directors Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: September 2023