Corrective Action Plans

Statement of Condition 2023-001 (Assistance Listing 14.157): During the year ended September 30, 2023, the Corporation paid an expense totaling $920 on behalf of an affiliated entity without HUD approval. Recommendation: The affiliated entity should repay $920 to the Corporation. Management Response: Agree. The affiliated entity repaid the Corporation $920 on November 17, 2023.

Views of responsible officials and planned corrective action: The Authority has an interlocal agreement with a neighboring housing authority for administration of the Section 8 Housing Choice Vouchers Program. The authority understands the reason for the finding, in that the inspection was one month late. Previously a quality control sample of HCV files administered by the neighboring Housing Authority had been reviewed each month. This was with respect to the income calculation, specifically. Housing Kitsap will add a verification of inspection requirements to this process. Heather Blough, Executive Director, will be responsible to implement this corrective action by June 30, 2024.

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Foster Care Federal Assistance Listing Number: 93.658 Significant Deficiency and Non-Material Non-Compliance – Allowability and Eligibility Finding 2023-005 Criteria or specific requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: For one (1) of the 40 participants selected, an amount of $1,004 was requested for reimbursement that was not paid to the third party facility. Questioned Costs: $1,004 and likely questioned costs of 90,594. Effect: By not having the required documentation in the files to support payment for costs recorded, the County may request reimbursement for costs not incurred. Cause: County oversight when performing reviews over payment reimbursements. Recommendation: We recommend the County implement a procedure to ensure all costs being requested within reimbursements have been incurred by the County prior to requesting reimbursement. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. The Data Integrity unit within the Finance Department will continue to review invoices, child by child, to verify correct placement information. The Supervisor will review sample of invoices to ensure each Facility is paid the correct amount depending on child placement. Responsible Individual(s): Annette Madden, Management Analyst, Data Integrity Unit, Finance Date of Implementation: 12/31/2023

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Non-Material Non-Compliance – Eligibility Finding 2023-002 Criteria or specific requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NCFAST. We noted several errors related to the following compliance criteria: a) The caseworker should prepare and submit a DMA-5097 form in the case of noncooperation as described in the Eligibility Review Document. b) When the Social Security Administration (SSA) terminates social security income (SSI) eligibility, the county is required to make an ex-parte determination for eligibility. This determination is required to be made within 120 days after the termination of the SSI payment. c) An OVS inquiry must be completed and agreed to information reported in NC FAST. d) An AVS inquiry must be completed and agreed to information reported in NC FAST. e) When forcing eligibility, documentation explaining the reasoning for the forced eligibility is required to be maintained on file. Condition: The following are the results of non-material non-compliance noted for each criteria listed above out of the 122 program participants selected for testing: a) There were two instances where the non-cooperation with IV-D was identified but no DMA-5097 was sent. (93 and 105) b) There were two instances where the County did not complete the ex-parte review for a participant whose SSI benefits were terminated during the year. The County should have forced eligibility, due to the COVID-19 exemption, but did not force eligibility for these instances. (63 and 121) There was one other instance where the County did force eligibility, but they forced it to the wrong program. (47) c) There was one instance where the resources found through the register of deeds did not agree to the resources in NC FAST which affected the countable resource calculation. (68) d) There were two instances where the OVS query was not ran at the time of the determination. (92 and 93) e) There were two instances where eligibility was forced but no documentation explaining the reasoning for was documented at the time of the determination. (114 and 122) Lastly, there were 31 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely. Context: There were 9 out of 122 unique participants tested with the errors noted above, in which one was determined to have been improperly determined eligible. Questioned Costs: We noted a total of $59,534 in benefit payment claims paid by the State of North Carolina based on an improper eligibility determination made by the County for which the State relied on; see item “c” above. As the County did not make the payment directly, it is not considered questioned cost for the County under Uniform Grant Guidance §200.516(a)(3); however, in accordance with NC general statutes §108A-25.1A, the County is financially responsible for the $59,534 of erroneous issuance of Medicaid benefits for an ineligible individual. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could provide funding to individuals who are not eligible. Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis. Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: The County will take a multi-faceted approach to mitigating such errors in the future. Training: The Quality and Training unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified including completing ex-parte determinations for eligibility when SSA terminates SSI eligibility, properly documenting and reacting to IV-D non-cooperation, correct and appropriate usage of forced eligibility, and performing the required electronic verifications to complete an application or review. This training will be delivered by the end of the third quarter of fiscal year 2024. Responsible Individual(s): Ellese Massey, ESD Quality & Training Manager Anticipated Completion Date: March 31, 2024 Process Improvement: The Economic Services Division (ESD) has begun training new hires in one function of the Medicaid program, for example, processing applications or recertifications/changes. This is to build a stronger foundation before they learn the second function of their assigned program. Our Quality and Training Team is adding additional time for training, as needed, to ensure our trainees receive the support they need while learning a new program. ESD has specific protocol for managing the recertification process for SSI terminations and will ensure this policy is followed moving forward. Responsible Individual(s): Kim Konior, Medicaid Program Manager and Ellese Massey, ESD Quality & Training Manager Anticipated Completion Date: March 31, 2024 Quality Sampling and Accountability: The Quality and Training Unit will complete monthly quality sampling for Medicaid. Error trends will be shared with the managers and their supervisors, who will work collaboratively with Quality and Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. The Quality Assurance team in OSI/CFAS will conduct an independent evaluation and review the second party review process at the divisional level to ensure review was accurate and errors were corrected timely. This team will report out to ESD Leadership quarterly on findings. Responsible Individual(s): Kim Konior, Medicaid Program Manager & Sonya English, Quality Assurance Supervisor Anticipated Completion Date: Currently Ongoing

Corrective Action Plan and Views of Responsible Officials The IT Manager, prior to the filing of any E-Rate or ECF grant documents, have all entries approved by his supervisor. The IT Manager will also set a meeting to review any documentation related to any applications for funding prior to submitting an application to ensure the District is prepared to adequately meet all funding requirements.

Recommendation: We recommend that the Project funds are only used for expenses of the Project. Additionally, we recommend the management company reimburse the operating cash of the Project $16,362 for overpayments. Action Taken: We agree with Finding 2023-001 described in the accompanying schedule of findings and questioned costs. The management company will reimburse the Project operating cash for the overpayments.

We will implement internal control processes to ensure all information is submitted in the PRF Portal by the specified due date.

FINDINGS – FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Education Passed Through Kansas State Department of Education Program Name: Education Stabilization Fund Cluster Federal Assistance Listing Numbers: 84.425W, 84.425U, 84.425D Finding 2023-001 Recommendations: The District should have an employee compare the Board Clerk’s supporting documentation and the Education Stabilization Fund spreadsheet report before its submission to the State of Kansas for its accuracy. After the approval by the secondary review employee, the report submitted should be printed, initialed by the secondary reviewer, stapled with the information used to compile the report and combined with all financial records for the fiscal year. Action Taken: We agree with the recommendation. Our targeted implementation date is March 2024. If the Kansas State Department of Education and/or Kansas State Department of Administration has questions regarding this plan, please call Rex Richardson at 620-675-2277.

As noted within the portal filing summary for the general reporting period 5, the Corporation’s consolidated cumulative lost revenues totaled $141,363,926. Through the period 5 report, $99,467,570 cumulatively, had been applied to lost revenues to date, leaving $41,896,356 in unreimbursed lost revenues. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the “Finding” section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions, if required. As of the date of this letter, PeaceHealth Networks has reported on all PRF funds received and has no future portal reporting obligations. Corrective Action Plan Completion Date: October 15, 2023

Finding: 2023-002: Questioned Cost – Material Weakness Costs for US Department of Transportation, Mobility Management Grant 20.507 Section 5307 included a $30,000 charge for use of the Data Management System (DMS). The charge is based on a contract rate charged to outside entities that varies depending on the number of users. Management stated the charge was to recoup costs for use of the DMS. Costs for the DMS consist of historical costs to get the system functioning, along with current personnel costs to operate the system and provide the contracted training. The historical costs occurred outside the period of performance and are thus unallowable. Personnel costs are already being charged to the grant through the allocated payroll and benefits of trainers and other personnel, and thus should not also be charged through the contract rate. In addition, if the contract rate includes a profit component this would also be unallowable to charge to the grant. Auditor Recommendation: We recommend that costs charged to federal grants be reviewed by an individual familiar with the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 as part of the SEFA review process. Contact Person Responsible for the Corrective Action: Lisa Cappellari, Chief Financial Officer, LisaC@paratransit.org Management Response and Corrective Action Plan: After the end of Fiscal Year 23-24 on 6/30/2024, Jody Wadley, Finance and Grants Manager, and Lisa Cappellari, Chief Financial Officer, will compile all expense to be charged to any federal grants. Tiffani Scott, Chief Executive Officer, will review the expense against the Cost Principles for Nonprofit Organizations contained in 2 CFR, Section 200 to make sure all expense is eligible.

Planned Corrective Action: ETFB procurement policy to be reviewed and updated to include internal controls for compliance with contract costs and price guidelines as outlined in the Uniform Guidance. -Add CEO or Officer review of contract costs and price guidelines for federal contracting agreements toensure accordance with the Uniform Guidance for General Procurement Standards. -Add obtaining and reacting to suspension and debarment certifications.

Name of Contact Person: Jacob Weavil, Finance Director Corrective Action/Management's Reponse: Regarding payroll records, the City is converting to Tyler Time and Attendence which will be a cloud based time keeping software. This will provide the same additional layer of backup support as the cloud-based storage for internal files. All payrolls starting from the first pay period after the network event are being racked with phyiscal timecards submitted by Departments on a bi-weekly basis. Propsed Completion Date: Immediately and ongoing.

Name of Contact Person: Michael Ferris, City Manager Corrective Action/Management's Response: The City has filled the vacant Director position in Public Housing with a temporary consultant who specializes in Housing and Urban Development (HUD) programs. This individual is assisting with training Housing staff and reviewing current internal controls to make improvements to operations. Proposed Completion Date: Immediately and ongoing.

Description of Finding: The District charged prior period wages and associated payroll costs to the High School Equivalency Program award. While the costs are allowable and within the grant period, a waiver from the federal agency allowing prior-year costs was not obtained. This results in a questioned cost of $35,844. Statement of Concurrence: The District agrees with this finding. Corrective Action: We have communicated with the federal agency overseeing this grant, and have requested approval and a documented waiver. This is currently being reviewed by the agency. We believe that these questioned costs are allowable and in line with the requirements of the grant. If the requested waiver is denied, the District will utilize alternative funding to cover the questioned costs. Projected Completion Date: We expect this matter to be resolved by the end of January 2024.

Finding Reference Number: 2023-004 Initial Fiscal Year: 2023 Summary of Finding: Significant Deficiency: The University Did Not Timely Complete Return to Title IV Funds (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268, Federal Pell Grant Program, ALN #84.063) Entity’s Corrective Action Plan Corrective Action Plan Summary: When processing the R2T4s for these three students the Director looked at the current date on the form and processed them according to the current date and not the date of withdrawal. For these students due to the date difference went from being in the greater than 60% category where a R2T4 was not necessary to now needing one processed. The university has implemented an audit process where by the date entered can be more easily verified to ensure accuracy. This date and the withdrawal date or LDA are now added to a withdrawal form that is shared between departments so that any variance will be easily identified. Anticipated Completion Date: September 21, 2023 Explanation: The corrective action plan was taken to resolve the prior year finding, helping to ensure that future dates are accurate. Name and Title of Responsible Person: Rocky Christensen, Director of Financial Aid.

Finding Reference Number: 2023-003 Initial Fiscal Year: 2023 Summary of Finding: Significant Deficiency: Return to Title IV Funds (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268; Federal Pell Grant Program, ALN #84.063) Entity’s Corrective Action Plan Corrective Action Plan Summary: When setting the R2T4 dates in the system we had failed to count the Saturday and Sunday preceding the break period of five days or more. The university has addressed the issue for the future POE periods and implemented a three step verification process moving forward. The three step verification involves two additional staff verifying the dates in the system to ensure accuracy. Anticipated Completion Date: September 21, 2023 Explanation: The corrective action plan was taken to resolve the prior year finding, helping to ensure that future dates are accurate. Name and Title of Responsible Person: Rocky Christensen, Director of Financial Aid.

Finding Reference Number: 2023-002 Initial Fiscal Year: 2023 Summary of Finding: Significant Deficiency: Documentation Regarding Offer of a Post- Withdrawal Disbursement (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268; Federal Pell Grant Program, ALN #84.063) Entity’s Corrective Action Plan Corrective Action Plan Summary: The university was not documenting the PWD notification that happens with students as part of our exit process. While the university was completing this the lack of documentation has been addressed. The university now has the student verify receipt of this information on the withdrawal form. Anticipated Completion Date: September 21, 2023 Name and Title of Responsible Person: Rocky Christensen, Director of Financial Aid.

Condition: A sample of 118 payroll-related expenditures were randomly selected for testing using a random sampling approach, of which included a total of 37 district employees paid & claimed under this grant. These payroll-related expenditures were reviewed to determine if appropriate internal controls were implemented and applicable compliance requirements were met. Upon completing this testing, we noted the following discrepancies: -There were 4 employee salary & benefits claimed that were not included in the 22-4998-E3 grant budget detail. The budget specified teachers & paraprofessionals, and support staff were not included, resulting in known questioned costs of $4,857.50. -There were 11 employees where a portion of the claimed payroll & benefits were deemed allowable per the budget but $8,947.88 was deemed not allowable, resulting in known questioned costs of $8,947.88. -Additionally, there were $6,686.25 of the employee salary & benefits that was not deemed allowable per the budget as the pay period dates did not align with “loss of learning” related pay dates or other approved activities. Plan: The District will review its policies and procedures to ensure that potential expenditures are approved are deemed to be allowable before spending federal funds. In addition, the District will consider implementing a monitoring process to ensure that control procedures are being followed. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Condition: During our testing of reimbursements, we noted that the District reported incorrect meal counts on their submitted reimbursement claim forms for the months of October 2022 and May 2023. We tested 2 months of reimbursement claims submitted by the District based on daily attendance records for breakfast and lunch. Of the 4 meal counts tested (2 months of breakfast and 2 months of lunch), we identified three variances where the count claimed for reimbursement did not agree to the underlying records per the school district. Plan: The District will ensure that supporting counts for each months claims are retained and properly reconciled to reimbursement requests. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Condition: The District did not claim expenditures in conformity with the approved detail budget. Plan: The District will periodically review the itemized budget and file amendments as necessary for any changes to ensure purchases conform. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Condition: During compliance testing of the District's accounting records to the expenditure report filed with the Illinois State Board of Education, we noted the District overclaimed $134,309 of expenditures at 6/30/23. Plan: The District will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Furthermore, the District will adequately document claimed expenditures that are consistent with the terms and conditions of each grant agreement. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Management’s Corrective Action Plan Management takes its responsibility to maintain effective internal control over the federal award that provides reasonable assurance that the agency is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award seriously and gave significant consideration to what additional controls would be effective to ensure the proper amount of indirect costs are charged to all federal grants. To prevent another occurrence, the organization will: On October 17, 2023, the agency refunded the indirect costs that were overbilled in error. By December 31, 2023 and annually thereafter, the Director of Grants Management will provide training and technical assistance to all Grant Specialists and Grant Accountants on allowable costs, including detailed training on proper determination of indirect costs for each grant. This training will also be incorporated into the onboarding process for any new grant staff. Continue its current policy that the Director of Grants Management complete a detailed review of each grant reconciliation monthly, to ensure all costs charged to the grant are reasonable and necessary for the performance of the award. This review will include appropriate tests of indirect costs including ensuring the appropriate indirect cost base is used, all items required to be excluded from the indirect cost base are excluded, and the appropriate indirect cost rate is applied to the indirect cost base. Continue its monthly analytical review to test the reasonableness of grant revenue relative to grant-funded expenditures. At least twice annually, the Controller will complete a second detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. At the end of each award cycle, the CFO will complete a third detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. Going forward, should indirect rates or methodologies change for any award, the CFO will review the grant reconciliation the first month following the effective date of the change to ensure the change has been properly implemented.

Management’s Corrective Action Plan Management takes its responsibility to maintain financial management systems that provide an effective internal control framework and effective controls over accountability for all funds, property, and other assets seriously and gave significant consideration to what additional controls would be effective in ensuring all journal entries are reviewed and approved by a qualified staff member who did not prepare the entry. To prevent another occurrence, the organization will: • Continue its current policy that no individual who created a journal entry should review and/or post their own entry in the accounting system. • Add a monthly check step whereby the CFO and Controller will each independently run a report of all journal entries that shows both the preparer and the reviewer/ poster to ensure no further instances occur where the preparer and the reviewer/ poster are the same individual. • In the event this verification detects an instance that violates the policy, the CFO and/or Controller will: 1) complete a documented review of the journal entry in question, and 2) provide progressive disciplinary action to the employee(s) in writing.

U.S. Department of Treasury The Tennessee Performing Arts Center Management Corporation respectfully submits the following corrective action plan for the year ended June 30, 2023. Name & address of independent public accounting firm: Kraft CPAs 555 Great Circle Road Nashville, TN 37228 Audit period: July 1, 2022 - June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FEDERAL AWARD PROGRAMS AUDITS 2023-001 Allowable Costs 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass Through Agency: Tennessee Arts Commission Recommendation: The Organization should ensure that charges to federal grants are allowable in accordance with cost principles contained in Uniform Guidance. Additional training should be considered to gain a further understanding of these requirements. Action Taken: TPAC Grants contacted the pass-through agency to offer a solution, to replace the unallowable expense with an allowable expense. TPAC will also have TPAC Grants as well as TPAC Finance take training on Uniform Guidance to gain a better understanding of these requirements in the future. If the U.S. Department of Treasury has questions regarding this plan, please call Julie Gillen at 615-782-4033.

Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and will provide additional training as deemed necessary.