Corrective Action Plans

Finding 2022-008 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material noncompliance Name of Contact: Jana Rae Koenig, Executive Director Corrective Action Plan: The Native Village of Point Hope will adhere to the Administrative Management Systems Manual Chapter III: Financial Management to ensure that all payment authorization forms are on hand for all employees. Additionally, pay rates should be compared to the payment authorized form during review of payroll runs for accurate transitions. Proposed Completion Date: Before the end of the next audit cycle.

Finding 2022-007 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material noncompliance Name of Contact: Jana Rae Koenig, Executive Director Corrective Action Plan: The Native Village of Point Hope will adhere to the Administrative Management Systems Manual Chapter III: Financial Management to ensure that all payment authorization forms are on hand for all employees. Additionally, pay rates should be compared to the payment authorization form during review of payroll runs. Proposed Completion Date: Before the end of the next audit cycle.

Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Interim Controller and Director of Finance are working to secure an ERP system which will allow for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. We also understand these findings are repetitive from the 2021 audit; however, due to catch-up of the prior year audits, we were unable to address these issues prior to completion of the 2022 audit. This delay was caused by a change in auditors as our previous auditor did not have the capacity to retain us as clients due to staff shortages related to COVID. A subcontractor has been retained to assist with providing information for the 2023 audit to bring the audits current. The auditors tested 84% of the total 2021 total direct grant expenditures and this issue was isolated to one payroll entry for $2,500.00, which is a result of a one-time, non-recurring clerical error. No issues were noted in the 2022 audit work related to this finding. We are currently analyzing and ensuring revenue and expenses for grants in 2023 and 2024 have proper recognition and billing of accurate and complete costs. This issue will be further mitigated with the implementation of the new accounting system on 1/1/2025. The ERP system includes electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. Timesheet training has been performed and timesheet completion is required for all employees beginning on 1/1/2025. This will provide support for hours worked/billed, as well as document the certification and approvals that all time entered is accurate and in compliance with contract requirements. and provide proper support for all grant and indirect labor costs. An indirect cost pool allocation structure is being designed and implemented to properly allocate the allowable indirect costs to each work effort. This proposed structure and rates will be submitted for approval in 2025. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: January 2025

Finding 2022-007 – Allowable Cost Documentation In response to the finding, GEM addressed allowable cost documentation by instituting the following: GEM established a formal credit card policy in the employee handbook that explains the policy and procedures for turning in receipts monthly. Anticipated date of completion: This policy has been in effect since September 30, 2023. Responsible party: Jamie Hicks, Senior Accounting Manager

Finding 2022-005 – Indirect Cost Allocations In response to the finding, GEM will improve program costs allocation documentation by instituting the following controls and procedures. GEM will allocate indirect costs and charges to the NSF program based on incurred costs and monthly allocations approved by the program administrator. These indirect costs will be separately reported in the accounting records. Anticipated date of completion: Monthly journal entry is set up with calculations for determining the dollar amount. The date of completion was October 2022 and have been updated since then. Responsible party: Jamie D. Hicks, Senior Accounting Manager

Finding 2022-004 – Allocation of Program Effort by Employees In response to the finding, GEM will institute controls and processes to document and allocate personnel time and effort to NSF program GEM will allocate time and effort via approved time and expense personnel reports and reconcile these the accounting records and NSF program charges. Anticipated date of completion: Process was implemented on December 31, 2022. Responsible party: Jamie Hicks, Senior Accounting Manager

Effective immediately, as a condition to issue a payment, all purchases exceeding the federal limit will require (a) evidence that quotes from at least three qualified vendors were obtained or (b) a written and signed statement that there are no other vendors providing the goods or services or (c) a written and signed statement that the purchase was made to address an emergency as declared by federal or local governments.

Action Taken: Non-compliance may be established in individual months for FY2022; however, upon the hiring of the new CFO in the final month of FY2022, the database records for case notes and grant distribution for the entire year of FY2022 were applied to payroll payments for the entire year and year-end invoices to each grant were billed aligning the total fiscal year in each grant’s final invoice of the fiscal year versus adjusting each of the months of FY2022 as submitted invoices could not be revised. Controls for correct assignment on a bi-weekly basis were established with the change in CFO hired in September 2022.

Action Taken: Non-compliance may be established in individual months for FY2022; however, upon the hiring of the new CFO in the final month of FY2022, the database records for case notes and grant distribution for the entire year of FY2022 were applied to payroll payments for the entire year and year-end invoices to each grant were billed aligning the total fiscal year in each grant’s final invoice of the fiscal year versus adjusting each of the months of FY2022 as submitted invoices could not be revised. Controls for correct assignment on a bi-weekly basis were established with the change in CFO hired in September 2022.

Management has contacted its HUD representative in order to obtain proper written approval for the $22,700 withdrawal made.

Management has contacted its HUD representative in order to obtain proper approval of the withdrawal from its reserve for replacements account

Compliance Requirement: Allowable Cost/Cost Principles Type of Finding: Material Weakness Condition: A walkthrough of fourteen individuals was performed to agree personnel files and to payroll. Of the fourteen files reviewed, six had no approved current pay rate documented, and the salary or hourly rate paid was not the rate contained in the file. Also, there was no timesheet provided to suppo1t the time charged to the federal grant for two of the fourteen individuals tested. Action Planned in Response to the Finding: Use a checklist within each personnel file to ensure all necessary documents are included and updated for current rates of pay. Official Responsible for Ensuring the CAP: Marilyn Powers-Campbell Planned Completion Date: December 2024

The filing system will be tightened to ensure immediate availability of documentation both electronically and paper trail.

Recommendation: As previously recommended by the OBO, the organization should update policies and procedures surrounding the award programs cost allowability to ensure unallowable costs are not charged to the program. Further, it should provide training to staff on updated policies, Federal and Grant Per Diem Program cost allowability requirements, proper expense documentation and retention procedures. Response: Procedures and trainings were developed as a response to the VA’s OBO audit that included cost allowability, document retention timelines and data collection for reporting. It also included a process for adding tracking codes to tag these expenses in our general ledger. These procedures were also provided to VA’s OBO for their records. These procedures will be further amended to exclude gift-in-kind from allowable expenses that can be charged to federal programs. Estimated Completion Date: Fiscal Year 2023 for training and developing standard operating procedures and September 2024 for gifts-in-kind amendment to revise allowable expenses.

Recommendation: As previously recommended by the Office of Business Oversight (OBO), the organization should develop standard operating procedures, and related oversight activities ensuring accurate SF-425 information reporting. Further, it should provide training to staff on the updated policies. Finally, it should submit the revised SF-425 with the correct allowable expense reported for the program. Response: In accordance with, and as a response to the OBO audit, procedures were developed and staff were provided with a series of trainings on VA GPD Program Compliance. Estimated Completion Date: Fiscal Year 2023

We agree with the finding that the same expenditures were included in reimbursement requests for assistance listings 21.023 and 14.231. The reimbursement requests were compiled using a separate database of individual clients for each assistance listing. Due to a data entry error, the same expenses were included in both databases. As part of CAC's internal controls, the databases are supposed to be reconciled to the appropriate expenditure accounts of the general ledger for each assistance listing. This reconciliation did not occur for these reimbursement requests. When Management reviewed the reimbursement request prior to submission, that review compared the reimbursement request to the database listing and not the general ledger. The following corrective action plan will minimize the occurrence of reimbursement being requested from multiple grantors for the same allowable expenditures. Beginning in the FY2025 fiscal year, invoices that are submitted to CAC management for review that are based on worksheet or database listings will be accompanied by a copy of the general ledger and amounts shown on the database or worksheet reconciled to the general ledger. The projected date for full implementation of the corrective action plan for this finding is June 30, 2025. The contact person for this corrective action are: Barbara Kelly, Executive Director, David Mincey, CAC Fiscal Services Manager/Internal Auditor, CAC Chief Financial Officer, to be selected.

Finding: Unable to support $13,395 of estimated salaries for SJH employees administering nursing home COVID testing. Corrective Action: Since the employees administering tests are primarily exempt employees and do not clock in to track specific tasks, St. John’s Health created a sign in sheet which indicates when an employee is engaged in manning a testing station. The employee fills in their name, date, time in, time out, and a description of what they were doing during that time. The sign in sheet is reviewed by someone who is familiar with the grant conditions and the reviewer also signs off on the sheet verifying that the time spent would meet the intent of the grant reimbursement. The corrective action plan is fully implemented as of September 2024. The contact person at the Hospital responsible for the plan is Alisa Lane, alane@stjohns.health.

We recommend that management either 1) provide training for its key accounting personnel so that they will be able to prepare SEFA and CYEFR for the County and/or 2) contract with an accountant or firm that has the relevant skills, knowledge and experience to prepare the SEFA and CYEFR. We further recommend that the Board of Commissioners enforce the County’s policy of requiring that all accounting records and related supporting documentation be made available to the County Treasurer so that there is a process in which all of the County’s financial activity pertaining to grants is compiled, reconciled and included in a complete set of grant financial reports utilized to prepare the SEFA and CYEFR for the County.

We recommend that management either 1) provide training for its key accounting personnel so that they will be able to prepare SEFA and CYEFR for the County and/or 2) contract with an accountant or firm that has the relevant skills, knowledge and experience to prepare the SEFA and CYEFR. We further recommend that the Board of Commissioners enforce the County’s policy of requiring that all accounting records and related supporting documentation be made available to the County Treasurer so that there is a process in which all of the County’s financial activity pertaining to grants is compiled, reconciled and included in a complete set of grant financial reports utilized to prepare the SEFA and CYEFR for the County.

Federal Award Finding and Questioned Costs Finding Reference Number: 2022-002 – Activities Allowed or Unallowed, Allowable Costs/ Cost Principles, Eligibility and Program Income Federal Program Information: Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY21; INORWB611-GY22 INORPS611-FY22; INORPS611-FY23 Awards: Assistance Listing Number 93.917 HIV Care Formula Grants (Part B) Award Periods: April 1, 2021 to March 31, 2022; April 1, 2022 to March 31, 2023 July 1, 2021 to June 30, 2022; July 1, 2022 to March 31, 2023 Description: Review and Retention of Eligibility Required Documentation Type of Funding: Material Weakness in Internal Control Over Compliance Recommendation: Inova Juniper Program’s (IJP) existing policies and procedures are in line with the requirements of the pass-through agreement with the Department; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification for all clients. View of Responsible Officials: Management concurs with the finding and has implemented, during 2021 and 2022, procedures to ensure the appropriate oversight is performed regarding eligibility. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Mara Carter, Senior Director Community Health, Inova Juniper Program, 703-321-2687 Corrective Action Planned: All exceptions noted during testing were from eligibility certifications prior to the actions noted below. Patients were not due to have re-certifications done at the time the services were provided. Below are the policies and procedures implemented and the control activities to ensure that policies and procedures are being followed with regard to eligibility verification for all clients.  VDH Part B Eligibility standards were modified to help reduce the documentation burden in which the annual eligibility screening was extended to a 24-month eligibility review and removal of the six-month recertification requirement. This was incorporated within the VDH contract on April 1, 2022.  Effective November 1, 2021, the list of acceptable documents changed by VDH. Bank statements were no longer an acceptable proof of residency and viral load values had to be included versus only lab results with undetectable. Also, VDH implemented a new eligibility electronic health record (EHR), Provide Enterprise, to help ensure all eligibility requirements are met for each Ryan White patient. Although this was implemented statewide, Inova continued to utilize the Provide Portal and went live with Provide Enterprise in January 2023. The existing Provide Portal at Juniper did not have an income calculator or the ability to immediately provide feedback that the required forms and eligibility requirement was not met. The new system in place, Provide Enterprise, has both functionalities.  Inova has strict monitoring practices in place. The practice manager in 2021 and new Senior Practice Manager who started in July 2022 reviewed 110-120 charts monthly, and our Business Analyst performed a 10% reaudit of those charts. The audits completed in 2022 were a result of the implemented processes due to the corrective action plan of the previous audit. These ongoing audits assist management to closely monitor adherence to the changes adopted in 2021 and 2022. If any gaps are noted during the audit, the Senior Practice Manager works with the team to fix discrepancies within seven working days. The goal of the monitoring process is to ensure adopted policies and procedures with respect to eligibility are followed.  In November 2022, a peer review process was implemented by the Senior Practice Manager to ensure prior submission to any eligibility packet to VDH, there is a second independent review of each packet. This ensures all internal processes are followed. After November 2022, weekly meetings continued with all eligibility team members and leadership. The peer review focuses mainly on proof of documentation for each requirement and income calculations.  Inova Juniper Program implemented a revised policy in February 2023. Once Provide Enterprise was fully implemented in February 2023, VDH also added a quality assurance meeting weekly to review all previously submitted packets for the week. The goal is to identify any gaps and opportunities in our processes. The revised policy focuses on the new EHR, Provide Enterprise, capability and to ensure processes include use of the income calculator and compliance with appropriate use of documents related to eligibility.  All team members went through a robust Provide Enterprise training and all new hires are required to attend the same training. This training incorporates all the appropriate documents needed to be eligible for Ryan White services as well as utilizing the income calculator. The Leadership team, and our internal quality council, review our eligibility scorecards monthly and discuss any trends or opportunities. In addition to the above, leadership also reviewed all job descriptions for our current eligibility team. It was determined based on the scope of their role, that realignment was necessary. The Patient Access Associate (PAA) I role did not require any healthcare or registration experience in order to accurately perform their role. The job focused purely on customer service experience and was an entry level position for the program. The PAA II role requires one year of healthcare registration or revenue cycle experience and the PAA III roles require two years’ experience in healthcare registration or revenue cycle. Given the level of detail orientation required for these positions and the ability to fully understand registration, HIPAA, insurance verification and grant mandates, all individuals with the appropriate requirements that were identified as PAA I roles were transitioned to PAA II and PAA III. Through attrition, all roles have successfully been reassigned. Planned Completion Date for Corrective Action Planned: Corrective action plan has been implemented.

The School District will review the Uniform Guidance requirements and ensure all supporting documentation for federal programs is maintained and readily available.

10/08/2024 Butte Valley Unified School District Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2022 Finding Reference Number: 2022 -003 Supporting Documents Relating to Elementary and Secondary School Emergency Relief Program Name: Elementary and Secondary School Emergency Relief (ESSER, ESSER I, ESSER II, ESSER III, and Learning Loss) Fund Federal Financial Assistance Listing Numbers: 84.425, 84.425C and 84.425U Federal Agency: U.S Department of Education Compliance Requirements: A. Activities Allowed or Unallowed; B. Allowable Cost Principles; F. Equipment/ Real Property Management Description of Finding An effective disbursement system to ensure compliance with the requirements of the program has either not been established or is not working as designed. District staff was unable to provide sufficient and appropriate audit evidence for certain expenses to determine compliance with activities allowed, allowable cost principles and/or equipment/ real property management for the Elementary and Secondary School Emergency Relief Program. Therefore, documentation to support the propriety of expenditures (e.g. date, purpose, amount, classification, approval, etc.) was unavailable or nonexistent for planned audit procedures related to internal control testing and substantive testing of compliance for the federal major program identified above. Corrective Action We already have revised procedures for the finding. We now have more than 1 person responsible for the filing of the invoices and the purchase orders, so nothing gets misplaced again. We realized how important this is and will not allow it to happen again. The Business Manager and District Secretary are overseeing accounts payable at this time and going forward. The Superintendent / Principal is also here to help oversee the District Office and make sure that things are properly filed. Name of Contact Person Jared Pierce, Superintendent/ Principal JPierce@bvalusd.org (530)397-4000 Kimberly Weed, Business Manager KWeed@bvalusd.org (530)397-4000

Finding 2022-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: We anticipate that all major inefficiencies within school payroll will be eradicated by June 30, 2025. Contact Person: Julie Hebert, Finance Director; Janet Jannell, Treasurer/Collector; Gale Clark, School Business Manager

2022-019 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster - ALN 93.045 - Special Programs for the Aging _Title III, Part C_Nutrition Services - 2201KSOAHD Management’s Response: Management will work with Aging to make sure they are tracking and reporting time correctly in accordance with the award parameters. Views of Responsible Officials and Corrective Action: Department personnel will need training on how to report time correctly in the payroll system to adhere to award parameters. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

Finding 2022-016 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-20-0001 Management’s Response: Management agrees it is critical to ensure spending occurs within the applicable expenditure periods. In the new financial management system (Workday), we have established parameters to fence the applicable expenditure periods. Further we are making gains to close out awards to further disallow spend outside the applicable expenditure periods. There was departmental turnover within the department at the end of 2022 with a loss of knowledge transfer during the change in personnel. Views of Responsible Officials and Corrective Action: With the aid of technology available through our new ERP system, management plans to enhance operations by having training documents and processes for various awards so as personnel attrition occurs there is continuity in processes. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS