Corrective Action Plans

Reference Number: 2022-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Lower Income Housing Assistance Program ? Section 8 Moderate Rehabilitation Federal Catalog Number: 14.856 Federal Grant Number: Not Applicable Category of Finding: Eligibility and Special Tests and Provisions ? Housing Quality Standards Inspections Classification of Finding: Significant Deficiency in Internal Control over Compliance Material Noncompliance Authority?s Response & Actions Taken The Authority has made significant progress in addressing the backlog of annual inspections since outsourcing the programmatic functions of the HCV program to a third-party contractor. The Authority remains committed to proactively making substantial movement toward 100% completion of unit inspections by working diligently with its HCV contractor to ensure this occurs. With that said, the Authority maintains that this finding and questioned costs do not consider the three scheduled inspections of the unit in question, between March and August 2022, that all resulted in cancellation or no-show. The auditors refused to take in consideration the evidence of the repeat scheduled inspection dates for this unit and the ?No Show? results. Notwithstanding the fact that in May 2023, the Authority completed the HQS inspection, and the unit passed. This is acceptable documentation which further evidence that the owner did meet its obligations to maintain the unit in decent, safe, and sanitary condition during the audit period. In alignment with the Authority?s HCV administrative plan, both the family and owner are to be provided reasonable notice for all inspections, at least 24 hours prior. The family must allow the Authority to inspect the unit at reasonable times with reasonable notice (24 CFR 982.51 (d)). When a family occupies the unit at the time of inspection, an adult family member must be present for the inspection. If the family misses two scheduled inspections without the Authority?s approval, the Authority will consider the family to have violated its obligation to make the unit available for inspection. This may result in termination of the family?s assistance in accordance with the termination procedures in the HCV administrative plan. If the family?s assistance is to be terminated, the Authority must notify the owner of its intent to terminate the family?s program assistance so the owner can begin eviction procedures. The Authority is obligated to continue to pay the owner until the eviction is completed. Therefore, the potential effect and questionable costs assumed by the auditor are not applicable when the HQS deficiency is due to the tenant?s failure to meet family obligations. The California?s statewide Declaration of Emergency and the City and County of San Francisco?s proclamation of Local Emergency due to COVID-19 was also still in effect during fiscal year 2021-22. The impact COVID-19 pandemic had on housing stability and mental health has been devastating, and disproportionately affected the most vulnerable populations in San Francisco. California State and the City both implemented an eviction moratorium as a mitigating strategy to ensure housing stability. The Authority also made it a priority to ensure health, safety and housing stability of its residents comprised of some of the most vulnerable populations in San Francisco. To that effect, the Authority collaborated closely with landlords and service providers to assess tenants needs and provided needed assistance throughout the COVID-19 emergency period (i.e., processing interims to assist renters experiencing financial hardship, ensuring food security, and delivering personal protective equipment). Anticipated Implementation Date September 30, 2023 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractor Kendra Crawford, Director of Housing Operations

Management will review time and effort documentation requirements with applicable employees.

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, and restricted purpose requirements. Name, address, and telephone of District contact person: Joanne Klein 516 176th Street E. Spanaway, WA 98387-8399 Corrective action the auditee plans to take in response to the finding: The District does not concur with the finding or questioned costs. The district had every intention to provide these iPads to the preschool students who were not in the district technology plan. However, the pandemic caused many distribution delays. The decision was made to provide these students with older surplus iPads. Since the iPads shipment was expected after the students returned to school. The District will work with the FCC to resolve this finding. District does not have any other Emergency Connectivity Grants. Anticipated date to complete the corrective action: 11/1/2023

"See Corrective Action Plan for chart/table"

Views of Responsible Officials and Planned Corrective Actions The timesheets did not reflect the correct hours charged to the program. After discussions with program management, it was discovered that correct communication to staff had not been completed regarding proper program and grant payroll coding for work done on the program. This has been corrected. The Foundation?s contract administrative staff is working more closely with program staff to ensure for each payroll that the time worked on programs is properly reflected on timesheets that are approved by employees and managers. Necessary changes are communicated between program and contract administrative staff to ensure that timesheets reflect work hours properly. Personnel responsible for implementation: Steven Hartman Position of responsible personnel: Associate Director, Contract Accounting Date of Implementation: August 31, 2023

INTERNAL CONTROL ? MATERIAL WEAKNESS AND NONCOMPLIANCE 2022-003 ? Procurement Contact Person: Finance Director Date for completion: December 2023 Recommendation: We recommend that the City adopt a proper procurement policy that is in line with Uniform Guidance. We further recommend that the City develops a centralized procurement process whereby appropriate procurement type is documented along with the maintenance of proper pre-award documentation. Views of Responsible Officials and Planned Corrective Actions: The City will work internally within the City Manager?s office and Finance Department to adopt a centralized procurement process and policy that is in line with Uniform Guidance. Staff identified to participate in the process will be trained as needed.

KCHD will implement internal controls to review outstanding items and ongoing projects monthly, particularly those charged to grants, for proper reporting to ensure compliance with the terms of the award. Specifically, the Business Manager and Administrator will identify any hidden issues that could violate Uniform Guidance reporting requirements. The Health Department expects to have this procedure in effect no later than July 1, 2023. Additionally, the KCHD plans to obtain adequate resources to assist the financial and grant reporting function to ensure compliance.

Candler County Hospital Authority respectfully submits the following corrective action plan for the year ended December 31,2022. The findings from the December 31, 2022 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 MATERIAL WEAKNESS 2022-001 COVID-19 Provider Relief Fund (PRF) ? Period 4 Recommendation: ? We recommend the Authority design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guidelines. ? Action Taken: Management agrees with this finding as stated and the additional actions that will be taken by the Authority. Management will design controls to establish an adequate review process to ensure consistent and accurate calculations and reconciliations in accordance with HHS guidelines. Management will contact HRSA and use either unreimbursed expenses or lost revenues to offset the duplicate expense issue.

FINDING 2022-005 Subject: COVID-19 ? Education Stabilization Fund ? Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425U200013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Material Noncompliance Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with the requirements related to the grant agreement and the Activities Allowed or Unallowed and Allowable Costs/Cost Principles compliance requirements. Context: (a) During allowable cost testing for vendor disbursements, we noted a portion of ARP ESSER funds were utilized to repair the chiller at the middle and high schools. The School Corporation incurred a total of approximately $284,000 in chiller repair costs between September 2021 and May 2022 and requested reimbursement for those expenditures from ARP ESSER funds in full. In October 2021, the School Corporation received an insurance claim check in the amount of $106,755 to cover a portion of the repair costs. The School Corporation did not deduct the amount received through insurance from the amount requested for reimbursement from federal funds, resulting in an overpayment of federal funds during the audit period. (b) Additionally, the School Corporation had not properly designed or implemented internal controls over recording transactions for payroll and fringe benefit disbursements to ensure the accuracy and classification of the payroll disbursements. Payroll disbursements make up approximately 45% of the program costs charged to the Education Stabilization Fund. One employee was responsible for processing payroll. Payroll reports were submitted to the School Board and Treasurer for review and approval; however, the reports only provided a total gross amount paid from each fund. The reports did not list the employees who were paid from the fund. In March 2021, the Treasurer implemented a review of the payroll distribution report, which is broken out by fund and individual employee. The lack of controls related to payroll disbursements was isolated to the 2020-2021 year. Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Description of Corrective Action Plan: The NJ-SP School Corporation will implement internal controls to ensure a system is established for when insurance claim checks are received that they are properly receipted and funds are accounted for and deducted from necessary reimbursement grants. This will give better proper oversight, reviews, and approvals over the insurance claim checks received. These controls will be implemented by July 1, 2023. The NJ-SP School Corporation will also implement internal controls to oversee that financial transactions related to receipts and payroll and fringe benefits disbursements are reviewed and verified by proper management to ensure that accuracy and documentation is in place. These controls were implemented on March, 2021. Responsible Party and Timeline for Completion: Dalton C. Tunis ? Corporation Business Manager/Treasurer Anticipated Completion Date for (b): March 2021 Anticipated Completion Date for (a): July 1, 2023

Deficiencies in the Medicaid Eligibility Determination Process Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Eva Fulcher - (919) 813-5343; Betty Dumas-Beasley - (919) 527-7739 The Department reviewed the errors identified in the audit and will follow-up with each responsible county to correct the beneficiary record. When applicable, the Department will issue overpayment recoupment notices to the affected counties as required by state statute. Anticipated Completion Date: June 30, 2023.

Errors in Medicaid Provider Billing and Payment Process Department Name: Health and Human Services Contact Name / Telephone Number of Person Responsible for CAP: Natasha Bostick-Drake - (919) 710-7891; Cathy Pace - (919) 527-7005 The Division of Health Benefits (DHB) will analyze each error identified in the audit and take appropriate action. A Tentative Notice of Decision (TND) will be sent to each provider to recoup any overpayment identified. Provider Education Letters will be sent to all providers with identified errors. DHB will conduct a six-month post payment review of the affected providers? fee-for-service paid claims to determine if errors are recurring. Anticipated Completion Date: December 31, 2023. DHB will work with General Dynamics Information Technology (GDIT) to update the Maternity Event billing rates that were in error for the affected time periods in NC Tracks. DHB will reprocess the claims and pay at the correct rate. DHB will review and enhance rate setting internal controls to mitigate the risk of this error recurring. Anticipated Completion Date: June 30, 2023.

See Corrective Action Plan for chart/table.

Finding 2022-002: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Plan to Correct: The Agency understands and agrees with the audit interpretation of this finding. The Agency in good faith, started the process of receiving bids for the HVAC project, entered into the contract, and committed funds to the project, using the guidance available at the time of the project commitment. This project was part of the Agency?s initiative to prevent, prepare for, and respond to coronavirus and accordingly, the Provider Relief Fund grants were used to help fund this initiative. The Agency committed to this project with understanding from the July 2021 FAQ which allowed projects not in the Reporting Entity's possession to be counted toward funding. The FAQ was updated in August of 2021 changing the status to needing to be fully completed. The Agency learned of the change too late to stop the project as management and the board had fully approved the project. The plans were done, equipment ordered, orders delayed due to supply chain issues, labor shortages, etc., were obstacles for the project to not be fully completed earlier. We decided to go forward with the project because of the incredibly positive outcome it would bring to our organization in relation to coronavirus. If we are awarded federal funds in the future we will consult with our CPA firm or other appropriate consultant as necessary prior to committing to such a large, costly, and timeconsuming project. Management acknowledges that the guidance changed and will work with HRSA to come up with a plan regarding this situation. Responsible Party: Denise Doucette, CFO/VP Estimated Completion: Ongoing.

Type of Finding: Noncompliance, material weakness Repeat Finding: No Condition/Context: The District spent $52,380 of federal funding on equipment and services related to the Maricopa County Juvenile Detention Center. These expenditures were not authorized within the budget for the related grant as the Juvenile Detention Center is a separate entity from the District. Action planned in response to finding: The District will establish proper internal controls over processing expenditures to ensure that only those expenditures that are allowed and approved within the budget be spent out of grant funds. Planned completion date for corrective action plan: For the period ending June 30, 2023. Name of the contact person responsible for corrective action: Adrian De Alba, Assistant Superintendent of Instruction and Student Services and Bonnie Romo, Financial Services Coordinator.

2022-006 Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Chris Holmes Title: Controller Phone Number: 202-235-1938 Estimated Completion Date ? done Corrective Action The results of the 2022 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on the allowability of trailing costs and the unallowability of newly incurred costs. From 2023, PSI will resume delivering in person training to its global finance and program staff.

Management agrees with the finding and will reimburse the project for overpaid management fees.

Educational Stabilization Fund ? Assistance Listing No. 84.425F ? Higher Education Emergency Relief Fund Institutional Portion Recommendation: We recommend the College review its existing policies around calculating it's MTDC and recording capital expenditures to ensure it is up to date with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management agrees with the recommended action. The College will update current policies and procedures to identify expenditures excluded from MTDC and develop a more robust review of the MTDC calculation. Name(s) of the contact person(s) responsible for corrective action: Kailey Block, CPA, Assistant Vice President of Administrative Services/Controller Planned completion date for corrective action plan: June 30, 2023

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425D Contact Person: Sarah Manobe, Payroll Specialist Anticipated Completion Date: January 9, 2023 Planned Corrective Action: Separation of duties has been established. We hired a payroll person that will be fully dedicated to conducting the duties of processing payroll from start to end. We also hired a full-time Human Resource Manager that will be responsible for conducting all other functions of the Human Resource department, this will ensure to have better internal controls.

SIGNIFICANT DEFICIENCY 2022-001 Financial Close Process Recommendation: The Authority should re-evaluate its financial reporting system: reviewing the general ledger mapping and close processes. This determines whether additional controls over the preparation of the final trial balances and related schedules can be implemented to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP and HUD Public Housing Authority accounting briefs. We recommend the Authority to review its current procedures for reconciliations and year end close procedures and evaluate the need for additional review to ensure accurate reporting. Explanation of disagreement with audit finding: While management agrees that improvements are needed, related to the newly implemented financial software the City of Arlington adopted; including mapping of the general ledger and with coordination with the Federal Data Schedule (FDS), management believes actual internal controls are effective as demonstrated by previous audits. The AHA should have until 6/30/2023 to complete the audit. However, because AHA is a component unit of the City, the timeline to complete the audit is much earlier, reducing the time available to complete the corrections needed to account for the new financial software. Action planned in response to finding: Management and the City of Arlington are working with consultants to improve general ledger mapping and crosswalks to the FDS. Name(s) of the contact person(s) responsible for corrective action: Mindy Cochran and Borhan Uddin Planned completion date for corrective action plan: June 30, 2023 2022~002 Housing Voucher Cluster-Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Authority reviews its internal controls over obtaining and maintaining income, expense tenant file documentation, and reviewing the calculation to ensure compliance with eligibility requirements. Explanation of disagreement with audit finding: There is no disagreement with this finding. However, management maintains that internal controls are effective noting that errors are found and corrected through the internal control processes. Human errors do occur, and internal controls cannot cover the thousands of transactions processed annually. AHA's SEMAP scores consistently recognize AHA as a high performer, scoring all points in indicators 3 and 10 which monitor correct calculations for adjusted income and correct tenant rent calculations. AHA does intend to increase internal audits through the addition of a dedicated compliance staff member. Action planned in response to finding: Both errors have been corrected. The total dollar amount of rental assistance provided was $162 for both errors. AHA is in the process of hiring for additional compliance reviews. Name(s) of the contact person(s) responsible for corrective action: Mindy Cochran Planned completion date for corrective action plan: Corrections have been made for the two files indicated, and hiring for compliance is expected to be complete by June 30, 2023.

Management will work with grant agencies to ensure they are in compliance with applicable liquidation periods for all grants in future years.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Cortney Parrish, Corporation Treasurer Contact Phone Number: 765-240-2346 Views of Responsible Official: We agree with the finding Description of Corrective Action Plan: As of fiscal year 2022, the School Corporation no longer pays teachers or aides from the School Lunch Fund, with the exception of one teacher being paid from the School Lunch Fund until December of 2022. As of January 1, 2023, only cafeteria employees are paid from the School Lunch Fund. Anticipated Completion Date: Completed

2022-001 RETURN OF FUNDS Condition: There were two students in our sample of return of funds that were not completed timely. The Department of Education requires that all determinations of a potential return of funds be completed within 30 days of the withdrawal date. Criteria: The Department of Education requires that all determinations of a potential return of funds be completed within 30 days of the withdrawal date. Cause: There was confusion on implementing the new 49% rule. These students were determined initially to meet this new rule, but later were determined to still be under the old rules, causing a late calculation. Effect: Amounts were not remitted back to the Department of Education timely. Perspective: Staff had not yet received adequate training on new 49% rule. Once training was received staff went back and corrected return of fund calculations. Recommendation: We recommend that all students who withdraw from all classes that were awarded Title IV funds, be completed within 30 days of withdrawal date. Views of Responsible Officials and Planned Corrective Actions: The College agrees with this finding. Staff have attended webinars for the rules regarding return of funds and now have a more accurate understanding of when the calculation is required.

Program: Temporary Assistance for Needy Families Program Assistance Listing No.: 93.558 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Social Services Award Year: 2021/2022 Compliance Requirement: Allowable Costs, Eligibility and Special Tests and Provisions Type of Finding: Material Weakness, Instances of Noncompliance Views of Responsible Officials: We concur with the finding. Corrective Action Plan: Finding Part 1: Two (2) out of 60 cases tested were missing the annual redetermination for the reevaluation of their benefits and eligibility requirements. Solano County has policies and procedures as well as systematic processes set up to ensure that redeterminations are processed annually. It is Solano County?s policy that the SAWS 2 Plus, Rights and Responsibilities and the Child Support Questionnaire and Notice and Agreements be processed which require workers to: ? Conduct a telephone interview with the recipient, print the forms, and document the County Use Section which requires worker?s signature and date. ? Mail the forms to the recipient for signature ? Upon return, review the SAWS 2 Plus and additional forms for completeness ? Initiate the required case action based upon information provided on the forms A redetermination of eligibility of the recipient shall be completed at least once every twelve (12) months. The annual CalWORKs Redetermination requires a face-to-face or telephone interview with the parent or person responsibility for the child or the person having responsibility for the care and control of the child. The Division Managers implemented a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent these errors in the future: ? The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the eligibility redetermination handbook with verbiage to emphasize the following: o The renewal be authorized only after required forms are received by the county and scanned into the document imaging system. o Ensure that redetermination dates are correct in the system at application and renewal. o Highlight these requirements when training this topic ? The CalWORKs Program Specialist will discuss the findings and redetermination requirements in the following ways: o Monthly Program Support Forum conducted with managers, supervisors, and lead workers o Issue a reminder memorandum to all staff o Written material will be published in the Monthly Program Support Newsletter to all staff Finding Part 2: In 31 out of 60 cases, we found that the review of the IEVS was not documented during the application or annual re-determination applicable to the fiscal year. However, we found that the related recipients/cases were eligible. It is Solano County?s policy to maintain program integrity. All CalWORKs (TANF) cases are required to be reviewed to assist with the eligibility determination using the Income and Eligibility Verification System (IEVS) at application and annual redetermination. ? IEVS is a computer cross match of State wage data, Unemployment Insurance Benefit data, wage data maintained by the Social Security Administration, and unearned income data maintained by the Internal Revenue Services and/or Franchise Tax Board. ? Staff is required to initiate the required case action and notices based on information received from the report, which includes generating adequate and timely notice. ? IEVS is system-generated at application. Effective February 2021, the CalWIN system auto-generates IEVS at least 15 days prior to the beginning of the redetermination due month. Specific corrective actions are outlined below to prevent these errors in the future: ? An ad-hoc report will be developed to generate monthly to help ensure the reports are reviewed and signed off by workers. A process will be put in place to ensure supervisors and lead workers follow up with the completion of these reports. ? The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the eligibility handbook sections for Application, Annual Redetermination, and IEVS Interfaces. ? The CalWORKs Program Specialist will discuss the findings and IEVS requirements in the following ways: o Monthly Program Support Forum conducted with managers, supervisors, and lead workers o Issue a reminder memorandum to all staff o Written material will be published in the Monthly Program Support Newsletter to all staff Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Manager Thomas West, Employment and Eligibility Services Manager Anticipated Completion Date: June 30, 2023

Finding 2022-004 ? Child Nutrition Cluster - Reporting Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Lunch reimbursement claims will be reviewed by a secondary individual prior to submission to IDOE and signed off on to document the review. Anticipated Completion Date: April 2023

Finding 2022-003 ? Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Melissa Dempsey Contact Phone Number: 812-546-2000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will establish a documented review of all Child Nutrition Cluster account payable claims before they are paid. Additionally, the School Corporation will transfer funds to replenish the school lunch fund. Anticipated Completion Date: June 2023