Corrective Action Plans

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Of the three covered transaction tested, one did not follow the County’s procedures as outlined above. The one covered transaction, totaling $47,283, did not include the appropriate provisions in the contracts nor did the County require a certification or check the EPLS to ensure the entity was not suspended or debarred prior to making payment. Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number and Email Address: 765-456-2804 Jessica.secrease@howardcountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will continue to review any vendors paid with federal grant funding on SAM.gov to see if they are suspended or debarred. This is tracked on a spreadsheet in the Auditor’s Office. One employee reviews the vendor on SAM.gov, and another employee verifies the information. We will ensure this internal control is implemented. Anticipated Completion Date: September 2024

CORRECTIVE ACTION PLAN September 18, 2024 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2023-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in January 2024. As part of our corrective action plan for this finding, the Center hired a consulting firm in September 2023, to perform a comprehensive review of the Center’s Electronic Medical Records systems to ensure that the system setup is correct and that proper reports are being generated. In addition, the Center retained the consulting firm to train all front desk staff, including the director and supervisors. The Consulting firm was also retained to conduct bi-weekly audits to ensure that the staff is complying with the sliding fee scale program. The auditor’s finding for the 2023 audit period reflects issues existing prior to implementing the above corrective action plan at the beginning of the 2024 fiscal year. We are seeing progress in documenting and calculation of the sliding fee discounts. We have hired a new front Desk Director. Her task, on a weekly basis, is to do a comprehensive review of the Center’s compliance with the sliding fee scale program and make corrections, as necessary. In addition, the Chief Compliance Officer will be conducting daily audits of transactions that occurred the previous business day to ensure compliance with the sliding fee program. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Name: Daniel Desire Title : Chief Financial Officer

Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of City contact person: Maria Simons, Financial Services Officer 129 N. 2nd Street, Yakima, WA 98901 (509) 575-6070 Corrective action the auditee plans to take in response to the finding: 1. Create a pre-bid checklist for City staff to use to vet potential sources of supply; 2. Add suspension and debarment verification to the Bidder Responsibility Criteria Form; 3. Add a clause or condition into contracts that state the contractor is not suspended or debarred; 4. Work with Information Technology on the possibility to update the Cayenta system to require requestor indicate on purchase requisition if proposed purchase is federally funded. Anticipated date to complete the corrective action: 1. Create a pre-bid checklist for City staff to use to vet potential sources of supply; by 12/31/2024 2. Add suspension and debarment verification to the Bidder Responsibility Criteria Form; Completed 8/30/2024 3. Add a clause or condition into contracts that state the contractor is not suspended or debarred; Completed 8/30/2024 4. Work with Information Technology on the possibility to update the Cayenta system to require requestor indicate on purchase requisition if proposed purchase is federally funded; by 12/31/2024

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Spokane January 1, 2023 through December 31, 2023 This schedule presents the corrective action the City of Spokane is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of City of Spokane contact person: Michelle Murray, Director of Accounting & Grants W 808 Spokane Falls Blvd Spokane, WA 99201 (509) 625-6320 Corrective action the auditee plans to take in response to the finding: The City currently has a robust process to verify and document its contractors, consultants and vendors are neither debarred nor suspended. This process adds required certification language to all City agreements to document compliance. While two of these contracts were reviewed and the compliant status of the providers were verified through the existing cooperative agreement, unfortunately the City’s process did not capture the needed requirement to verify at the lower tier. The City is now putting into place a requirement that all subawards, purchase agreements and contracts involving federal funds over $25,000 will include the required certification even if the contract is derived from “piggy backing” and includes suspension and debarment language. The City will also add measures to our existing process and enhance training to capture such agreements that were not initially identified as federal funding and later classified as such to include additional steps to ensure the required certification language is included to correct this oversight. Anticipated date to complete the corrective action: Immediately

The Board acknowledges the finding related to procurement practices under Finding 2023-001. We recognize the importance of adhering to federal procurement requirements, specifically those outlined in 2 CFR 200.319(d), to ensure compliance and maintain the integrity of federal funds. Management will review and update policies to ensure they align with federal regulations specified in 2 CFR 200.319(d) and will provide training to relevant personnel on federal procurement requirements.

Finding Number: 2023-002 Compliance Requirement: Reporting Programs: United States Department of the Treasury ALN Number: 21.019 ALN Name: Coronavirus Relief Fund Contract Periods: June 16, 2023 – June 16, 2024 (City of New Orleans, Louisiana) Planned Corrective Action: The Organization is committed to improving its timeliness of reporting, and is developing a plan to align and adhere to all grantor’s reporting requirements. The Organization is also hiring several new staff to ensure adequate internal capacity to deliver in a timely manner. Person Responsible: Chief Operating Officer (performance reporting) and Vice President, Finance & Administration (fiscal reporting) Expected Completion Date: October 31, 2024

Management’s response and corrective action is as follows: The responsibility to monitor projects in the affordability period recently transferred to the City-Parish. However, our office has had insufficient capacity thus far to inspect all projects within their 20-year affordability period. We have prioritized inspection of projects currently under construction to ensure that our office can continues to meet our community’s affordable housing needs. Our team has worked diligently with the Finance Department, the Human Resources Department, and the Mayor-President’s Office to create an expanded organizational chart and capacity plan. That plan was approved by the EBR Metro Council earlier this year and hiring activities are ongoing. Simultaneously, we have procured additional consultant support to provide technical expertise throughout this monitoring. Expected Implementation Date: December 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development

Management’s response and corrective action is as follows: Architect certification is not required by the Department of Housing and Urban Development nor our policies and procedures. It is listed in our contracts as one of the many different types of reimbursement documentation our office will accept. For many projects, an architect certification for each draw would be financially prohibitive and would likely reduce the financial viability of affordable housing developments. Our office does conduct intermittent on-site or desktop monitoring throughout the course of the project to ensure evidence activities. Additionally, all construction projects must complete permit requirements to ensure housing quality. Evidence of monitoring or activity was provided to the auditors. Expected Implementation Date: October 2024 Contact person: Marlee Pittman Miller, Director, Mayor-President’s Office of Community Development

Management’s response and corrective action is as follows: After reviewing the condition, cause, and effect of the presented Finding, the City-Parish finds it important to clarify that the duplicative charges were initially identified and documented as a self-reported finding. This discrepancy was discovered during the subrecipient monitoring component of this award and was promptly reported and reconciled prior to being presented as an audit finding. Upon identification of the duplicative charges, totaling approximately $22,000, immediate corrective action was taken to address the non-compliance. Dated January 5, 2024, a memorandum was filed disclosing the duplicative reimbursements, documenting the actions taken to rectify these charges, and recommending further steps to enhance the internal controls of the non-profit organization. The following information summarizes the East Baton Rouge City-Parish American Rescue Plan Act (ARPA): Duplication of Benefits - Findings and Corrective Action Memorandum: This memorandum documents the incidental reimbursement of multiple duplicative items associated with the subrecipient’s grant agreement and the corrective actions undertaken to resolve these findings, ensuring compliance with the terms of this award. During the routine subrecipient monitoring reviews, it was discovered that duplicate reimbursements occurred for 12 items between separate federal awards (American Rescue Plan Act SLFRF and CARES Act). In accordance with 2 CFR 200.522(c), a corrective action plan was provided to resolve the non-compliance. To address this, the following actions were taken: 1) Reconciliation of Duplicate Reimbursements: The non-profit entity has since reconciled the total value of $22,222.98 in duplicate reimbursements with an equivalent value of eligible expenses, including all necessary backup documentation to satisfy existing procurement and reimbursement requirements. 2) Development of a Duplication of Benefits Policy: It was recommended that the non-profit entity develop a comprehensive duplication of benefits policy to strengthen their internal controls further. These additional safeguards are considered best practices and are intended to minimize the risk of future non-compliance. Additionally, a comprehensive, grant specific, financial management policy template was provided to support the non-profits action to adopt and implement an appropriate standard of internal controls. The City-Parish is committed to maintaining robust internal controls and ensuring compliance with federal regulations. Immediate corrective measures were proactively taken to address these duplicative charges. Additionally, the City-Parish's third-party grants manager has established recurring weekly monitoring meetings with the non-profit entity to support the development and implementation of an adequate system of internal controls. Continuous efforts are being made to improve these processes to prevent such issues in the future. Expected Implementation Date: January 2024 Contact person: Courtney Scott, Assistant Chief Administrative Officer, Mayor-President’s Office

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Office of Administration Audit Finding Number: 2023-010, SLFRF Program Subrecipient Monitoring Name of the contact person responsible for corrective action: Stacy Neal Anticipated completion date for corrective action: September 2024 Recommendation A.: Develop policies and procedures to determine whether recipients of SLFRF program funds are subrecipients or contractors. Work with the state agencies to ensure accurate and documented determinations are prepared for all recipients and modify subrecipient records as needed. OA partially agrees with the auditor’s finding. Corrective action planned is as follows: OA believes there are opportunities to improve the classification of subrecipient vs. contractor to ensure compliance with federal regulations. We concur that OA, as the responsible party, should modify a department determination of subrecipient when there is a conflict with the regulation. Finally, we agree that clear communication on roles and responsibilities of OA vs. departments related to compliance is essential and can be improved. Given this position, we disagree that OA needs to issue procedures that restate the rules the uniform guidance and SLFRF regulations already state. We will continue to have discussions with agencies and ensure compliance with federal regulations. Recommendation B.: Develop a subrecipient monitoring program in accordance with the Uniform Guidance, that including performing risk assessments for each subrecipient for the purposes of determining the appropriate subrecipient monitoring procedures; monitoring for compliance with federal requirements and subaward terms and conditions and ensuring subaward performance goals are achieved; and reviewing subrecipient single audit reports. Ensure tasks delegated to state agencies are adequately communicated and establish procedures to ensure those tasks are appropriately completed. OA agrees with the auditor’s finding. Corrective action planned is as follows: OA approached the SLFRF money to consider all spending (whether to subrecipients or any other payment) as high risk due to the large dollar amount of one-time funding that is subject to rules that have changed over time. We have continued to treat this unique and highly publicized funding as high risk for fraud and exercise due diligence to mitigate that risk. OA agrees however, that our universal determination related to the SLFRF does not meet the specific uniform guidance rules. OA agrees to provide additional communications to departments to ensure agencies understand their responsibilities for sub-recipient monitoring including sub-recipient specific risk assessments and monitoring. Finally, OA will implement random reviews of the sub-recipient monitoring compliance.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-013 CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: A- Risk Assessments DHSS disagrees with this recommendation because the risk assessment process performed by BCFNA is in compliance with the substance and spirit of federal regulations – both of the federal funding agency, USDA, and 2 CFR 200, Uniform Grant Guidance. BCFNA risk assessments consider relevant information and are used to determine the extent and timing of monitoring as set out in the Nutritionist Manual. The BCFNA risk-based monitoring approach already allows for monitoring subrecipients more frequently than required by USDA. 2 CFR 200.332 states pass-through entities are to evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: (1) The subrecipient's prior experience with the same or similar subawards; (2) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (3) Whether the subrecipient has new personnel or new or substantially changed systems; and (4) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). The BCFNA formal risk assessment process takes into consideration the results of current and previous experience with the same subaward (item 1 in the suggested criteria) as well as whether the subrecipient has new personnel or new or substantially changed systems (item 3 in the suggested criteria). These observations are made when performing onsite monitoring by Nutritionists who are familiar with the program, its requirements and its participants, and are trained in recognizing significant issues. BCFNA also takes into consideration the results of the subrecipient’s prior experience with similar subawards in other programs such as SFSP, NSLP and Child Care Licensing Reviews (item 1 in the suggested criteria), audit results (item 2 in the suggested criteria) as well as the results of Technical Assistance Reviews offered to new subrecipients which could move up the planned monitoring schedule. B- Subrecipient Monitoring Procedures DHSS disagrees with this recommendation. The State Auditor’s Office (SAO) states in this finding, “While our review found the sample monitoring reviews were performed in accordance with the policies and procedures outlined in the Internal Nutritionist Manual we identified areas where these policies and procedures could be strengthened and improved...” The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve it’s process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This is incongruent with the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher-ranking requirements set forth by specific federal grant funders and awards. In addition, the DHSS has a strong system of internal controls documented in the Nutritionist Manual which is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” The DHSS through BCFNA has and will continue to review, strengthen and enforce subrecipient monitoring procedures in accordance with federal program requirements and management evaluation. BCFNA has and continues to exceed what is required by the federal awarding agency by implementing a risk-based monitoring plan that allows for more frequent onsite monitoring than required by the USDA. In addition, even though COVID waivers allowed for monitoring to be suspended during the COVID Public Health Emergency, the BCFNA continued to monitor through the use of desk reviews. BCFNA also returned to onsite monitoring months before it was required by the USDA. Furthermore, BCFNA has recently hired a financial manager to help identify red flags with new and returning sponsors and recently enhanced training and technical assistance opportunities based on issues found during monitoring. Corrective Action Plans Due to the size of the CACFP program it is imperative that a risk-based approach be used in performing monitoring and follow up activities. DHSS through BCFNA follows up and ensures that subrecipients take timely and appropriate action on all deficiencies detected through on-site reviews of the subrecipient using a risk-based approach approved by the USDA. Standard practices are in compliance with federal regulations. Physical verification or review of supporting documentation immediately at the time of submission to verify the CAP is not a federal requirement. Follow-up during the next scheduled review is in accordance with USDA regulations and BCFNA policy and procedure. BCFNA reviews Corrective Action Plans (CAPs) submitted by subrecipients to ensure they are acceptable and correct noted issues. Supporting documentation of CAP implementation may be reviewed by BCFNA’s trained Nutritionist performing the monitoring reviews prior to the next monitoring visit if deemed necessary, or during the next onsite monitoring visit. This follow up is timely and appropriate because the scheduling of the next monitoring visit is determined by the USDA-approved risk-based approach. For example, subrecipients that had significantly deficient issues in their monitoring will be reviewed onsite within 90 days to verify whether corrective actions have been taken and if not, move towards termination. The corrective action plans of other subrecipients that were deemed to not be as significant by the Nutritionist, such as using the wrong percent of milk, are verified at the next monitoring review which could range from 1 to 3 years. The criteria used by the SAO do not specify what is timely or appropriate and allows for BCFNA’s professional judgement and discretion of what is timely and appropriate. Claims testing BCFNA standard practice is test only the selected month(s) claim(s) per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. Actual noncompliance has not been noted in regards to testing. The BCFNA Nutritionist Manual allows for expanded testing if needed and BCFNA does perform expanded testing if deemed necessary. However, the USDA risk-based monitoring approach implemented by BCFNA sets prompt follow-up standards for significant deficiencies to determine if addressed, and if not, move on to termination. Overclaim recoupment BCFNA standard practice is to pursue recoupment of overclaims of only the test month per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. In addition, BCFNA officials pursue recoupment of overclaims for facilities/sponsors with terminated contracts on a case-by-case basis, taking into consideration various factors. BCFNA strives to maintain an appropriate balance between adequate monitoring and not creating barriers to program participation per USDA and the Paperwork Reduction Act. Starting the termination process is more effective than performing additional testing and pursuing historically unsuccessful recoupment of overclaims. CACFP is an important program that provides healthy meals to children and adults. The CACFP plays a vital role in improving the quality of day care and making it more affordable for many low-income families. This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults who are enrolled for care at participating child care centers, day care homes, emergency shelters and adult day care centers. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. USDA prohibits creating barriers to program participation and provision of services. The steps over and above the USDA requirements suggested by the SAO would place significant barriers to participation in the CACFP program and in turn cause harm to needy children and adults. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies.

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2023 State Agency: Department of Health and Senior Services Audit Finding Number: 2023-012 CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: The agency does not agree with the audit findings or believes that corrective action is not required. Explanation and specific reasons are as follows: CACFP Subrecipient Reimbursements DHSS disagrees. The DHSS through BCFNA maintains a strong system of internal controls over meal reimbursements to CACFP facilities/sponsors to ensure costs are allowable and supported. The system is in compliance with Uniform Guidance and USDA program requirements. The system includes subrecipient monitoring based on risk assessments per the substance and spirit of Uniform Guidance, initial and ongoing training and technical assistance opportunities, and reviews of invoices. Throughout the SAO’s finding they repeatedly acknowledge that the BCFNA monitoring process is in compliance with Nutritionist Manual which is based on USDA requirements, but is somehow not in compliance with broader federal requirements. This goes against the accepted hierarchy of federal compliance guidance which says that 2 CFR 200 Uniform Grant Guidance is broader and less specific than the higher ranking requirements set forth by specific federal grant funders and awards. The SAO has not noted any specific noncompliance with federal requirements regarding subrecipient monitoring. The SAO’s finding noted the DHSS could enhance or improve its process but not that it is out of compliance with federal requirements for subrecipient monitoring. The SAO is trying to hold DHSS to a higher standard than what is federally required. The DHSS’ strong system of internal controls which is documented in the Nutritionist Manual is in compliance with federal regulations and is used as a best practice by the USDA for other states. The report from the most recent USDA Management Evaluation Report for Fiscal Year 2023 issued November 2023 stated “The FNS determined that the SA Monitoring of Sponsors and SA Oversight of Sponsor Monitoring’s has adequate management controls in place for administering the CACFP in accordance with Federal regulations. The FNS staff reviewed SA practices that included detailed SA review forms, spreadsheets that provided extra oversight, and written procedures detailing the monitoring process. The SA provides online CACFP trainings along with a handbook to institutions that detail policies and procedures governed by the SA. The SA developed an extensive tracking system in addition to a very thorough review tool that contains meal component and pattern calculation. The SA conducts oversight of the review process and tracks each step to confirm completion of any follow up required of institution. The SA CACFP training resources and online modules were reviewed and evaluated to ensure it contained the correct information and up to date policies and procedures. The FNS staff reviewed the SA policies and procedures and interviewed key SA staff regarding procedures for each respective area of this Section. All files reviewed are compliant with Program requirements. The FY 2023 CACFP ME review did not identify any significant reportable issues.” This entitlement program provides reimbursements for nutritious meals and snacks to organizations that serve eligible children and adults. CACFP processes an average of 700 claims per month and provided healthy meals in Missouri to over 31 million children and adults in 2023. The increased claim testing and recoupment suggested by the SAO would create a significant barrier to participation for sponsors/facilities (many of which are small child care centers, day care homes, emergency shelters and adult day care centers) which is prohibited by USDA. Reviewing supporting documentation with every individual reimbursement claim at the time of submission as suggested in the finding is not feasible given the number of reimbursement claims processed monthly by program staff already functioning at capacity. Neither is it required by Uniform Guidance, the USDA or standard subrecipient monitoring procedures. The BCFNA already requires claims to be paid on a reimbursement basis rather than in advance and performs various reviews of the claims in CNPWeb, so the additional step of requiring supporting documentation with every reimbursement claim at the time of submission is unnecessary and is intended as a specific condition to remedy high risk subrecipients per 2 CFR 200.208. Furthermore, BCFNA offers technical assistance training and reviews in addition to regular monitoring reviews. In addition to the edit checks within the CNPWeb system which validate such things as capacity limits and licensing, BCFNA staff has, and continues to perform, additional verification such as spot-checks for inconsistencies (i.e. a greater number of enrolled participants as compared to licensed or total capacity or suspicious claim irregularities or patterns). Each claim submitted also requires a certification of truthfulness, accuracy, completeness with potential criminal, civil or administrative penalties in accordance with U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812. As noted by the SAO, the risk based monitoring approach implemented by BCFNA has been effective in identifying significant issues and claim errors in recent years. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. DHSS disagrees with the methodology the SAO used in its calculations. Out of the SAO’s test sample of 60 monitoring reviews, only 9 of the overclaims were over the $600 threshold of acceptable risk set by the USDA. 7 CFR 226.8(f): In conducting management evaluations, reviews, or audits in a fiscal year, the State agency, FNS, or OIG may disregard an overpayment if the overpayment does not exceed $600. A State agency may establish, through State law, regulation or procedure, an alternate disregard threshold that does not exceed $600. The SAO left the inflated error percentage in the body of the finding despite repeated requests and only included the lower suggested rates in footnote 4. The SAO also did not explain how their test of monitoring reviews performed by BCFNA, instead of a sample of claims submitted, was representative of CACFP reimbursements that would lend to projecting to the total population. BCFNA monitors using a risk-based approach as required and in response to known erroneous claims and to proactively address issues. A sample of monitoring reviews is proportionally more likely to include a higher number of claims with discrepancies. For example, fifty five percent of the monitoring reviews completed during fiscal year 2023 were graded as a B or C and were give additional technical assistance and/or monitoring follow up as a result.

023-003 –ELIGIBILITY Material Weakness/Material Noncompliance Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third-party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

FINDING 2023-001 Material Weakness – Procurement, Suspension, Debarment Contact Person Responsible for Corrective Action: Dana Gault Contact Phone Number: 765-382-3762 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The City Controller will search the SAM website for vendors the City has entered into a covered transaction with over $25,000 or more and print out the results. A debarment and suspension certification letter from the prospective third-party contractor, that are not in SAM’s system, will be collected or a clause included in the third-party contract regarding disclosure which will be reviewed by the Department Director and City Controller. The Department Directors will monitor throughout the year for debarment and suspension of thirdparty contractors that are not in SAM’s system. Anticipated Completion Date: Completion date for the planned corrective action is November 1, 2024

Finding 2023-002 Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Summary of Finding: Material Weakness, Non-Compliance The County did not have controls in place to verify and ensure that an entity with which it plans to enter a covered transaction is not suspended or debarred. INDIANA STATE BOARD OF ACCOUNTS 21 Contact Person Responsible for Corrective Action: Dennis Spaeth Contact Phone and Email: 765-458-5464 auditor@unioncountyin.us Views of Responsible Official: Official concurs with finding. Description of Corrective Action Plan: Any vendor that Union County uses in the future, will be researched to make sure they are eligible to receive federal funds for transactions exceeding $25,000. This will be accomplished by having the County Auditor along with the Deputy Auditor perform one of the following to verify that potential vendors are eligible for the receipt of federal funds: 1) check the Sam.gov website 2) obtain a certification from the vendor, or 3) ensuring a clause or condition is included in the contract with the vendor for the covered transaction. Anticipated Completion Date: A new procedure is in place effective August 2024. The documented oversight will be available and provided for review with the 2024 annual audit.

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of District contact person: Mark Lane, CFO 223 E 4th Street Port Angeles, WA 98362-3015 (360) 417-2383 Corrective action the auditee plans to take in response to the finding: The County in its administration of its Coronavirus State and Local Fiscal Recovery Funds has historically complied with the federal suspension and debarment requirements principally through (1) ensuring each of its direct award and subrecipient contracts contain a clause or condition in the award contracts that states the contractor or subrecipient is not suspended or debarred, (2) requesting a certification to that effect, or (3) checking the SAM system to insure the contractor was not debarred or suspended. In this situation, the County procured IT equipment needed to improve the County's capability to conduct virtual meetings from a vendor under a "piggy-back" agreement under which debarment and suspension verification had been completed by another state agency. This vendor was also well known to the County as it had previously been utilized in procuring equipment with funding under the CARES Act. Staff managing this vendor relationship were unaware that reliance on prior debarment and suspension verification performed by another agency was not appropriate. In addition, due to significant turnover occurring in our SLFRF grant administration team occurring in late 2022 and early 2023, the single invoice triggering this finding--while properly documented with appropriate supporting documentation and approvals from staff managing the vendor relationship--was not reviewed by the SLFRF grant administration team to insure it was properly accompanied by a documented verification of debarment/suspension prior to its payment. As noted by the SAO in its audit finding, the vendor in question was not debarred or suspended from receiving federal monies, and no questioning of costs is involved. While the County has spent almost all of its SLFRF funds to-date under agreements containing certification language addressing debarment or suspension where required, the County recognizes that in this single situation involving the procurement of goods totaling $31,239 that its internal controls did not function properly to detect that proper debarment or suspension verification had occurred. We view this very much as an isolated incident, particularly given that over $9.8 million of the $15.02 million of SLFRF direct funds awarded to the County have been expended by the County through the end of 2023 in accordance with federal guidance and requirements regarding these funds under a program whose guidance rules have been subject to constant change since the American Rescue Plan Act was first signed. Regardless of the isolated nature of this incident, the County's management remains committed to insure this situation does not reoccur going forward, and as a result has or will be implementing the following corrective actions: • To the very limited extent disbarment/suspension language does not appear in contracts for goods or services being funding through County SLFRF funds, expenditures for all projects involving purchases of goods and services will first have to be approved and reviewed by the County's SLFRF grant administration staff who will verify disbarment/suspension status prior to the entering into contracts or the disbursement of SLFRF funds. • In the cases of piggy-back agreements, SLFRF grant administration staff will verify disbarment/suspension requirements have been met prior to payments for goods or services being approved that are funded with SLFRF funds; and • Appropriate messaging has been and will continue to be communicated to all SLFRF funded project owners and staff, reiterating requirements that all federal procurement policies must be adhered to for all County purchases of goods and services involving SLFRF funds, including that debarment and suspension verification has been completed and documented, and that such documentation must be forwarded to SLFRF grant administration staff before any disbursements of SLFRF funds will be made. We thank the SAO staff for identifying this issue and bringing it to our attention. Anticipated date to complete corrective action: Immediately.

Finding 2023-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the projects and related expenses submitted to FEMA for reimbursement. Current Status: In progress. Resolution: Management will develop and implement additional internal controls to ensure documentation is retained to evidence the operating effectiveness of the internal controls. These internal controls will ensure expenses included in FEMA grant applications are reported completely and accurately. The additional internal controls will include a reconciliation of application expense detail to final paid invoices along with a notation that each expense is allowed to be included in the FEMA submission. The reconciliation will be reviewed and approved by the Cottage Health Director of Finance prior to final FEMA submission and evidence of the review will be retained. Contact Person: Lawrence Thomas, Director of Corporate Finance Anticipated Completion Date: November 29, 2024

Finding ref number: 2023-001 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: Caryn Metsker, Director of Financial Services 800 Eastmont Avenue East Wenatchee, WA 98802-4443 509-888-4686 Corrective action the auditee plans to take in response to the finding: The Eastmont School District respectfully does not concur with the finding regarding our internal controls for ensuring compliance with allowable activities, costs, and restricted purpose requirements in regard to the Emergency Connectivity Funds. The District has completed the necessary corrective actions by revising our board policies and procedures to ensure compliance with allowable activities, costs, and restricted purpose requirements. However, these changes were not implemented by the end of the 2022-2023 school year because the audit for the 2021-2022 school year had not been completed until the 2023-2024 school year. Consequently, the District was unable to implement the new process until the audit status for 2021-2022 was confirmed, ensuring that the corrected steps were compliant The District did not receive any specific guidance from the State Auditor's Office on how to properly document the unmet need identified in the audit. Despite our efforts to seek assistance and clarification, the lack of direction hindered our ability to address the finding promptly. The necessary changes to our policies and procedures required approval from the Board of Directors. This approval, governed by a strict process, was not obtained until December 2023. We began working on the changes immediately following the previous audit but were constrained by the formal approval process. The District is disappointed that despite our efforts to comply, the State Auditor's Office issued another finding for the 2022-2023 audit based on a differing opinion on the "unmet" need. This repetition of findings, despite our documented efforts and changes, suggests a misalignment in expectations and understanding. The audit for the 2022-2023 school year consumed significant resources and taxpayer dollars, which we believe could have been better utilized. The time spent reviewing our information, which was largely unchanged except for the updated policy and procedure, appears redundant. We had asked for documentation and guidance from the State Auditor's Office but did not receive the necessary support or compliance assistance. The District is committed to maintaining high standards of accountability and compliance. We regret that our efforts to address the audit findings were not deemed timely enough and that this has resulted in an additional finding. We will continue to enhance our processes and seek clearer communication and guidance from the State Auditor's Office to ensure that future audits are more aligned with our compliance efforts. We hope this response provides a clear understanding of our position and the steps we have taken. Anticipated date to complete the corrective action: The corrective action has already been implemented within the school district.

City staff will contact all Community Based Organizations (CBOs) that received Emergency Rental Assistance 2 funding to determine if they were required to complete a Single Audit per the Single Audit Act. This communication will include, if applicable, a request that they submit the organizations most recent audit for review by staff. Should a Single Audit identify any findings or other deficiencies, staff will ask the CBO to provide an update as to the status of the deficiency and if it has been appropriately addressed. Staff will document this communication in the electronic file of the CBO who was required to complete a Single Audit.

HSD acknowledges the deficiencies identified in the audit which were due to a long-term position vacancy and recruiting challenges in a competitive job market. This position was filled as of May 2024, and all outstanding reports for 2022 and 2023 CDBG, HOPWA/HIFA and ESG FFATA reports have been submitted as of July 2024. The city has the resources in place to assure timely accurate and timely FFATA reporting for all applicable sub-awards by the due date as the required by federal regulation.

The Human Services Department The Human Services Department has acknowledged the issue identified regarding timesheet pre-approvals and will take immediate steps to address the issue. HSD will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavailable on the day payroll approval is due. HSD will maintain compliance with payroll policies and ensure the accuracy of timesheet approvals. Office of Housing The Office of Housing has acknowledged the finding regarding timesheet pre-approvals and will take immediate steps to address the issue. Office of Housing will ensure that proxy timesheet approvers are properly assigned in cases where the primary supervisor is unavailable on the day payroll approval is due. This adjustment will be incorporated into the previous improved practices, eliminating the need for pre-approving timesheets. By ensuring that proxy approvers are in place, the department will maintain compliance with payroll policies and ensure the accuracy of timesheet approvals. Parks and Recreation Department The Parks and Recreation Department acknowledges the finding regarding timesheet preapprovals and will ensure that proxy timesheet approvers are assigned moving forward as part of the department's ongoing commitment to improved practices. In addition, the department would like to clarify that the pre-approval noted occurred before the implementation of the current corrective action plan, which addressed the prior year's finding. The department reassures the State Auditor's Office (SAO) that the newly adopted practices, which prevent preapprovals, will continue to be strictly followed, ensuring compliance and accuracy in payroll processing, even during pay periods that coincide with holidays.

HSD acknowledges the identified weakness and implemented an updated Accounts Payable control procedure in 2024, that includes an additional standard monthly report and review process to ensure that reimbursements are processed with the required 30-day period.

HSD acknowledges the deficiencies identified in the audit which were due to a long-term position vacancy and recruiting challenges in a competitive job market. This position was filled as of May 2024, and all outstanding reports for 2022 and 2023 CDBG, HOPWA/HIFA and ESG FFATA reports have been submitted as of July 2024. The city has the resources in place to assure timely accurate and timely FFATA reporting for all applicable sub-awards by the due date as the required by federal regulation.

HSD acknowledges the identified issues, which were primarily due to a long-term vacancy of key staff responsible for conducting these duties. HSD notes that these are multi-year grants, with previously assessed contracted providers who have experience administering these funding sources for multiple years on behalf of the city. Therefore, HSD prioritized ensuring that essential services and agreements continued uninterrupted to prevent homelessness among vulnerable populations. The vacancy was filled as of October 2023. Risk assessments and monitoring plans are now in place and are expected to be completed before December 2024. Staff is trained on the most current HOPWA procedures and CAPER reporting requirements. HSD remains committed to dedicating the necessary resources to ensure ongoing compliance with all relevant program requirements, while also reinforcing its capacity to deliver essential services to those in need.

2023-002 Suspension & Debarment Recommendation: We recommend the County review and update procurement policies for the entire County to include suspension and debarment to ensure it meets the minimum requirements of 2 CFR 200 for all federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The county is reviewing and updating its Uniform Grant Guidance Federal Guidelines policy and procedures to include suspension and debarment, ensuring compliance with all federal grants requirements. Name(s) of the contact person(s) responsible for corrective action: Steve Wipperfurth, Finance Director Planned completion date for corrective action plan: December 31, 2024