Corrective Action Plans

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will prepare and retain detailed documentation including system reports, queries, screenshots, and other evidence supporting the program information being reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its policies and procedures to retain all records relating to federal awards for a period of 5 years after all the federal funds are expended. For future related programs with this requirement, the Department will develop and implement internal control policies and procedures that ensure systems properly display complete and accurate data on the federal reporting dashboard as instructed by the federal agency’s reporting guidelines. Additionally, these policies and provisions will ensure that any future ERAP award funding received by the Department will be separately reported to avoid commingling. Finally, the Department will require that ERAP personnel verify the reported program information to ensure all report element sections are complete and accurate, and that it matches the underlying benefits and financial systems data. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Tracy Raymer, DES Business Analyst Manager Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: Develop and implement written policies and procedures to ensure it prepares and retains detailed documentation, such as system reports, queries, or screenshots, to support the program information it reports to the federal agency for the UI program for a period of at least three (3) years. Beginning July 2024, the Department has assembled and retained all detailed supporting source documentation that supports the data provided in the 9050 - Time Lapse of All First Payments except Workshare report and will retain it for a period of no less than three (3) years.

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Jacqueline Butera, DES Administrator Jean Ahumada, DES BAM Manager Anticipated completion date: March 18, 2024 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The controls the Department put in place to address the federal regulation requirements, are multi-year remediation plans. The controls include recruiting and retaining a workforce with a strong knowledge and understanding of Unemployment Insurance Laws, Policies, and Procedures, as well as proper case management skills. From December 2022 through March 2024, the Benefit Accuracy and Measurement (BAM) unit experienced an 18 percent attrition rate. Given the fact that the BAM unit is made up of nine (9) auditors, one of which is a lead who does not receive a full caseload, an 18 percent attrition rate results in a significant impact on the distribution of workloads amongst experienced and new staff, respectively. As of December 2023, the BAM unit was 90 percent staffed with only 67 percent of auditors working a full caseload. This is because new hires with prior program knowledge do not receive a full caseload until three (3) months from their new hire date. During SFY 2023, the Department carefully balanced meaningful recruitments, staff training, and case assignments in order to support staff retention while addressing the federal timeliness requirements. As of March 18, 2024, the Department fully implemented the multi-year remediation plan, and has shown sustainable performance improvement in both the paid and denied claims accuracy measures since September 2023, due to these controls. As of SFY 2024, the Department has met all Paid Case Accuracy and Denied Case Accuracy timeliness performance measures.

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Jacy Wilmes, DES Deputy Business Administrator Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will immediately report the required missing information for its subawards on the FFATA Subaward Reporting System for the WIOA cluster. The Department will also follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than the month-end of the month following the sub-award action. In addition, the Department will implement procedures requiring independent reviews to ensure the sub-award data is reviewed for accuracy prior to and after uploading to the federal government’s reporting system.

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Tarry Haynie, DES Senior Fiscal Analyst Anticipated completion date: June 30, 2025 Agency’s Response: Concur To ensure the Department’s Division of Employment and Rehabilitation Services (DERS) Finance and Business Operations Administration (FBOA) performs the required monitoring of its sub-recipients and complies with the award terms and program requirements, it has added additional internal controls by updating the monitoring schedule to include backup fiscal monitors. The FBOA will also update its procedures to include the process for backup monitors to take on primary monitoring duties in the event an assigned staff member is unable to perform the onsite monitoring review as scheduled. During fiscal year 2023, the fiscal compliance team within the FBOA consisted of only three staff members. They have since onboarded two additional staff, bringing the total number of fiscal compliance monitors to five. One of these additional staff members completed training and was assigned a full caseload in December 2023. The second new staff member is currently undergoing training and is expected to finish training and absorb a full caseload beginning March 2025. The Department is on track to complete all required onsite sub-recipient fiscal monitoring for fiscal year 2025.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is in the process of developing written policies and procedures to address matching, level of effort, and earmarking. The policies and procedures will address communication with subrecipients and maintaining records and documentation of the amounts used to fulfill matching requirements.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Department will update written policies and procedures related to procurement to incorporate applicable aspects of Federal Regulations 2 CFR §§200.321, 200.322, 200.323, and 200.327. The updated policy will address competition through competitive bids, sole source selections, and retention of procurement documents. In addition, the policy will state the Federal requirements that are to be included in purchase orders and contracts.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department resumed monitoring duties and developed a monitoring schedule to ensure subrecipients maintain program compliance. The Department also established a risk assessment tool that assess risk associated with each subrecipient. Records of subrecipient monitoring will be kept for a period of time to demonstrate monitoring activities were performed.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is no longer reimbursing the subrecipient for unsupported or ineligible costs and is pursuing repayment of funds from the subrecipient. Written policies for reviewing and approving subrecipient reimbursements, as well as, risk assessment were reviewed, updated and amended to ensure ongoing compliance. Staff has been trained and new policies were implemented in FY 2024 subsequent to the period reviewed in this audit. Contract Specialists in the Special Needs Division have received additional training through HUD TA support on CoC standards to ensure all request for reimbursement from subrecipients are eligible, reasonable and appropriately documented, including any allocations and purchasing requirements.

Assistance listing numbers and program names: 14.231 Emergency Solutions Grant Program 14.231 COVID-19 - Emergency Solutions Grant Program 93.558 Temporary Assistance for Needy Families 93.558 COVID-19-Temporary Assistance for Needy Families Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department will stop the reimbursement of costs to all nonprofit and contracted subrecipients for items that are disallowed and/or restricted by the regulations of the federal Emergency Solutions Grant (ESG) program and Temporary Assistance for Needy Families (TANF) grant, including payments to personnel that violate the conflict-of-interest disclosure requirements. The Department will revise its expenditure review procedures to ensure compliance with these regulations prior to disbursing any ESG and/or TANF funding to any subrecipient for any purpose. These revisions will include review and approval by applicable management personnel prior to disbursement of federal funding. The Department is also in the process of establishing a divisional Monitoring and Compliance Policy and Procedure Manual which will establish procedures specific to subrecipient monitoring. The Department will continue to assess the risk of noncompliance violations for each subrecipient and establish a plan of action to address noncompliance. The plan of action will include an array of training and educational processes to ensure applicable personnel are knowledgeable of programmatic compliance requirements and Department contracts. The Department will also monitor subrecipients per its updated policies and procedures and will ensure proper oversight of federal expenditures as required by federal regulations. The Department has amended its contracts with the applicable subrecipients to more clearly outline the regulatory requirements and expectations for expenditures under the ESG and TANF grants. The Department will also continue to resolve the unallowable costs reimbursed to subrecipients as deemed appropriate by the applicable federal agencies.

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

Eastern Carolina Human Services Agency, Inc. Corrective Action Plan For FY Ending June 30, 2023 Section II. Financial Statement Findings. 1. Finding 2023-001 - U.S. Department of Health and Human Services, Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: Internal control processes over financial accounting did not ensure that all transactions were properly recorded. Internal control processes over financial accounting did not ensure that key accounts were reconciled or received on a periodic basis. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director. Action Plan: After review/monitoring of the previous Finance Officers duties and responsibilities, it was determined that the internal control processes of the finance department were not carried out properly to meet the requirements of 2 CFR Part 200 Section 200.302. Therefore, the agency terminated the Finance Officer. The agency immediately began the search for a new Finance Officer via Indeed and other employment hiring agencies. This process took much longer than expected which left an unexperienced Accounting Technician to operate the Finance Department along with limited finance knowledge of the Executive Director. After several advertisements for the vacant position the agency interviewed numerous applicants and was finally able to hire the current Finance Officer. The Finance Officer has worked continuously to insure that the internal control process of the department is implemented by making sure all accounts are reconciled and reviewed with supporting evidence of each review. With this process back in place, management and the Board of Directors will review and sign off on each account's financial statements. Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-002 - U. S. Department of Housing and Urban Development Voucher Cluster, Assistance Listing #14.871/14.879 Statement of Condition: For the year ended June 30, 2022, the Organization did not submit their audited financial statements to HUD by the required deadline. For the year ended June 30, 2023, the Origination did not submit their unaudited or audited financial statements to HUD by the required deadline. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: The submittal of the GAAP-based unaudited and audited report for FY ending June 30, 2022, was a management oversight due to the lack of a Finance Officer in place. The agency currently has a Finance Officer in place who will submit timely GAAP-based unaudited and audited financial information electronically to HUD via the Financial Assessment Sub-System (FASS-PH). Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-03 - U.S. Department of Health and Human Services Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: The origination did not submit the data collection form and required reporting package to the Federal Audit Clearinghouse (FAC) for the year ended June 30, 2023, by the required due date. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: Management will ensure that the audit and data collection forms are completed timely and the data collection form and required reporting package are submitted electronically to the FAC each fiscal year going forward. To further ensure this finding is resolved, training for the Finance Officer/Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Section II - Findings relating to the financial statements which are required to be reported in accordance with generally accepted government auditing standards. 1. Finding 2022-001 Statement of Condition: Controls over the vendor payment process were not properly followed. Action Plan: Submitted previously with Financial Statements and Independent Auditor's Report FY Ended June 30, 2022. Current Status: Corrected The Management Department (Finance Officer and Executive Director), with the supervision of the Board of Directors Finance Officer, will continue to make every effort necessary to meet all HUD submission as required, in order to be in compliance with all HUD rules and regulations. Respectfully submitted, Trudy Murray Executive Director

Finding: 2023-009 All Programs Description of the Findings: During the review of the procurement compliance requirement related to major program, it was determined that the USWA did not have a document procurement policy in place until August 2023. Views of Responsible Official(s) and Planned Corrective Actions: While the Alliance did not have a standalone procurement policy in place until August 2023, it did have purchasing policies embedded in its Accounting and Finance Manual that covered purchases relative to our work at that time. No further corrective action is needed however policies are reviewed annually to ensure compliance under 2 CFR 200.516(a). Completion Date: August 2023 Responsible Official(s): ShaQuina Davis

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County obtain certifications from vendors stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has ensured that any entity that receives American Rescue Plan (APRA) funding is registered on SAM.gov before any funds are disbursed by the County. An addendum will be added to all current and new contracts that will require signed certification from the vendors/contractors related to debarment and registration with SAM.gov. Name of the contact person responsible for corrective action: Sherri Crow, Director of Budget and Finance Planned completion date for corrective action plan: February 1, 2025

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends that the County review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding and that appropriate monitoring is performed for each subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that all subrecipients of American Rescue Plan (APRA) funds are monitored by using appropriate subrecipient monitoring procedures to ensure compliance with the grant awarded throughout the contract period. This process was started in 2024 as part of the 2022 Corrective Action plan and many of the subrecipients were in compliance for 2023. Due to a change in personnel early in 2024 this was not followed up on until later in the year. Name of the contact person responsible for corrective action: Sherri Crow, Director of Budget and Finance Planned completion date for corrective action plan: December 1, 2024

Finding Number: 2023-005 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 - Coronavirus State and Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Chad Van Santen, Grant County Auditor Karl Lindquist, Grant County Coordinator Corrective Action Planned: Grant County management will review vendor payments requiring checking for suspension and debarment in accordance with requirements of funding in the future. Anticipated Completion Date: December 31, 2024

Finding 2023-003 Finding Summary: In connection with the audit performed, it was noted that there was an instance where a patient received more federal assistance and another patient received less federal assistance than allowed based on federal poverty guidelines. Responsible Individuals: Kathryn Boyd, President and CEO Corrective Action Plan: The use of applying slides automatically, without reviewing the account first, has been prohibited by billing staff. In addition, clinic staff are not to apply any payments until the slide has been applied. If there are any issues with the slide, the clinic staff has been instructed to contact the billing staff for review and resolution. The Director of Revenue Cycle will randomly audit staff throughout the year to ensure additional slides are not applied and report out to the Chief Executive Officer. Anticipated Completion Date: 12/02/2024 (disallowing application of slides was previously implemented in 2023)

2023-001 – ALN 14.850 – Public & Indian Housing – Allowable Costs Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Mr. Justin Jones, Executive Director Projected Completion Date: December 31, 2024

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the requirements of the compliance requirements. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by March 31, 2025.

We are in process of submitting the required operating budget and self-certification letter to the USDA. Anticipated Completion Date- 12/31/2024 Completed.Responsible Contact Person-Kathleen Boyce, CFAO

Corrective Action: The district will ensure that all supporting documents will be stored electronically first and stored physically as a secondary option. Each department will be responsible for maintaining a copy of all supporting documentation. All checks and contracts will be included in the procurement packets for all expenditure. We are currently implementing this process and strengthening internal controls. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: October 31, 2024

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

Finding 2023-005: Internal Control Deficiency and Noncompliance Over Procurement Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: AdviseWell, Inc. did not have internal controls in place throughout the audit period to sufficiently document the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price or sole source justification if warranted. Additionally, management did not have evidence of internal controls being in place throughout the audit period to document that vendors were not suspended or debarred prior to entering into a procurement transaction. AdviseWell, Inc. did not have or use documented procurements procedures throughout the audit period. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-04 finding, to ensure that sufficient documentation of history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection of, and the basis for contract price; ensure vendors are not suspended or debarred prior to entering into the procurement process; and document these procurement procedures with an annual review of these with staff. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

Finding 2023-002: Internal Control Deficiency and Noncompliance over Activities Allowed/Allowable Costs Principles, Period of Performance Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: Management did not have adequately designed internal controls in place over expenses charged to the federal program. Management also did not consistently retain evidence to support the existence of certain expenditures and thus the expenses were not adequately documented. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-01 finding, to ensure expenditures are appropriately reviewed and approved prior to entering into the expenditure or requesting reimbursement from the federal program. Documentation will be maintained to support that expenditures were reviewed for appropriate period of performance. Management will ensure all duties are appropriately segregated. In addition, following the October 2023 implementation, care will be taken to ensure that invoices for vendors using electronic invoicing systems will be downloaded in a timelier manner to ensure electronic invoices do not expire within those systems. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023