Corrective Action Plans

US Department of Health and Human Services HIV CARE Formula Grants Passed-through State of Hawaii Department of Health 1250 Punchbowl Street Honolulu, HI 96813 Hawaii Health & Harm Reduction Center (HHHRC) respectfully submits the following corrective action plan for the year ended June 30, 2022 for the finding identified in the schedule of findings and questioned costs as identified by our auditors, KKDLY LLC, who are located at Topa Financial Center, 745 Fort Street, Suite 2100, Honolulu HI 96813 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Material Weakness Finding 2022-001 Eligibility U.S. Department of Health and Human Services HIV CARE Formula Grants CFDA No. 93.917 Condition During the in-take and re-assessment process for the Ryan White HIV/AIDS Part B (RWB) program, case managers are responsible for (1) ensuring that all required forms and documents are received from clients, (2) reviewing those forms and documents for completeness and accuracy to verify that RWB program eligibility requirements are met; and (3) inputting the client?s information into e2 Hawaii, HHHRC?s system to monitor and track all RWB program clients. Effective April 1, 2022, HHHRC updated their policies and procedures, requiring a manager or knowledgeable employee other than the case manager to sign off on the certification forms to document their review of eligibility determinations for completeness and accuracy. We selected a sample of 60 clients receiving assistance under the RWB program as part of our eligibility testing. Within the 60 files, we examined 61 annual or semi-annual certification forms dated prior to April 1, 2022, and 32 annual or semi-annual certification forms dated April 1, 2022 or later. Of the 61 certification forms dated prior to April 1, 2022, we noted 59 certification forms did not contain evidence of a review performed by a manager or a knowledgeable employee other than the case manager. Of the 32 certification forms dated April 1, 2022 or later, we noted 6 certification forms were not signed off by a manager or knowledgeable employee other than the case manager. Criteria The Uniform Guidance, as prescribed in 2 CFR section 200.305, requires that non-federal entities receiving federal awards establish and maintain internal control over federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Internal controls over compliance with RWB eligibility requirements should include formal policies and procedures to ensure that data used to determine eligibility are complete and accurate in compliance with RWB program requirements. Eligibility determination procedures should be performed by case managers and reviewed by a manager or knowledgeable employee. Cause HHHRC implemented a formal policy requiring a manager or knowledgeable employee other than the case manager to sign off on the annual and semi-annual certification forms for each client. This formal policy was implemented on April 1, 2022. As such, the certification forms that were prepared prior to this date were not reviewed in accordance with this policy. Effect Without appropriate internal controls, noncompliance with RWB eligibility requirements may occur. Refer to Finding 2022-002 for instances of noncompliance identified in the current year. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediate previous audit as Finding 2021-001. Recommendation We again recommend that HHHRC adhere to established policies and procedures to ensure that eligibility determinations performed by case managers during the in-take and re-assessment process are reviewed by a manager or knowledgeable employee other than the case manager for completeness and accuracy. Views of Responsible Officials and Planned Corrective Action HHHRC has implemented a formal policy and review process by a manager or higher level within the organization for every certification form within 1 week of completing the form. As noted earlier in the audit, HHHRC has made significant progress on this compliance measure with certifications dated after April 1, 2022 having significantly higher review rates (26/32 had review compared to 2/60 prior to April 1, 2022). Additionally, HHHRC has added an additional policy of the HIV Director or Clinical Deputy Director will review twice annually a random selection of at least 20 certification forms to ensure there was manager review documentation and this internal control will hopefully identify any deficiencies in this practice.

2022-004 Significant Deficiency in Compliance and Internal Control over Compliance - Collateralization Special Tests Same as 2022-002 above. 2022-002 Significant Deficiency in Compliance and Internal Control over Compliance ? Collateralization Special Tests Name and Contact Person: Janelle Friday, Tribal Administrator Corrective Action: Klawock Cooperative Association has switched banks and will collateralize the accounts. Proposed Completion Date: June 30, 2023

SUBRECIPIENT CASH MANAGEMENT Department of Health and Human Resources (DHHR) Assistance Listing Number 93.788 The DHHR Bureau for Behavioral Health concurs with the recommendation to mandate additional documentation to support amounts of drawdowns that appear to exceed a subrecipient's immediate cash needs. Upon identification of the condition that led to this finding, the bureau provided additional guidance to all internal grant staff. The guidance was distributed on October 25, 2022 and requires a documented justification for approval of any invoice that appears to exceed 10% of total grant amount for cash on hand. The bureau also intends to seek out and provide technical assistance and/or training for internal staff and subrecipients to ensure they understand the cash management requirements within 2 CFR 200.305.

Finding No.: 2022- 003 Condition: The District's expenditure report filed for June 30, 2022 included expenditures paid in July and August 2022. These amounts were not reported as committed or obligated. Plan: Grant expenditure reports will be prepared on the cash basis and obligations reported. The liquidation of the obligations will be reported on subsequent liquidation reports. Anticipated Date of Completion: August 31, 2022 Name of Contact Person: Dr. Mike Ruff, Superintendent Management Response: There is no disagreement with this finding and management will monitor all future federal reimbursement requests. Committed and obligated expenditures will be reported appropriately, and will be paid within 90 days after project completion.

Finding No.: 2022- 003 Condition: The District's expenditure report filed for June 30, 2022 included expenditures paid in July 2022. These amounts were not reported as committed or obligated. Plan: Grant expenditure reports will be prepared on the cash basis and obligations reported. The liquidation of the obligations will be reported on subsequent liquidation reports. Anticipated Date of Completion: July 31, 2022 Name of Contact Person: Jake Flowers, Superintendent Management Response: There is no disagreement with this finding and management will monitor all future federal reimbursement requests. Committed and obligated expenditures will be reported appropriately, and will be paid within 90 days after project completion.

Twin Oaks will implement a policy so that only the cash needed will be drawn down to cover expenses to ensure that excess cash is not drawn down. This will be reviewed on an annual basis or as needed.

2022-002 ? Noncompliance and material weakness for federal awards. The District agrees with this finding and has taken corrective action to ensure that established procedures are followed timely and appropriately. 1) New Braunfels ISD will be contracting with an outside entity to provide an evaluation of business office practices and procedures in order to identify areas in which improvement is needed. 2) New Braunfels ISD has documented due dates for Federal drawdowns so that there is a level of responsibility for all involved in ensuring that these are completed in a timely manner. The due date is the last Friday of each month. 3) The drawdowns will be completed by the Director of Financial Services and backed up by the Assistant Director of Financial Services. They will then be reviewed by the Chief Financial Officer.

DTC had multiple key leadership changes shortly prior to and during the financial audit. DTC will ensure related policies and procedures are updated, staff trained, and documented evidence is maintained. DTC will comply with 2CFR section 200.305 requirements.

Finding 2022-001 Lack of Internal Controls over Cash Management Name of Contact Person: Karen Linnell, Executive Director Tamara Hamby, Accountant Corrective Action Plan: Account and grant receivables will be tracked and collected within 30 days of the closing of the quarter. We will be aggressive in collecting past due receivables. We will continue to follow the specific grant guidelines on drawing down funds. Proposed Completion Date: December 1, 2022

Cash Management ? 10.557 Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) Corrective Action Plan: Upon being advised that the State of Hawaii Department of Budget and Finance determined that the "administratively feasible" time period of advance payments was 21 calendar days", the WIC Accounting Section implemented the following changes to its Invoice payment process. 1. The WIC invoice payment workflow tracking system was revised to also track the number of days from the ASAP draw date to the check process date on Data Mart. 2. The Accountant meets with the Account Clerk weekly on the invoice workflow system to review invoices in the workflow from receipt to when payment checks are processed. 3. Within two workdays from the date that the Accountant makes the ASAP draw and transfers federal funds to the State Treasury to pay for approved invoices , the Account Clerk prepares and "pouches" the invoices to ASO Pre-Audit. 4. If a payment check is not processed within 14 calendar days from the date an invoice is pouched to ASO Pre-Audit, the Account Clerk notifies the Accountant, and contacts ASO to verify that the invoice was received. After implementation of the revised changes, WIC saw a significant improvement in the number of days it took DAGS to enter a check process date on Data Mart. Implementation Date: July 1, 2022 Responding Officials: Melanie Murakami, Public Health Program Manager and Paul Uchima, WIC Services Administrative Officer/Family Health Services Division

Management?s View and Corrective Action Plan Finding 2022-001 ? Cash Management Cluster: Research and Development Cluster Grantor: National Cancer Institute and National Science Foundation Assistance Listing #: 93.397, Cancer Centers Support Grants and 47.049, Mathematical and Physical Sciences Title: Case GI SPORE, Case Comprehensive Cancer Support Grant, MRI: Acquisition of an SEM instrumented to conduct in-operando observations of materials performance under external stimuli Award Year and Number: 08/21/21-07/31/22 (CA150964), 04/01/21-03/31/22 (CA043703), 08/01/20-07/31/23 (DMR-2018167) The University believes it is in compliance and currently follows regulations pertinent to cash management in 2 CFR Part 200.305(b) (Uniform Guidance) which requires "payments methods must minimize the time elapsing between the transfer of funds from the United States Treasury or the pass-through entity and the disbursement by the non-Federal entity." As such, organizations are to minimize the time difference between vendor payment and requesting reimbursement from the sponsoring agencies. We acknowledge that there are discrepancies in the interpretation of the Office of Management and Budget (0MB) cash management compliance requirements and the Uniform Guidance Part 200.305(b). In October 2017, the Council on Governmental Relations (COGR) sent a letter to the Office of Federal Financial Management (OFFM) expressing concerns that the cash management requirement language in the 2017 Compliance Supplement was not aligned with the requirements for cash management included in the Uniform Guidance Part 200.305(b). COGR's stance is for the Compliance Supplement to be updated to correspond with the cash management requirements as written in the Uniform Guidance Part 200.305(b). In August 2021, COGR sent a follow-up letter to OFFM regarding the 2021 Compliance Supplement emphasizing the inconsistency has yet to be addressed or resolved and most recently followed-up again in June 2022. In September 2022, The Office of Research Administration (ORA) sent a letter in support of COGR's June 2022 Comment Letter and followed up in November 2022 as well, with no response. The Office of Research Administration is sincerely devoted to ensuring institutional compliance with Uniform Guidance and the Compliance Supplement. It is important to note that these exceptions pertain to accounts payable transactions only. ORA will be cognizant of OMB's current interpretation of the Cash Management requirements and will continue to monitor for additional guidance regarding discrepancies in the Compliance Supplement. Primary responsibility for implementing this corrective action plan for this finding rests with Diane Domanovics, Assistant Vice President for Sponsored Projects. Sincerely, Joan Schenkel Associate Vice President for Research

Finding 2022-001 ? Non-compliance with Cash Management Requirements of the Capital Fund Program Corrective Action The Authority will expend the unexpended Capital Fund Program grant proceeds held, prior to drawing down additional funding from Capital Fund Program grant allocations which are budgeted for capital improvements. The Authority?s Executive Director, Jeff Sklet has assumed the responsibility of executing this corrective action as of March 31, 2024.

Agency: U.S. Department of Agriculture passed through State Department of Education

Management is implementing an enhanced, more detailed invoice review process where invoices will be reviewed irrespective of materiality by leadership on the RETAIN team. In addition, the invoice process will include periodic meetings to go through expenditures in detail prior to invoice submission. The contacts for this finding are Kori Smith, RETAIN Program Manager, KASmith4@mercy.com and Alice Parisi, Foundation System Director, Alice_Parisi@mercy.com.

The HIDTA Financial Manager, in conjunction with the City's Finance Assistant, will request smaller dollar amounts with new advances in order to liquidate the prescribed HIDTA guideline of 21 days.

Finding 2022-004 Personnel Responsible for Corrective Action: Assistant Comptroller ? Brian Huggins Anticipated Completion Date: July 2022 Corrective Action Plan: The University has implemented a process to document all allowable costs prior to funds being draw down that will be prepared by a Senior Accountant, reviewed by the Assistant Comptroller and approved by the Comptroller prior to requesting reimbursement/cash drawdowns from the Federal Government. Moreover, the University is implement a quarterly grant review process with the grant Principal Investigator to review grant expense allocations. G5 drawdowns will take the second Monday of each month.

Written policy will be adopted to reflect the process being undertaken to minimize the time elapsing between the transfer of funds from the US Treasury. Current process of carrying out detailed analysis of anticipated expenses for the quarter will be reflected in the policy.

Recommendation: The Auditor noted the Organization should consider implementing policies, procedures, and internal controls specific to federal awards which are in writing and are approved by the appropriate level of management or those charged with governance. Planned Corrective Action: Management agrees with the recommendation and has implemented the following steps. A procurement policy, compliant with the Procurement Standards codified in 2 C.F.R. ? 200.317 through ? 200.327 has been approved by the Board of Directors. This policy states the procedures required for documentation for procurement of goods and services related to all Federal awards. Specific additional procedures have been implemented providing an additional level of review for all Federal expenditures, including a quarterly reconciliation of reporting submitted to the granter.

Material Weaknesses identified was from 2022-01 - Housing Quality Standards Inspections During audit procedures, it was identified that the Unit's Inspections were completed but if there was a failure, re-inspections were not completed as required within the 30-day period. The cause was identified that we did not have the necessary internal controls over compliance in place. That we are not re-inspecting units timely. The failure rate of 40 units examined during audit resulted in 14 failures for re-inspection. The recommendation was that we implement internal control processes and procedures to ensure that re-inspections are completed on a timely basis. Management Response: We became aware of a concern and performance issues with our HCV manager in the summer of 2021. She provided her notice of intent to resign effective December 31, 2021. We began a search for a manager in the fall of 2021 through many processes, including posting the position, inquiring of other housing authorities of our open position and networking. Additionally, we brought in a consultant to complete requirements of our contract effective January 1, 2022. This is a specialized position and one that requires experience for the position. We hired an experienced manager in May 2022 to organize the HCV program. During this audit period HUD had in place a moratorium on inspections due to COVID outbreak. We did not at this.time need to inspect units. However we did inspect units, of the 40 that had inspections we recognize as a result of the audit that we failed 14. We requested a listing of the 14 failed inspected units as a result of the audit. Senior Management was not informed during the audit process, rather during the reporting phase of the audit. Once we received the 14 names we reviewed them. Upon first inspection two of the names immediately were known. One of the persons was living in a situation where she would not have been able to pass inspection, she was a Choice for Independent living recipient approved for services by Medicaid. She was assigned to a case manager and should have been receiving services in her existing housing, however area agencies were unable to provide services per her eligibility requirements and therefore we placed her on our waitlist and worked towards housing her. She was transferred to our housing and is receiving services effective January 2022. During her first months with us she received inspections regularly to ensure that she would not fail and be in jeopardy of eviction. She is now receiving services, doing well and passing inspections. The second person was one of our Choice for Independent living residents in one of our units, his unit failed inspection on Sept. 20, 2021 and a work order for repairs was completed on October 14, 2021, which was within the 30 day re-inspection process. However this was not reported in our housing software, rather was in our work order software. We identified that three of the additional tenants that failed inspection had been re- inspected in May of 2021 and had passed within a few days of their inspection which was under 30 days, however once again was not reflected in our software. During our review process it became known to us that there is a flaw in our software package that we have been addressing with PHA Web for some time. We are working towards accurate notifications within our software. Additionally, during the period of time reviewed we had staff shortages due to COVID positive employees and a needed to change work schedules to maintain our properties effectively. We had created a practice of quarantining due to exposure and or symptoms which affected our HCV inspection staff members, both having tested positive with symptoms. Corrective Actions: We recognize and appreciate the information to work towards improvement of our HCV program. In May 2022 we hired a new Manager for our HCV program. The new Manager is working on preparing a new administration plan to be implemented for our HCV program. The new Manager is working on hiring a team and organizing existing staff to ensure that necessary details including inspections and follow up inspections are kept on track as required and documented properly. There is a process in place for HQS inspections to be followed and reports will be utilized. We have worked on training additional staff members and certifying them in HQS inspection process to ensure inspections are done timely. All our current voucher holders will be receiving a scheduled inspection to create a baseline and to move forward effectively. We anticipate completion of inspections according to our plan to be within six months of this report.

Finding 2022-002 Contact Person: Lily Rakness Parra, County Clerk Corrective Action Planned: Washakie County agrees with the finding of 2022-002. A Sams.gov account has been activated in order to verify that entities that are being utilized for County business are not excluded from or are ineligible for participation in Federal programs or activities. Also, the County is currently drafting a Procurement Policy for Washakie County to utilize for the use of Federal funding as well as in an everyday manor of purchasing and maintenance of county facilities in order to satisfy above finding.

Cook County BOE FA 2022-001 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) S425U2120012 (Year: 2021) Questioner Costs: $195,559 Description: The School District made cash drawdowns in excess of the immediate cash needs of the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: In order to prevent drawdowns from being mixed up between two federal grants, an additional financial staff member will sign off on the drawdowns. Estimated Completion Date: August 1, 2023 Contact Person: Jackie Sparks, Finance Director Telephone: (229)-896-2294 Email: jsparks@cook.k12.ga.us

Finding Number: 2022-002 Condition: The College drew down HEERF related expenses for the institutional expenditures at a rate that differed from the final, reported expenditures. This was based on the identification of expenditures that were later not included in the final annual reporting, placing the timing of drawdown for reported expenditures to be outside of the cash management regulations. By extension, the institutional quarterly reporting was also incorrect as it is based on the initial expenditure classifications. Planned Corrective Action: The College drew down funds based on expenditures that management deemed to be qualified however, at year-end, concluded to charge other expenditures to the grant causing the mismatch in the timing of drawdowns and final expenditures charged to the grant. Although HEERF and other COVID 19 Pandemic funding has ended, in the future, such expenditures will be discussed and documented prior to the drawing of funds. Contact person responsible for corrective action: Amanda Ewers, Director of Finance and Gary Black, Chief Financial Officer Anticipated Completion Date: Corrected reporting was submitted on March 22, 2023

Individual Responsible for Corrective Action Plan: Romero Brown, Virginia Alliance Director Corrective Action: Weekly Monitoring: Management will proactively check the Virginia Portal each week to determine if any payments have been made. This will allow us to stay updated on incoming funds. Cross Training: Management will initiate cross-training sessions for additional staff members to ensure that Club payments can be processed even in the absence of the current staff. This step will enhance our operational resilience. Calendar Prompts: Management will implement calendar reminders to ensure that payments are promptly presented for processing within five days of receiving the deposit notification. This measure will help us adhere to the required disbursement timeframe. By implementing these actions, we aim to mitigate delays in the disbursement process and establish a more efficient workflow. Anticipated Completion Date: June 30, 2023

Corrective Action Plan: To ensure accurate reporting and remittance of interest, the Agency shall implement the following steps: 1. Responsible staff will review; Uniform Guidance training resources on the U.S. Treasury website; ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO); and training resources on the State of Vermont, Agency of Administration website. Status; completed. 2. Responsible staff will communicate with Vermont Treasury to ensure the interest accrued by HAF program funds are attributed to the HAF program and will be reflected on all reports sent to financial and program staff. Financial staff will set an automatic reminder in Vision to ensure interest is remitted per 2 CFR section 200.303(a). Status; completed. 3. Responsible staff will communicate with U.S. Treasury and U.S. Department of Health and Human Services regarding the unremitted interest and will remit the interest accrued above $500 for 2021 and 2022. Status: communication with U.S. Treasury and U.S. Department of Health and Human Services is initiated, estimated completion date March 31, 2023. 4. Responsible staff will review quarterly reports and ensure interest is being accrued and attributed to the HAF program. If interest is not accruing or any abnormalities are noted, program staff will communicate with financial staff and Vermont Treasury to address the issue. Status: completed and ongoing. 5. Upon receipt of the yearly report from financial staff, Responsible staff will request the annually accrued interest in excess of $500 be remitted to the U.S. Department of Health and Human Services per 2 CFR section 200.303(a) and any instructions issued by U.S. Treasury. Status: completed and ongoing. 6. Responsible staff will verify with financial staff that interest has been remitted. If any errors have occurred, program staff will communicate with the Supervisor and financial staff to address said errors and properly account for and remit the interest. Status: completed and ongoing. Scheduled Completion Date of Corrective Action Plan: Mach 31, 2023 Contacts for Corrective Action Plan: Maxwell Krieger, DHCD General Counsel maxwell.krieger@vermont.gov Naomi Cunningham, Housing Program Administrator naomi.cunningham@vermont.gov Chris Banning, ACCD Administrative Services Director IV christopher.baning@vermont.gov Tracy Badeau, ACCD Financial Director I tracy.badeu@vermont.gov

Contact Person Kirk Geadelmann, Finance Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023