Corrective Action Plans

Beginning immediately on the date of the single audit report, management will recalculate expenses monthly as well as on a YTD grant year basis after the month has closed and request reimbursement for only those expenditures.

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

• Condition: During our testing of reimbursement requests, we identified amounts that were requested for reimbursement prior to the expenses being incurred. • Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the account is being invoiced for the correct expenses during the proper timeframe. • Planned Corrective Action: During the newly established monthly meetings that will take place, MHA and the Accounting Rep will review the expenses being submitted for reimbursement together to ensure no invoices are submitted in advance.

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

We concur with the recommendation, and a formalized and independently monitored process was implemented to reconcile refundable advances routinely and in coordination with the recognition and allocation of allowable costs effective August of 2023.

2022-005- Internal Control Over Compliance and Compliance – Cash Management Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: June 2024 Management’s Corrective Action Plan:NGA has developed procedures to capture all required documentation during the federal disbursement request process. Staff were informed in January 2023 of the requirements for federal drawdown documentation and the CFO proceeded with a desk audit of compliance for the first and second quarter of fiscal year 2023 in April 2023. The CFO will continue to monitor compliance and adequate document retention in the second half of the fiscal year and provide training to staff when documents are not available in shared drive folders. We will also implement a regular review of the SEFA beginning in September 2023 and use that review to ensure that revenue and cash transactions correspond to the expense reports they were based on.

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced federal funding. The service being used to insure all deposits is called IntraFI Cash services. This is a sweep account that will automatically move all deposits to other financial institutions to assure that they are under the 250,000 limit. Funds are wholly available at any time. Proposed Completion Date: Already implemented.

Agency: Person Responsible for Corrective Action: Name Title: Anticipated Completion Date Response to Finding: 2021-008 CASH MANAGEMENT National Center for the Advancement of STEM Education, Inc. (nCASE) : Nancy Priselac Executive Director : December 8, 2023 Management concurs with audit recommendation. Correction Action to be Taken: nCASE has put written procedures in place to compile the SF425. The procedures also detail the approval process by management for the final review of the SF425. nCASE is working with a consultant to ensure that the numbers in the SF425 match the data output from our accounting software and is replicable. This has been implemented internally and performed by nCASE. nCASE has taken corrective measures in our accounting software by detailing the audit log and recording all changes with supporting documentation. There is final weekly review and approval of the changes. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

Corrective Actions Taken:

1.       SCMRC revised its federal drawdown procedures in 2024 to require documented review and approval of all expenditures before submitting any drawdown request.

2.       A Draw Down Request Workbook is now prepared by the Controller and reviewed against supporting documentation, including invoices, timecards, and purchase records.

3.       The CEO reviews and signs off on each Draw Down Request prior to submission.

4.       Completed Draw Down Request Workbooks are submitted to HRSA for prior approval and retained for audit purposes.

5.       Internal drawdown audits are conducted monthly to confirm alignment with federal cash management standards.

Corrective Action Plan:

1.       Updated drawdown procedures have been incorporated into SCMRC’s financial policies and will be re-reviewed annually.

2.       Refresher training on 2 CFR § 200.305 and internal drawdown requirements will be conducted by Q4 2025.

3.       Results of monthly drawdown audits will be included in the Finance Committee compliance dashboard starting in September 2025.

4.       SCMRC will continue to require documented CEO approval on all federal drawdown submissions to ensure sustained internal control.

Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.

Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.

Finding Reference Number: MW2021-08 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: All advance draws in 2021 were properly recorded as deferred revenue in the accounting books, see Statement of Financial Position. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI consider this finding resolved. As covered in the corrective action to MW2021-006, CUAHSI implemented the drawdown procedure as documented in company policy which includes twotiered preparation and review and requires review and approval by the Prime funder for working capital advances. CUAHSI stopped the non-compliance in 2023 by halting all draws against NSF awards in late March 2023 (when this non-compliance became known to the current Executive Director) until June 15th, 2023, at which time CUAHSI completed a draw from an NSF aligned with the current policies. The certified SF-270 and draw documentation was reviewed and approved by NSF. Name of Contact Person: 􀁸 Jordan S Read, Executive Director 􀁸 Telephone: (339)933-4660 􀁸 Email: jread@cuahsi.org Projected Completion Date: NA; is complete

We agree with the finding and acknowledge that this issue has been previously identified in past audits. The repeat occurrence was primarily due to understaffing and turnover within the finance department compounded by the COVID 19 pandemic of 2020, which significantly impacted the internal controls on the accounts payable process. While deferred revenue at 9/30/2021 was $1,377,071 and a due to grantor agency at $269,375 total grant accounts receivable net at 9/30/2021 is $2,206,868 which exceeds these two liability balances. The fundamental cause for deferred revenue is insufficient financial and grant administration staffing to maintain current on agency advances, expenditures reimbursements and reporting. As reported in Findings 2021-102, finance has implemented a Grant Tracker system that will provide timely information on the status of grant reporting with timely reporting and review to grant managers, program directors and the executive director. Complete adoption of this tool by all grant administrators will be completed by September 30, 2024. Anticipated Completion Date: Ongoing