Corrective Action Plans

Finding 2023-008 MDHHS, PACAP - Inappropriate PACAP Allocation Management Views MDHHS disagrees the exceptions identified should rise to the level of a significant deficiency and noncompliance. The comprehensive set of quality control processes continue to operate as designed to identify any errors greater than 5.0 percent of the total difference of the given statistical group from the previous quarter and none of the errors identified in the finding fell outside of this range. For part a., the auditor’s review included all related statistical records within each statistical group for the 15 sampled cost pools. This includes all statistics used in the cost allocation process for the entire fiscal year because the costs that originate in these cost pools are referenced in all other cost pools. After review of all fiscal year 2023 statistical data, 6 individual statistical records out of 6,548 were found to be in error. After recalculating the cost allocated amounts related to this error, we identified that approximately $15,346 was overclaimed to the Low-Income Home Energy Assistance Program (LIHEAP) out of $1,732,426,561 (0.0009 percent) of costs allocated in fiscal year 2023 by MDHHS. The other program areas identified were underclaimed. For part b., MDHHS acknowledges the exclusion of a participant from two quarters (quarter three and quarter four) of the Family Independence Specialists/Eligibility Specialists Random Moment Time Study (RMTS) in the sample. Although the actual dollar value impact of excluding a participant is indeterminable, MDHHS concluded the impact would be immaterial because there are over 6,000 RMTS participants each quarter and RMTS results vary little from quarter to quarter from non-programmatic changes. Planned Corrective Action For part a., MDHHS will ensure the vendor’s RMTS report is modified to resolve formatting issues related to trailing zeros in SIGMA codes. Additionally, the vendor and MDHHS staff will individually check to ensure accurate SIGMA codes for those with trailing zeros. For part b., MDHHS will implement additional quality control processes when gathering the participant list for the RMTS. MDHHS will modify the reports used to gather the participant list to eliminate filtered restrictions for sub-unit codes to ensure all eligible participants are included in the time studies. Anticipated Completion Date MDHHS will implement additional quality control measures effective July 2024. Responsible Individual(s) Suzanne Kyes, MDHHS Matt McCool, MDHHS

2023-002 – Allowable Costs/Cost Principles Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that it retains documentation supporting time and effort on federal grants and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and related services, in collaboration with Portsmouth Schools Finance department will monitor that the certification of pay certifications are completed on a semi-annual basis. Finance will communicate via email, the list of personnel required to have the certification and also review once they are completed by the Office of Special Education. Finance will review all dates and signatures. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

2023-003 - Allowable Costs/Cost Principles – Internal Control and Compliance over Allowable Costs/Cost Principles (Significant Deficiency) Condition: During our audit, we noted that three (3) out of forty (40) samples summed up to $39,055.50 had no proper source documents to support the transactions charged to the grant brought by lost official receipts, hence, identified as not adequately documented. Alternatively, the City created a memo to document the loss of receipts signed by the department head. Management concurs. Corrective Actions: The City has an existing purchasing policy and procedures requiring documentation of all purchases made. Finance department has already sent a reminder to all department heads regarding the policy and procedure and why they must comply. Implemented Name of Responsible Person: Manuel Carrillo Jr., Director of Recreation & Community Services

Views of responsible officials and planned corrective action: The Authority acknowledges that this error occurred. When we identified this issue, we contacted the grantor agency for guidance. They explained how to submit a refund and acknowledged that since the grant was still open, we had the ability to correct an incorrect draw. This refund has been processed and the Authority has put additional internal controls in place to ensure the proper match is calculated for each grant draw in the future. Additionally, upon final grant closeout, all the numbers are verified and reconciled back to the grant agreement, including the match.

Department of Health and Human Services 2023-005 Value-Based Medical Student Education Training Program – Assistance Listing No. 93.680 Condition: Indirect cost expense was improperly calculated. Auditors’ Recommendation: We recommend the institution strengthen its internal controls to ensure that calculations are reviewed and adjusted for, if necessary, in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: UMMC’s transition to Workday resulted in the need for multiple F&A bases to be created in Workday to accommodate our DHHS negotiated agreement. However, since our go-live we have only been using one modified total direct cost base to calculate F&A. UMMC is in the process of engaging a Workday Certified consulting firm to review the operational efficiency of Workday for Post-Award Accounting. The scope of this engagement will be to align our usage of Workday to industry best practices, including best practices for F&A calculation. During the scope of this project, we will review these established bases to ensure they meet the needs of our negotiated rate agreement provisions. In the meantime, we are reviewing the F&A calculations on existing projects when an invoice or financial report is prepared to ensure accuracy. F&A will be recalculated with each invoice and/or financial report and any necessary adjustments will be made before the invoice or financial report is submitted to the sponsor. Name(s) of the contact person(s) responsible for corrective action: Julie Schwindt, Director, Post-Award Accounting Planned completion date for corrective action plan: June 30, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Julie Schwindt at 601-984-1058.

Condition: The Commission was unable to provide adequate source documentation to support that the match requirement was met. Planned Corrective Action: Management agrees that match requirements for Continuum of Care awards have not been maintained as required by the Uniform Guidance. In July 2023, management was notified by HUD after completion of an on-site monitoring visit that the Commission's claimed matching expenses that were not adequately supported by source documentation. In response, management has placed in service additional controls to ensure the compliance requirements are being monitored and in place for the new program. Contact person responsible for corrective action: Steve Raiche Anticipated Completion Date: 6/30/2024

Finding 2023-006: Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. The secondary review of match claim workbook did not identify the clerical errors. During testing of expenditures, the following items were identified: a) The number of hours an employee worked per the approved timesheet vs. the hours claimed in the match claim workbook resulted in a clerical error. (1 instance) b) Per review of the supporting timesheet and paystub, an employee had mobile crisis pay which was not accurately reduced in the calculation for match in the match claim workbook (2 instances). Responsible Individuals: Staff Supervisors (Michelle Theesfeld, Kari Van Dam) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. CEO will review all grant staff that also provide mobile crisis to ensure that mobile crisis pay is removed before allocating salary and fringe benefits to grant programs. Anticipated Completion Date: Beginning in January 2023, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made. On occasion, payment requests do not have an invoice number. To prevent duplicate payments, the Accounts Payable staff require original invoices and uses a system generated invoice number, or a will use a manual entry numbering convention to prevent duplicate invoice numbers. The invoice data is entered by an Accounts Payable specialist and reviewed by the Accounts Payable Manager. On occasion, A/P must request corrected invoices from vendors who try and reuse invoice numbers. The A/P Manager reviews invoice numbers during the check run for accuracy. Purchasing and A/P will also periodically review the vendor database for duplicate vendors. For construction projects that list a pay application number instead of an invoice number, A/P will implement a consistent invoice numbering convention to avoid duplicate payments. The A/P specialists will also review the PO payment history prior to processing. Responsible party(ies) for corrective action(s): Accounts Payable Manager Corrective action(s) timeline: December 1, 2023

GEAR UP Program In-Kind Match Planned Corrective Action: The corrective action plan is to review In-Kind Match monthly, to ensure we there are no missing documentation & review for accuracy. Person Responsible for Corrective Action Plan: Shelley Belong Anticipated Date of Completion: December 1, 2023

PAX implemented a dedicated cost center in the books and records specifically for tracking cost shared expenses midyear during FY23 rather than the previous practice of recognition of cost share at year end closing. Full implementation of contemporaneous tracking of cost share was implemented in FY24. Additionally, PAX now reconciles against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit finding related to matching, level of effort, and earmarking requirements, and recognizes the need for stronger internal controls and improved documentation to ensure full compliance with federal regulations. To address the finding, VIDE is committed to enhancing monitoring. VIDE will establish a dedicated team within the Federal Grants Office to conduct quarterly reviews of documentation, including student counts, poverty data, and funding allocations, and to document all monitoring activities and findings. They will also report any identified issues to management and recommend corrective actions. The IDEA State Office will establish clear procedures for Local Education Agencies (LEAs) to report student counts and poverty data, develop a process for verifying the accuracy of this data, and ensure all necessary data is collected and documented to support level of effort and earmarking calculations. To ensure all relevant staff understand the new policies and procedures, VIDE will provide comprehensive training.

The Government concurs with the auditor's findings and recommendations. DHS transitioned from a manual payroll process to the Government electronic Timeforce (STATS) system. All time and attendance are now vetted and approved through the various levels of applicable management, ultimately being approved by the Agency Head or designee. The payroll is generated based on the cost centers listed on the Notice of Personnel Action (NOPA). Processes are now in place ensuring each respective staff NOPA is updated at the start of each fiscal year to reflect new year’s applicable ERP code. Additionally, once payroll costs are generated, it is reconciled by the dedicated Financial Analyst for SNAP. Additionally, a workflow is now established in the NOPA approval process to ensure the current org, objects and projects are listed on the Notice of Personnel Actions (NOPA) which is utilized for payroll purposes.

We already implemented a formal review and approval process in 2023 and anticipate this finding to be resolved on our next year audit. We will also ensure the review and approval is properly documented.

CORRECTIVE ACTION PLAN Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing No.: 21.027 Federal Agency: Department of the Treasury ? Pass-through from the State of California Award No.: WWID 4SSO10370 & CA 1910156 Award Year: Fiscal year 2021-2022 Category of Finding: Activities Allowed or Unallowed, Allowable Costs Name responsible for correction action plan: Emily Armstrong, Revenue Services Manager The corrective action planned: Payments applied to the 93 water bills and 81 wastewater bills will be reversed on the customer?s accounts. A notice will be issued to customers via mail and email (where possible) of the discrepancy. The funds will be returned to the State pursuant to their outlined procedures. Moving forward, the City will ensure that there is a multi-layered approval process to review the eligibility period of any State funding to identify the correct eligible applicants prior to disbursement. For future funding related to water and/or waster bills, the list of eligible applicants will be compiled by an analyst within the department and will be reviewed by the Revenue Services Manager and Assistant Finance Director prior to disbursement. Anticipated completion date: March 24, 2023

Management Response #2022-017: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: The procedures adopted in 2024 will be formally documented and published that will ensure proper cost sharing or matching are clearly understood and defined. The requirements for matching as well as consistent monitoring metrics will be outlined in the procedures document as well. Greater and enhanced documentation will be properly maintained and available for review as required. Responsible Party: Tamara Barnes, CFO

Responsible: Thomas Hoover, CFO Corrective Actions: Update Finance policies to specify that documentation of review and approval of both the costs charged and the allocation methods of costs charged to federal grants be maintained. Completion Date: March 29, 2023 Explanation: Policies have been in place over the coding of costs allocated to federal grants in compliance with CFR 200 and were enhanced in 2023 in response to an OJJDP/OCFO recommendation. Review and approval of costs after being approved by an authorized signer takes place in multiple steps and concludes with preparation of reimbursements and financial grant reports (FFR). In order to further demonstrate compliance as recommended, Management has updated Finance policies to capture the documentation and maintenance of such documentation of Supervisory review and approval.

FINDING # 2022-016No finding in prior yearDue to the COVID-19 pandemic and the resulting remote teleworking period that was in place at DOH during the FY 2022 audit period, some payment documents were approved remotely without physical documents in hand, and the payment documentation for the 17 of 60 ELC general disbursement transactions examined were either not delivered to the office to be filed yet or have been delivered but misfiled. DOH Central Accounts Payable will review and improve its current procedures and controls to ensure all physical payment documents are reviewed, approved, and filed correctly under the current hybrid remote working conditions in place now since the pandemic ceased.COMPLETION DATE/CONTACT PERSON April 11, 2023Michael Palasciano(609) 376-8518Michael.Palasciano@doh.nj.gov

Finding Number: 2022-004Prior Year Finding: NoFederal Agency: U.S. Department of EducationFederal Program: COVID-19 - Elementary and Secondary Schools EmergencyRelief Fund (ESSER)Assistance Listing: 84.425C, D, U, WPass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:201787-01 (3/13/20 ? 9/30/22)Compliance Requirement: Allowable Costs/Cost PrinciplesType of Finding Significant Deficiency in Internal Control over Compliance,Other MattersRecommendation:We recommend that the Board review its policies and procedures to verify that controls are inplace to ensure expenditures are not reimbursed under more than one Federal Program.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding: ESSER funds will no longer be used for Food and NutritionServices.Name(s) of the contact person(s) responsible for corrective action: BCPS grant managers,and Fiscal Services staff.Planned completion date for corrective action plan: For immediate implementation andongoing

Subject: Hennepin County?s 2022 Corrective Action Plan Finding# 2022-003?Matching Program: Continuum of Care Program (ALN 14.267) Type of Finding: Significant Deficiency in Internal Control over Compliance Condition: While testing the matching requirement, we noted that internal controls are not properly designed. While the County was able to provide documentation that the matching requirement was met, we noted the following: - The documentation to demonstrate that the required match was met was on a calendar-year basis for all grants in total instead of on the required grant-by-grant basis. - The data utilized in determining the match requirement was met was obtained from the State?s information system, MAXIS, and the County did not retain this data. - Reporting of the match on the HUD Annual Performance Report is completed by multiplying the total direct costs by the required match percentage instead of the actual match. - There was a lack of evidence that a supervisory review was periodically performed over matching. In addition, while we were able to test a manual compensating control over matching, we were not able to review and test the automated application controls and related ITGCs within the MAXIS system. The State was not able to provide information regarding the design and implementation of MAXIS system controls nor were we able to test those controls directly. Hennepin County?s Corrective Action Planned in Response to Finding: Program staff will establish internal controls which includes determination of the required match on a grant-by grant basis semi-annually and retain County records of reviews preformed. Hennepin County Employee Responsible for the CAP: Michael Radcliffe Planned Completion Date for CAP: December 31, 2023 Hennepin County will encourage the State to provide an independent audit of the design and implementation of MAXIS system controls for the benefit of all counties. Hennepin County Employee Responsible for the CAP: Andra Roethler Planned Completion Date for CAP: December 31, 2023

U. S. Department of Housing and Urban Development (Pass-through from Virginia Office of Community Planning and Development) Assistance Listing #14.267 Finding: 2022-003 Known Questioned Costs for a Federal Program Not Audited as a Major Program Criteria: In accordance with 2 CFR 200.516(a)(4) known questioned costs that are greater than $25,000 for a program that is not audited as a major program must be reported as an audit finding in the federal awards section of the schedule of findings and questioned costs. In September 2022, the U. S. Department of Housing and Urban Development, identified $1,463 of unallowed expenditures and a deficit of $27,464 in the required cash match under the Continuum of Care program for the year ended December 31, 2021, as a result of monitoring. Rapid Rehousing Requirements: Criteria: 24 CFR 578.51; 24 CFR 578.57 Condition: The Federal awarding agency has determined, in accordance with 24 CFR 578.51; 24 CFR 578.57; $1,463 of allowable HMIS expenses were not documented and that in accordance with 2 CFR 200.1; 2 CFR 200.103(a)(11); 2 CFR 200.306; 24 CFR 578.73 the grantee failed to match $27,464 on its Continuum of Care rapid rehousing project. Corrective Action Plan: The CFO will ensure that the HMIS expenses are being captured in financial documents be setting up a new account code in the financial software. Staff members that have HMIS hours will also record those hours separately on their timesheets each pay period. NRCA will be submitting copies of timesheets which record data entry by line item as further documentation of the HMIS expenses submitted in answers to the monitoring report. While NRCA respects the position of the Department of HUD, NRCA also believes management followed the grant agreement as submitted. NRCA sees resolution to this matter with the Department of HUD and is currently seeking counsel to ensure this resolution in an acceptable and appropriate manner. Persons Responsible: Michelle Cox, Chief Financial Officer and Krystal Thompson, Chief Executive Officer Timing for Implementation: Immediate

Persons responsible for corrective action plan: Resty Rios, Staff Accountant Resty.rios@crihb.org Adrianna Davisson, Grants Manager Adrianna.davisson@crihb.org The Clinic has recently hired a Grant Manager whose responsibility will be to ensure to receive Agency approval in regards to any key staff changes including level effort, prior to implementation. The anticipated completion date is 6/30/2023.

CORRECTIVE ACTION PLAN JUNE 30, 2022 REFERENCE: 2022-101 CFDA NUMBER 84.425D ? COVID 19 ? EDUCATION STABILIZATION FUND CFDA NUMBER 84.425U ? COVID 19 ? EDUCATION STABILIZATION FUND U.S. DEPARTMENT OF EDUCATION ? 2021 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER: S425D210038 & S425U210038 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Wendi Allardice - Superintendent Karen Hancock - Title I/ESSER Grants Manager 2. Corrective action planned: A. Protocols developed to obtain at least 3 vendor quotes for any items over 10,000 with an analysis and justification of vendor chosen. B. Protocol in place for checking for vendor suspensions or debarment prior to purchase approval. C. Monthly meeting for comparison of proposed and estimated purchases and actual purchases and charges to the Grant. 3. Anticipated completion date: Anticipated completion date for above listed plan: 08/31/2022

We already implemented a formal review and approval process in 2023 and anticipate this finding to be resolved on our next year audit. We will also ensure the review and approval is properly documented.

Action Plan: We will work with our departments to ensure that controls for grants are documented with written procedures. These procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, re-performable manner with the name of the responsible individuals, the specific control(s) they performed over compliance for the grant, and the date(s) the controls were performed. Contact Names Responsible for the plan - Marcia Saulo Anticipated completion date of the plan - September 20, 2024

Action Plan: We will work with our departments to ensure that controls for grants are documented with written procedures. These procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, re-performable manner with the name of the responsible individuals, the specific control(s) they performed over compliance for the grant, and the date(s) the controls were performed. Contact Names Responsible for the plan - Marcia Saulo Anticipated completion date of the plan - September 20, 2024