Corrective Action Plans

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

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

Finding 2022-004: Matching Every Program Director is trained on how The Light House invoices grants to enhance knowledge and decrease mistakes. The Light House finance department has taken over the billing process for all grants for The Light House and Light House Bistro. The streamlined approach provides strict oversight and quality control over what and who is billed to every grant. The Light House finance office is carefully watching the SNAP E&T federal Grant to make sure that the required 50% match is being covered by non-federal funds and not charged back to any federal funds no matter the funding source. Responsible Party: Terry W. Brukiewa, Completion date: 8/1/2022

Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: March 2024

Corrective Action: Management will review all cost allocations and implement documented policies and procedures to ensure sufficient support of any allocations of costs is maintained as required by 2 CFR §200.403. In addition, Management has developed a cost allocation worksheet and framework and is in the process of implementing a new procedure to ensure it is reviewed by accounting and grant managers to ensure accurate reporting. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: March 2024

Finding No. 2022-007 -Activities Allowed or Unallowed, Eligible Uses - FEMA Condition During the closeout procedures, the Cenh·al Office of Recovery, Reconstruction and Resiliency (COR3) office performed a 100% validation on Rental Equipment, supporting documents including conh"act smmnary record, invoices, and proofs of payment. As a result of the validation, the total validated amount is $979,259 from an original amount of $1,260,775 submitted by the Corporation for reimbursement. Corporation response The Corporation agrees with the finding. Corrective Action Plan Upon receiving the audit findings, we initiated an immediate review of our FEMA-funded projects and expenditures. We are implementing immediate corrective actions to address the identified deficiencies and ensure strict compliance with FEMA guidelines regarding eligible uses. • Policies and Procedures Review - Simultaneously, the Corporation is reviewing our existing policies and procedures related to FEMA funds, with a specific focus on eligible activities. Any necessary revisions will be made to strengthen our policies and ensure rigorous adherence to FEMA guidelines and regulations. • Enhance Internal Controls - We are enhancing our internal controls related to FEMA fund utilization. This includes implementing additional checks and balances to improve the accuracy and reliability of our project management processes, ensuring they align with FEMA guidelines. ■ Communication Protocols Enhancements - We understand the importance of transparent communication regarding the use of FEMA funds. To address this, we are enhancing our communication protocols to ensure that all relevant stakeholders are informed of FEMA guidelines, project eligibility requirements, and any changes to procedures. • Return of Funds - Initiate the communication process with the Central Office of Recovery, Reconstruction, and Resiliency to obtain instructions for returning the funds to FEMA. Follow FEMA's specific guidelines on the return of funds, including the appropriate documentation, timelines, and c01mnunication procedures. ■ Finance Team - The Corporation has made changes to its management staff structure in the finance and budget department, with the mission of improving the monitoring process and compliance with federal and local regulations and the support of independent consultants. A new Finance and Budget Director and the Associate Director of Finance and Budget have been appointed. Names of the contact persons responsible for corrective action plan Jesus A. Rodrfguez Aviles - Financial Planning and Analysis Associate Director Cecilia Robles Kakiuchi - Financial Planning and Analysis Director Anticipated Completion Date Fiscal Year 2024

Grantee Response and Corrective Action Plan: We concur with this finding and have implemented measures to mitigate the repetition of additional occurrences. In July 2023, the Accounting Manager, Grants Manager, and Grants Supervisor attended the 2023 Southern Grants Forum in Nashville, TN. This investment in training assisted these key employees in understanding and implementing procedures to effectively match Federal Grant awards. We have updated our Policy and Procedures Manual to reflect a new policy of matching Federal Grant awards with non-federal funding. The Grants Supervisor reviews all invoices submitted by the Grants Manager to ensure compliance with this new policy.

PAX will implement a dedicated cost center in the books and records specifically for tracking these expenses. This will allow for better transparency and accountability in reporting. Additionally, PAX will reconcile against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures. Dije Kucana, Comptroller, effective immediately

Name of the Contact Person Responsible for the Corrective Action Plan: Gia Scruggs, City Manager Corrective Action Plan: The private contractor engaged in 2017 to provide government management and operations services staffed the engagement with less than 40 staff including 5 consultants. The City, since the termination of the services contract effective December 31, 2021, has 79 staff involved in City management and operations roles including 5 elected officials. The additional staff, including an additional 5 in accounting/finance, affords the City the capacity to effectively account for and report on restricted funds received in connection with state and federal grant programs. The City Manager staff has grown by an additional 3 staff persons from the contractor level that was assigned in 2021 to monitor grants providing sufficient City staff for current grant programs to be monitored and grant conditions complied with. As the City continues to be eligible for additional state and federal grants, a Grants Administrator position has been added to staff organization and the plan is to organize a grants management team devoted to reporting and compliance assurance as well as seeking to apply for state and federal grant and program funds. Anticipated Completion Date: City Finance Department staff, together with the City Manager, are presently monitoring compliance and reporting relating to state and federal grants and program support. Third-party contractors will no longer be used for these tasks, and as more restricted funds are received by the City, the grants management team will be organized. Presently, the City has only one federal grant program and one state program. The corrective actions have been implemented and are presently operative and in place

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

PAX will implement a dedicated cost center in the books and records specifically for tracking these expenses. This will allow for better transparency and accountability in reporting. Additionally, PAX will reconcile against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures. Dije Kucana, Comptroller, effective immediately

PAX will implement a dedicated cost center in the books and records specifically for tracking these expenses. This will allow for better transparency and accountability in reporting. Additionally, PAX will reconcile against this cost center to ensure that the expenses reported to the grantor and budgetary allocations align with the actual expenditures. Dije Kucana, Comptroller, effective immediately

Finding No.: 2019-006 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 6U79SM062447-04M001 and 6U79SM062447-04M004 Area: Matching, Level of Effort, Earmarking Questioned Costs: $-0- Contact Persons: Perlie Santos, Chief Financial Officer; Reyna Saures, CGC Director; Vincent Camacho, Grants Administrator. Corrective Action: CHCC does not concur with these findings. CHCC affirms that the Match used to support activities of H71040 and H81040 were from verifiable records, and not from other federal funds. Costs were reasonable and necessary to accomplish the program’s objectives and were provided to and approved by the awarding agency. Finding No.: 2019-006 Continued Furthermore, CHCC sought clarification with SAMHSA and received notice that a match waiver for the Territories of up to $200,000 is applicable to all SAMHSA grants received based on the following federal statute: “Pub. L. 96-205, title VI, Sec. 601, Mar. 12, 1980, 94 Stat. 90, as amended Pub. L. 98-213, Sec. 6, Dec. 8, 1983, 97 Stat. 1460; Pub. L. 98-454, title VI, Sec. 601(b), Oct. 5, 1984, 98 Stat. 1736, subsection (d): ``Notwithstanding any other provision of law, in the case of American Samoa, Guam, the Virgin Islands, and the Northern Mariana Islands any department or agency shall waive any requirement for local matching funds under $200,000 (including in-kind contributions) required by law to be provided by American Samoa, Guam, the Virgin Islands, or the Northern Mariana Islands. Therefore, whatever match amount required per year should be reduced by $200,000 for the Northern Mariana Islands. Summarized below are the required and reported match amounts derived from the Final FFR for Grant SM062447, which included activities for H71040 and H81040 for fiscal year 2019. SOC_CHH61040_Matching_Revised013019.docx SOC_CHH71040 Matching.docx SOC_CHH81040_FY19 Matching.docx SOC_CHH81040_NCE Matching.docx Proposed Completion Date: Not applicable as CHCC does not concur with the findings.