Corrective Action Plans

The County will create a monthly reconciliation of program income for the grant. This reconciliation will ensure that amounts reported in the IDIS system agree to those amounts reported in Workday. The reconciliation will be reviewed by the department and a copy provided to the Fiscal Services Supervisor Senior – Grant Accounting each month for review by Fiscal Services.

Program: Port Security Grant Program Finding: 2024-004 Contact Person: Karen Rindone Assistant Fire Chief Long Beach Fire Department Phone: (562) 570-2544 Email: Karen.Rindone@longbeach.gov Planned Actions: The Fire Department will ensure that all grant funds are expended in compliance with grant guidelines, including the completion of a biennial Equipment Inventory and the submission of a certification letter verifying its accuracy to the grantor every other year. Effective June 16, 2025, the Fire Department will conduct an Equipment Inventory and submit a verification letter to the grantor confirming its completion on a biennial basis. The current Equipment Inventory will be completed by the Support Services Bureau by September 30, 2025. The Fire Department will ensure the accompanying verification letter is sent to the grantor along with the updated inventory list. This biennial requirement will be integrated into the Department’s annual calendar. Following the FY2025 inventory, the next cycle will occur in FY2027 and continue in every odd-numbered fiscal year thereafter. Expected Completion Date: 9/30/2025 Finding: 2024-004 Program: Port Security Grant Program Federal Award Number: EMW-2021-PU-00259 Contact Person: Don Kwok Assistant Director of Finance City of Long Beach Harbor Department Phone: (562) 283-7575 Email: Don.Kwok@polb.com Finding: The Harbor Department failed to properly record the disposition of a federally funded asset. The asset was still marked as “in service” within the equipment listing for FY2024. However, the item had in fact been disposed of during FY2024 after an accident. The asset had a $0 value prior to the accident which initiated the disposal. Corrective Action Plan: The Harbor Department will enhance its written procedures on equipment disposals and provide training to appropriate Finance, Security, and Maintenance Division staff in FY 2025 to ensure compliance and timeliness in following equipment disposal procedures.

The City will improve its internal controls by implementing a new policy and procedures that will require staff training and outline detailed procedures for complying with program income regulations. The policy will: (1) require staff to annually participate in HUD trainings related to program income, (2) require staff to immediately deposit and reconcile program income upon receipt, (3) require staff to prepare a monthly program income report and (4) require management to review the program income report to ensure program income is applied to eligible expenses prior to drawing down grant funds.

Finding Reference: 2024-011 - Program Income, Ryan White (UMMC) Responsible Official: Mustafa Khawaja, Interim Director of Post-Award Corrective Action Planned: Based on feedback received from a Sponsor-led site visit in 2024, UMMC practices and policies are appropriately aligned with the intent of the program. UMMC will make efforts to ensure that all practices and policies are clearly documented and evaluated periodically. Estimated Completion Date: June 30, 2025

The Organization will review the terms and conditions of all federal awards to determine if program income is applicable to the federal program. For such federal programs, the Organization will ascertain the requirements for determining or assessing the amount of program income, and the requirements for recording and using program income. If required in accordance with the program, the Organization will implement a process for tracking and reporting the program income generated and used during the fiscal year. Further, the Organization will add another level of review of financial reports to ensure that program income is properly reported in accordance with the terms and conditions of the award. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Jeffery McNeal, Chief Financial Officer

Finding #2024-001 – Program Income Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 10, 2024 Corrective Action Plan: Effective immediately, the Organization will comply with the program income compliance requirement of the U.S. Department of Housing and Urban Development (HUD) Continuum of Care Program by netting program income generated from the pass-through grant to the amount to be reimbursed prior to submitting the reimbursement request to HUD, in accordance with the protocol outlined in the manual issued by the Behavioral Health Authority (BHA).

Financial Reporting and Review Process Description of the Finding: BSEDC did not have a secondary review process over the required financial reporting to Federal EDA. The lack of a secondary review process allowed for errors and omissions to go undetected, thus resulting in omission of $3,614 of loan origination fee income and interest income from federal program income calculations. Planned Corrective Actions: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director have implemented processes for the Senior Director of Finance to perform a secondary review of the required reporting to Federal EDA before it is submitted. Timeline for Completion: BSEDC implemented the secondary review process in October 2024 with the completion and submission of the FY24 annual report to Federal EDA. Responsible Person or Party: BSEDC’s Senior Director of Finance and Director of Business Finance/Program Finance Director are both responsible for ensuring that the secondary review is complete before submitting reporting to Federal EDA.

FINDING 2023-004 Finding Subject: Twenty-First Century Community Learning Centers – Cash Management, Program Income and Reporting. Summary of Finding: The School Corporation had not established an effective system of internal controls related to the grant agreement and the Cash Management, Program Income and Reporting compliance requirements. Cash Management The school submitted reimbursement requests without taking into considering the program income or reducing the request by the program income earned due to the lack of adequate program income. Program Income Controls had not been designed or implemented adequately to ensure that the proper fees were assessed and that the cash collections remitted were accurate. Additionally, the school-maintained program income in a separate fund and comingled with other non-grant funded program revenues. The unit did not deduct program income from allowable costs prior to claiming reimbursement. Reporting The total requested reimbursements for the audit period were understated by $32,605 when compared to the ledger. Of the two End of Year reports selected for testing neither properly included program income that was received during the year due to inadequate tracking of program income. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a system of internal controls to strengthen our policies and procedures and ensure the proper tracking of Program Income is reported and submitted accurately for Twenty First Century Learning center grant funds. Description of Corrective Action Plan: We have reached out to our liaison at the Department of Education to determine if program income should be reported monthly or annually. Management will be working with the Safe Harbor Director to implement a system to ensure separation of the Twenty first Century grants and other funds that are under the Safe Harbor program. Anticipated Completion Date: The anticipated date of correction for this is January 1, 2025.

Management Response/Corrective Action Plan: The Community Development and Finance Departments acknowledge that EN funds were drawn when it appeared that PI funds were available. The finding was partly influenced by the nature of first quarter draws and the need to record prior year expenses. We have corrected the discrepancy and to address this in the future, we plan to implement a balance sheet account to better track PI balances and expenditures.

Management Response/Corrective Action Plan: The Community Development and Finance Departments acknowledge that EN funds were drawn when it appeared that PI funds were available. The finding was partly influenced by the nature of first quarter draws and the need to record prior year expenses. We have corrected the discrepancy and to address this in the future, we plan to implement a balance sheet account to better track PI balances and expenditures.

2) Finding 2023-002 a. Program Information: 14.267 Continuum of Care Program b. Criteria: In accordance with 2 CFR 200.307, program income (in this case, tenant rent) must be correctly determined and properly recorded in the accounting records. Eligibility and rent determination evaluations are performed for new tenants before move-in and annually for existing tenants to determine their portion of rent to pay via the Tenant Income Certification or Re-certification or Permanent Supportive Housing – Eligibility and Rent Determination forms which are approved by the San Diego Housing Commission. Housing program tenants are required to pay up to 30% of their income for rent. c. Condition: For one out of 12 transactions tested, The Center collected $344.40 which could not be directly traced to an individual tenant. Because it could not be directly traced, the Tenant Income Certification or Re-certification or Permanent supportive Housing – Eligibility and Rent Determination forms could not be identified and tested for accuracy or completeness and compliance with the tenant’s share of the rental payment could not be determined.

FA 2023-001 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Cash Management Program Income 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 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425U210012 Questioned Costs: $309,623 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School emergency Relief Fund Program. Corrective Action Plans: No after-school program expenditures have been or will be included int eh ESSER expenditures for FY2024. Estimated Completion Date: July 1, 2024 Contact Person: Chris Griner, Chief Financial Officer Telephone: 706-546-7721 Email: grinerc@clarke.k12.ga.us

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Condition/Cause The Authority did not properly report program income in IDIS during the year, and therefore could not support that program income was applied prior to drawing down entitlement funding. In some instances, program income received was not reported in IDIS, and one receipt was entered into IDIS twice. When received, program income is reported in a separate general ledger account in the financial reporting software. The Fiscal Officer then enters the program income into IDIS on a regular basis. No control exists to ensure completeness or accuracy of information entered into IDIS related to program income. Recommendation We recommend the Authority develop a procedure/internal control to ensure program income is entered accurately and completely within IDIS. This will allow for documentation to support that program income is being utilized prior to drawing down entitlement funding. This will also ensure compliance with reporting requirements for reports generated within IDIS on an annual basis. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over Program Income for the Child Nutrition Cluster. After this review, we will implement a system to ensure that compliance with the federal program income requirements is met. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

2022-003 Child Nutrition Cluster Recommendation: School Corporation management should establish a system of internal controls to ensure compliance with the grant agreement and program income requirements. Documentation should be retained to support the existence and accuracy of all program income earned. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation with review existing control processes surrounding program income and strengthen procedures to ensure documentation to support program income is adequate and reviewed. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

FINDING 2022-001 Condition: The Organization had allocated expenditures, which supported an activity that generated program income, to a federal award that was not a major program. This program income was not deducted from total allowable costs or added to the award. The auditor discovered the expenditures during a scan of the expenditures allocated to federal awards and requested that the Organization analyze its charges to federal awards to determine if there were additional amounts. The total of such expenditures discovered was $3,655. Recommendation: The Organization should reevaluate its procedures and controls regarding the allocation of expenditures, which supported an activity that generated program income, to a federal award to ensure proper compliance. Planned Corrective Actions: The Organization agrees with the finding and plans to carry out the recommendation noted above by October 31, 2023.

Finding 2022-002 a. Program Information: 14.267 Continuum of Care Program b. Criteria: Housing program tenants are required to pay up to 30% of their income for rent. Eligibility and rent determination evaluations are performed for new tenants before move-in and annually for existing tenants to determine their portion of rent to pay. In accordance with 2 CFR 200.307, program income (in this case, tenant rent) must be correctly determined and properly recorded in the accounting records. c. Condition: For two out of 10 transactions tested, the amount of rent collected by The Center from the tenant was more than the amount determined on the Eligibility and Rent Determination form. Response: a. The Director of Housing and Youth Homeless Services is working with the housing complex property manager to memorialize the practice of either having the tenant reduce a future payment by the overpayment amount or refunding the overpayment amount to the tenant. In addition, they are working together to implement an actively level control whereby the Director of Housing and Youth Homeless Services’ team and the housing complex property manager are performing a more detailed review on a monthly basis to ensure overpayments, in particular, are detected and corrected timely. Contact persons responsible for corrective action: a. Victor Esquivel, Director of Housing and Youth Homeless Services b. Angela Reyes, Chief Financial Officer Anticipated completion date: a. November 1, 2023

Finding Reference Number: MW2021-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI used a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2021 program income. CUAHSI staff missed the NSF filing deadline for declaring federal fiscal year 2021 program income by one day (submitted November 16th, 2021). Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time beginning in 2023 and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.

In response to finding number 2021-SA5, management agrees with the finding and will design, implement, and maintain policies and procedures that ensure program income is tracked and expended appropriately.

Finding Reference Number: MW2020-009 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2020: CUAHSI uses a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2020 program income. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI uses a single payment gateway to segregate payments appropriately per event and per grant. Program income for subsequent years has been reported to NSF annually and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2020: CUAHSI uses a single payment gateway for registration on CUAHSI events and was able to accurately document and produce grant-specific totals for audit year 2020 program income. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI uses a single payment gateway to segregate payments appropriately per event and per grant. Program income for subsequent years has been reported to NSF annually and appropriate staff and policies are in place to ensure future compliance. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

CUAHSI uses a single payment gateway for registration on CUAHSI events, which is the organization’s only source of program income during the audit year (2019) up to present day (February 2024). The CVENT platform segregates events and CUAHSI program staff align these event codes to the grants supporting the events. Though identifiable through the CVENT system, our external contract accounting team failed to record and classify the program income to the correct grant in the accounting books and incorrectly included some grant expense reimbursement revenue in the program income transactions and totals provided to the auditors. Reporting program income to NSF through the annual program income report was not affected and was reported accurately. CUAHSI has addressed this issue by building its financial team and hiring accounting employees (as of September, 2023) with the skills, knowledge, and experience to appropriately manage the finances of federal awards. The new accounting team has applied proper identification of the events and have corrected the misclassification done by the former contractors.

Program income of $293,591 was entered into Sage and submitted to the auditor along with all other General Ledger details. Separately, CUAHSI reported program incomes of different (smaller) amounts to NSF that are likely reflective of actual incomes generated by the active awards. Potential mischaracterization in General Ledger detail may have resulted in overstating program income. The organization is working to implement processes that are 2 CFR Part 200.307 compliant and will be work with their cognizant agency to reconcile accurate program income relative to award draws.