Corrective Action Plans

Finding 2022-032 Pandemic EBT Food Benefits, ALN 10.542 - Report of Disaster Supplemental Nutrition Assistance Benefit Issuance Management Views MDHHS disagrees that federal regulations require MDHHS to maintain copies or screenshots of the Report of Disaster Food Stamp Benefit Issuance (FNS-292B) information reported on the federal website. MDHHS normally has the ability to access the information on the federal system. However, during audit fieldwork, the FNS-292B information that MDHHS submitted on the federal website was not viewable to the auditors because the reports were under federal review. MDHHS did not a retain a copy or screen prints of the submitted reports; however, MDHHS did maintain the underlying reports used to compile the submitted FNS-292B reports and this was provided to the auditors during fieldwork. Planned Corrective Action Although MDHHS disagrees that federal regulations require MDHHS to maintain copies or screenshots of FNS-292B information reported on the federal website, MDHHS will maintain screenshots of the report submission going forward. Anticipated Completion Date Completed Responsible Individual(s) Dawn Sweeney, MDHHS

(#2022-003) Allowable Costs ? Documentation to support the estimates for lost revenue was not provided to management timely for review and approval. Corrective Action Plan BOCES will ensure that clear and appropriate supporting documentation is in line with grant terms and is provided by the department and reviewed with the Finance Office prior to any submission for grant disbursement. Responsible Party Ms. Amy Windus, Executive Director of Finance Anticipated Completion Date June 30, 2023

FINDING 2022-003 (Medical Assistance Program) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Internal controls are being updated and will be adopted by the Board. The Township and Fire Department have worked on division of duties. Now the Fire Department will process a payment and will be approved by someone else in Fire Department. Then, the bill will be reviewed by the Township Accounting Specialist and will be paid by the outside accounting service. After the check is written, the Trustee will sign. If an invoice is over $5000 the Trustee will sign off prior to the payment. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted in the accounting software and coded to the proper account. The accounting software is reconciled on a monthly basis to ensure all transactions are accounted for properly and accurately. Anticipated Completion Date: 9/30/23

FINDING 2022-004 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, if there was not a problem with the finances of this grant could this not have been a comment. There is not any one of us involved with this grant that would have known about the prevailing wages part of it. Description of Corrective Action Plan: Projects requiring prevailing wage are complete, so we can't change this one, but will review grant agreements and try to remember to ask grantor if prevailing wage applies if any new grants are received, so we can develop controls and monitor compliance. Anticipated Completion Date: 02/27/2023

Finding ? 2022-001 ? Inadequate Records Retention Federal AL# 14.241 ? Housing Opportunities for Persons with AIDS Criteria: Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient (2 CFR ?200.334). Condition: Documentation supporting the Housing Quality Standards inspections to ensure housing met quality standards listed in 24 CFR ?574.310(b)(1)-(2) for the special tests and provisions compliance requirement for AL# 14.241 was missing. Cause and Effect: Policies and procedures regarding records retention is not in accordance with 2 CFR ?200.334 as it does not explicitly state a time period for records retention. As a result, events occurred during the year with no records retained as support. Recommendation: We recommend management update the written records retention policies and procedures to include a time period that is in accordance with 2 CFR ?200.334 and then communicate that policy to all employees to following during the daily course of operations. Additionally, we recommend an annual review of the policies and procedures to ensure continued compliance with 2 CFR ?200.334. Management?s Response: Homeless Alliance management agrees with the finding. Finding 2022-00 1 Response and Corrective Action In conjunction with our FY22 annual audit, please see the agency's corrective action plan below: Condition: Documentation supporting the Housing Quality Standards inspections to ensure housing met quality standards listed in 24 CFR ?574.3 10(b)(1)-(2) for the special tests and provisions compliance requirement for AL# 14.241 was missing. Corrective action: The agency has hired a full time compliance specialist for the program in which the finding occurred. The compliance specialist will be responsible for ensuring that all required documentation is retained appropriately. Moreover, agency management will update our written records retention policy to include a time period that is in accordance with 2 CFR 200.334 and communicate that policy to all employees. An annual management review of the agency's records retention policy will also be implemented. Expected completion date: June 30, 2023 Party Responsible: Haley Phelps Contact information: 405-415-8410 hphelps@homelessalliance.org

Finding: The Office of Financial Management did not have adequate internal controls over and did not comply with requirements to ensure Coronavirus State and Local Fiscal Recovery Funds were used only for allowable activities. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $300,000,000 Status: Corrective action not taken Corrective Action: The Office does not concur with the audit finding. The state of Washington created a separate fund to track the Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) expenditures. The state, through legislation, approved the transfer from the CSLFRF account to various state transportation accounts. The Office reaffirms that all expenditures from the transportation accounts that received the CSLFRF funds were used to maintain government services. The State Administrative and Accounting Manual requires all state agencies to establish internal controls over payments for goods and services, including ensuring payments are lawful and for proper purposes, reviewing payments to ensure they are supported, as well as documenting the review of all payments. State agencies continued to follow their established internal controls to ensure expenditures from the transportation accounts were proper and allowable for both non-CSLFRF and CSLFRF funds. The Office will continue to: ? Work with the U.S. Treasury through upcoming desk audits to ensure no questioned costs are required to be repaid. ? Document all correspondence with the grantor during the audit resolution process. Completion Date: Not applicable Agency Contact: Brian Tinney Statewide Accounting Director PO Box 43127 Olympia, WA 98504-3127 (564) 999-1781 brian.tinney@ofm.wa.gov

Finding 2022-002 Document Retention (Significant Deficiency) Federal Program: Child Nutrition Cluster Finding: Per 7 CFR 200.334, ?Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.? Management Corrective Action: While the school?s annual total meals served for the 2021-22 audit year were more than the meals claimed for reimbursement, the school was unable to reconcile all of the individual months. The school has since implemented and automated system to record lunches served. This point-of-sale system will eliminate the ongoing monthly accounting required to support monthly claims assuring the numbers served reconciles with the numbers claimed. Chris Ashmore has already implemented this system and tested the subsequent year-to-date audit period to assure this corrective action has, in fact, eliminated the problem.

FINDING 2022-003 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors and have updated our policies and procedures. Anticipated Completion Date: The internal control monitoring and checks and balances will be implemented immediately and continue going forward.

Assistance listing number and program name: 21.027 COVID-19 State and Local Fiscal Recovery Funds Name of contact person and title: Kori Kappes, Finance Administrator Anticipated completion date: June 30, 2024 Agency’s Response: Concur The Department will ensure subaward entities provide all records to the division relating to federal awards. The Department will also ensure it retains all records for a period of 3 years from the final expenditure report submission date. The Department will continue to resolve the $10,000 of questionable costs as deemed appropriate by the State of Arizona Office of the Governor and the United States Department of Treasury.

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security Name of contact person and title: Molly Bright, DCAD Assistant Director Anticipated completion date: December 31, 2023 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Develop and implement written policies and procedures to ensure the system used to process ERA claims and report program information produces summarized data on its federal reporting dashboard that are complete and accurate and comply with the federal agency’s reporting guidelines. The Department will develop written policies and procedures to ensure the information produced by the system used for processing ERA claims and program information is accurate and complete when providing this data to the federal reporting dashboard. These policies and procedures will bring the Department into compliance with the federal agency’s reporting guidelines. Department staff will be trained in accordance with the policies and procedures. 2. Follow its policies and procedures to retain all records relating to a federal award for a period of 3 years from the date of its submission of the final expenditure report. The Department will improve its compliance with its Record Retention policies and procedures, and will retain for 3 years all records that are required as outlined within the provisions of the federal awards received by the Department. 3. Verify the ERA-reported program information and the federal reporting dashboard to the underlying system data during each report’s review and approval process. The Department will, during each report’s review and approval process, sample the information from the underlying system prior to submitting it to the federal agency to verify its accuracy. This process will be included within the Department’s written policies and procedures created for ERA federal reporting. 4. Prepare and retain detailed documentation and submitted reports, such as system reports, queries, or screenshots, to support the program information it reports to the federal agency for each ERA award. The Department will assemble and retain all detailed documentation and submitted reports, such as but not limited to the aforementioned items, to provide support for the program information that the Department reports to the federal agency for each ERA award it receives. These documents and reports will be maintained in accordance with the Department’s Record Retention policies and procedures and federal requirements.

Assistance listing number and program name: 12.401 National Guard Military Operations and Maintenance (O&M) Projects Agency: Department of Emergency and Military Affairs (DEMA) Name of contact person and title: Jensen Forde, CFO Anticipated completion date: April 30, 2024 Agency’s Response: Concur DEMA HR anticipates having this completed by April 2024 at the latest. All employee records will be audited, corrected and maintained per the finding. HR staff has received a copy of the Department’s Record Retention Schedule and effective immediately will adhere to the policy.

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

The District did not provide a corrective action plan

The District did not provide a corrective action plan

US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023

Strengthen record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implement procedures to maintain institutional knowledge during employee turnover, including documented policies, cross-training, centralized recordkeeping, and formal transition protocols by March 31, 2026. Consider extending retention periods for documents supporting high-risk federal programs or key internal control activities beyond minimum requirements by April 30, 2026. Establish a centralized electronic filing system with version control and backup procedures for all federal award documentation by May 31, 2026. Create detailed internal control documentation templates and ensure all control activities are evidenced in writing by June 30, 2026.

Strengthen record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implement procedures to maintain institutional knowledge during employee turnover, including documented policies, cross-training, centralized recordkeeping, and formal transition protocols by March 31, 2026. Consider extending retention periods for documents supporting high-risk federal programs or key internal control activities beyond minimum requirements by April 30, 2026. Establish a centralized electronic filing system with version control and backup procedures for all federal award documentation by May 31, 2026. The new bookkeeping firm will assist in implementing this system and establishing appropriate file organization structures for grant-related documentation. Create detailed internal control documentation templates and ensure all control activities are evidenced in writing by June 30, 2026.