Corrective Action Plans

• Condition: During our testing of reimbursement requests, we identified an invoice that included expenses outside the period of performance for a grant in the federal program. • 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 Accounting Rep will review the expenses being submitted for reimbursement together to ensure no invoices are submitted outside the grant period.

• Condition: A prepayment for a 2023 training conference was recorded as an expense and reimbursed from a grant in the federal program. • Response This expense was recorded incorrectly and subsequently reimbursed due to miscommunication. • Planned Corrective Action: MHA will have staff attend additional training.

The County plan has been implemented.

Finding 2022-004 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Tracy Bye, CFO Response: Launch Alaska takes exception to the auditors’ findings. Launch Alaska codes expenses in accordance with the Launch Alaska Policy and Procedures for Uniform Guidance, GAGAS and FAR Part 31. Only those supported expenses that are allowable and allocable to Federal grants are charged to grant GL accounts. FY22 has examples of costs being segregated and posted to appropriate accounts based upon these cost principles. The CFO has over 30 years of GAGAS and FAR Part 31 experience and has final authority over which costs are coded for Federal reimbursement. Records for the transactions reside within QBO and the former CPAs JE files. All transactions for the covered period were reviewed by the CEO and CPA prior to entry into QBO. The CFO reviewed the postings monthly and requested changes to the GL coding when required. These changes were recorded by the CPA via AJE. We agree that the CPA did not post corrections in a timely manner in most cases. The Business Manager and new CPA review the expense entries weekly and at the close of each monthly period. The CEO/CFO have final authority on GL coding and are required to approve each expense entry prior to payment to ensure that the Policy and Procedures for Uniform Guidance is adhered to. This process takes place in both Ramp and QBO. Proposed Completion Date: Launch Alaska updated its Policy and Procedures for Uniform Guidance in early FY22 and is completing a second review at this time to incorporate the system and internal process changes discussed above. A final draft of the changes is expected to be reviewed for adoption by the Launch Alaska Finance Committee Board members in November 2023.

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. 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. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. 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

The AOS team has already contacted CCJFS. They are aware of the issue and will take the necessary steps to avoid making this mistake in the future. The Auditor’s office will closely monitor the reporting and coding of expenditures against grant resources.

Information on Federal Program(s) - Department of Health and Human Services, Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan Rural Distribution, Schedule of Expenditures of Federal Awards Reporting Periods 2 and 3, Agency Fiscal Year-Ended June 30, 2022. Management’s Corrective Action Plan In response to the deficiency identified, the Agency will modify its existing internal control protocols in the following ways: • Develop emergency internal control protocols to be implemented during emergency situations whereby all items recoded by accounting staff are reviewed and signed off by the Controller or Director of Finance to ensure appropriate treatment. Train all accounting staff on this expectation. • Ensure adherence of record retention policies and procedures which are consistent with regulatory requirements. • Modify its petty cash protocols to include the review and adequate documentation of all receipts to verify allowability prior to reimbursement. Train all petty cash reviewers on this expectation. Individual Responsible for Corrective Action Plan Auston Johnson Controller 215-386-3838 Anticipated Completion Date: October 31, 2023

Contact Person: Begay, Business Manager Anticipated Completion Date: December 31, 2023 KRCI policy and procedure was reviewed and revised beginning November 2021 and completed in July 2022 at a Board retreat. The KRCI Business Office was reorganized to ensure separation and segregation of duties in August 2022. KRCI is fully staffed and returned staff that were not working during the closure to return the Campus to full improvement. KRCI now employs a Clerk for Accounts Receivable, a Business/HR Tech for Human Resources and Accounts Payable, a Facilities/Property Tech for receiving and inventory, and a Business Manager in July 2022.

Recommendation: See finding 2022-001, specifically the recommendation relating to appropriate oversight in the finance department. We recommend that the finance department continue to hire and train its employees on various programmatic requirements and resources, to ensure compliance with both existing and new federal compliance requirements. Planned Corrective Action: We agree with the recommendation. Since year end the Agency has hired a COO, and CFO to fill vacancies within the Agency. Under this new leadership structure, the Agency will continue to work on establishing appropriate controls.

Recommendation: See finding 2022-001, specifically the recommendation relating to appropriate oversight in the finance department. We recommend that the finance department continue to hire and train its employees on various programmatic requirements and resources, to ensure compliance with both existing and new federal compliance requirements. Planned Corrective Action: We agree with the recommendation. Since year end the Agency has hired a COO, and CFO to fill vacancies within the Agency. Under this new leadership structure, the Agency will continue to work on establishing appropriate controls.

Recommendation: We recommend the review and approval of timecards be completed by a direct supervisor, that payroll records be regularly reviewed against timecards, and all supporting documentation for program costs be retained internally. Planned Corrective Action: We agree with the recommendations and plan to have corrective actions fully implemented by the end of fiscal year 2023.

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard requirements are now in place to maintain complete supporting documentation for each draw, including linkage to underlying expenses. Review and Approval Controls: Formal review procedures have been established, requiring documented evidence of supervisory review and approval prior to submission of draw requests. Anticipated completion date: Completed in 2022 Contact person responsible for corrective action: Angela Treptow, Interim Finance Director

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

Community Services Block Grant (CSBG)-Federal Assistance Listing Number 93.569 - Material Weakness in Internal Control over Compliance Finding 2021-004 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-005 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. 35 • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present, STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform. Wipfli, LLP was engaged for accounting services in August of 2023 and subsequently, implemented Bill.com to facilitate accounts payable approval processes and document retention. The software has established hierarchies built within the system to ensure all invoices are properly reviewed and approved prior to processing. All staff included in the approval process were trained to utilize the system for processing. Wipfli staff is engaged for the accounts payable processing activities in the system. All STOP staff have or will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

Community Services Block Grant (CSBG)-Federal Assistance Listing Number 93.569 - Material Weakness in Internal Control over Compliance Finding 2021-004 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-005 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. 35 • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present, STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform. Wipfli, LLP was engaged for accounting services in August of 2023 and subsequently, implemented Bill.com to facilitate accounts payable approval processes and document retention. The software has established hierarchies built within the system to ensure all invoices are properly reviewed and approved prior to processing. All staff included in the approval process were trained to utilize the system for processing. Wipfli staff is engaged for the accounts payable processing activities in the system. All STOP staff have or will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

We will implement policies and procedures to ensure compliance with applicable grant requirements.

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the state and local partners in each federal award to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. These policies and procedures will be designed to identify requirements for recipients and sub-recipients of grants, ensure accurate equipment and real property management, procurement, recipient and subrecipient monitoring and reporting. Further, policies will ensure a proper understanding of all grant requirements and compliance of the same.

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

Item 2021.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance. • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant’s period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail. • Review these procedures annually to ensure ongoing compliance with the grant’s period of performance.

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

Finding Number 2021-003: Allowable Costs/Cost Principles - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Health and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Management agrees with the finding. The Organization will review and modify policies and procedures over the program to ensure management implements policies and procedures to ensure there is understanding of the terms and conditions of Federal awards. Anticipated Completion Date: by December 31, 2024. Responsible Person: Matthew Matthiesen, CFO.

Assistance Listing Number 21.019 Noncompliance Over Major Federal Program Coronavirus Relief Fund Activities Allowed or Unallowed and Allowable Costs/Cost Principles Chairman Board of County Commissioners: Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended within the allowable period of performance. It should be noted that OMES did not review any of the submitted information to determine eligibility prior to sending reimbursements for items that have now been determined questionable. County Clerk: Documentation was scanned into the Purchase Order's images and once the Purchase Order was paid, the images were then deleted by the Board of County Commissioners secretary. Images were later recovered by the software system and since the incident, restrictions have been implemented to no longer allow deletions.