Corrective Action Plans

Program: AL 20.509 ? Formula Grants for Rural Areas ? Allowability & Subrecipient Monitoring Corrective Action Plan: The Controller Division, Audit Section, will provide support through continued engagement and work collaboratively as an additional resource to the NDOT Transit staff and transit recipients. NDOT Transit staff in collaboration with the Controller Division will be improving the standard operating Procedures which will be utilized for the in-depth review of monthly invoices moving forward. Contact: Khalil Jaber Anticipated Completion Date: Ongoing

Program: Various, including AL 93.778 ? Medical Assistance Program ? Allowable Costs/Cost Principles Corrective Action Plan: The Print Shop will complete a detailed analysis on the analyzed data, and update rates. State Accounting will offset rates to spend down its fund balance to a 60-day operating level. Contact: Philip Olsen / Ann Martinez Anticipated Completion Date: June 30, 2025

Program: AL 93.558 ? Temporary Assistance to Needy Families; AL 10.561 ? State Administrative Matching Grants for the Supplemental Nutrition Assistance Program; AL 93.658 ? Foster Care Title IV-E ? Allowable Cost/Cost Principles Corrective Action Plan: DHHS will continue to train staff on the proper RMTS procedures, which includes correct method of validation. Contact: Patrick Werner Anticipated Completion Date: 06/30/2023

Program: Various, including AL 10.561 ? State Administrative Matching Grants for the Supplemental Nutrition Assistance Program; AL 93.558 ? Temporary Assistance for Needy Families; AL 93.566 ? Refugee and Entrant Assistance State/Replacement Designee Administered Programs; AL 93.575 ? Child Care and Development Block Grant ? Allowable Costs/Cost Principles Corrective Action Plan: Several areas within DHHS are currently working to improve upon the process of determining how staff are paid during the hiring process and when turnover occurs. Contact: Patrick Werner Anticipated Completion Date: 02/01/2024

CAP for Finding: 2022-704 Finding 2022-704: Research and Development Cluster?Unallowable Costs Planned Corrective Action: We agree with the condition that expenditures noted by the auditors were posted to federal awards in error. Our institution has robust policies and procedures in place along with multiple levels of review for transactions that post to awards. However, there may be rare instances where a transaction posts to an award for which it is not allowable or allocable. As noted by the auditors, they sampled from a population of $86.9 million from certain expenditure codes and only questioned $650 in costs. These expenditures have now been transferred off the awards to non-sponsored funding. To help Research Administrators manage Research and Development Awards, RSP (Research and Sponsored Programs) offers a variety of tools. RSP maintains a website that houses policies and procedures related to all relevant Research Administration topics. In addition to this, the RSP website has FAQ (Frequently Asked Questions) pages on a variety of Research Administration topics. RSP also offers a comprehensive training program called RED (Research Education Development). We offer courses that include topics such as a basic introduction to research administration, closeout of awards, cost-share, cost-transfers, and many others. We will remind administrators and their staff of all the relevant information our website houses and that they should take any pertinent RED. Lastly, we will remind staff that they can retake courses if they haven?t taken them recently and want to refresh their knowledge. Anticipated Completion Date: 5/31/23 Person responsible for corrective action: Kyle Everard, Manager of NSF-DOE Team Research and Sponsored Programs Kyle.Everard@rsp.wisc.edu

FINDING 2022-003 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Jamie Arce, Controller Contact Phone Number: 574-322-4863 Views of Responsible Official: Management agrees with the finding. Description of Corrective Action Plan: The City will review its existing policies and procedures surrounding adequate supporting documentation and will update policy as required. Training on this requirement will be provided to all City Staff involved in procurement. Anticipated Completion Date: October 31, 2023

Finding # 2022-007 Title of Finding Subrecipient Monitoring Contact Person Brook Hinzman Anticipated Completion Date June 2023 Corrective Action planned to be taken: Will comply and monitor subrecipient spending going forward.

Item: 2022-003 Assistance Listing Number: 14.241 Programs: Housing Opportunities for Persons with Aids Federal Agency: U.S. Department of Housing and Urban Development Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 144347 Award Year: July 1, 2021 ? June 30, 2022 and July 1, 2022 ? June 30, 2023 Compliance Requirement: Allowable Activities and Costs Criteria: In accordance with 2 CFR ? 200.405 - Allocable costs ? a cost is allocable to a particular Federal award or other cost objective if the goods or services involved are chargeable or assignable to that Federal award or cost objective in accordance with relative benefits received. This standard is met if the cost is incurred specifically for the Federal award, benefits both the Federal award and other work of the non-Federal entity and can be distributed in proportions that may be approximated using reasonable methods and is necessary to the overall operation of the non-Federal entity and is assignable in part to the Federal award in accordance with the principles in subpart E. Condition: In fiscal year 2022, the Organization did not have an adequate process to review and approve employee cell phone costs charged to the program resulting in non-program costs being charged to the program. Name of Contact Person: Mike Fett, CFO Phone Number: (602) 265-8338 Anticipated Completion Date: September 30, 2023 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish additional policies and procedures to ensure adequate review of cell phone bills occurs and terminated and transferred employees are removed immediately. Additionally, we will implement proper review controls over the cost reimbursement reports to identify issues like these timely.

Item: 2022-002 Assistance Listing Number: 14.231 Programs: COVID-19 Emergency Solutions Grant ? Homeless Street Outreach Federal Agency: U.S. Department of Housing and Urban Development Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 154962-0 Award Year: July 1, 2021 ? June 30, 2022 and July 1, 2022 ? September 30, 2022 Criteria: In accordance with 2 CFR ? 200.405 - Allocable costs ? a cost is allocable to a particular Federal award or other cost objective if the goods or services involved are chargeable or assignable to that Federal award or cost objective in accordance with relative benefits received. This standard is met if the cost is incurred specifically for the Federal award, benefits both the Federal award and other work of the non-Federal entity and can be distributed in proportions that may be approximated using reasonable methods and is necessary to the overall operation of the non-Federal entity and is assignable in part to the Federal award in accordance with the principles in subpart E. Condition: In fiscal year 2022, the Organization did not have an adequate process to review and approve employee cell phone costs charged to the program resulting in non-program costs being charged to the program. One employee's phone bill continued to be charged to the grant after they stopped working on the program. Name of Contact Person: Mike Fett, CFO Phone Number: (602) 265-8338 Anticipated Completion Date: September 30, 2023 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish additional policies and procedures to ensure adequate review of cell phone bills occurs and terminated and transferred employees are removed immediately. Additionally, we will implement proper review controls over the cost reimbursement reports to identify issues like these timely.

The allocation of costs between our two federal programs and other programs are made by the Program Director or after discussion between the Program Director and the Federal Grant Manager; then communicated to the accountant. In addition, our accountant has the program knowledge and ability to question cost allocations. Beginning mid-September, 2023, the basis for allocations will be documented on an invoice or other supporting documents. Effective June 2023, weekly payroll time records allocating hours to projects and programs are prepared by each employee. Those time records are approved by the Program Director or the Treasurer, as appropriate. The allocations are then reviewed by the Federal Grant Manager and entered bi-weekly into the accounting records.

Audit Finding Reference Number: 2022-002 Recommendation - South Shore should enhance its internal control processes related to preparation and review of the monthly claim for reimbursement. Corrective Action Plan - We have adjusted our policies and procedures to assure that every claim submission is reviewed by both the Controller and CFO prior submission. Claim form and appropriate documentation will be submitted to the Controller who will give initial review. Review will consider timeliness of items claimed as well as appropriateness for the particular federal grant. CFO will then provide final authorization in writing to both grants accountant and controller at which time claim for reimbursement can be submitted by grant accountant.

Nevada Urban Indians, Inc. (NUI) will implement an allocation disclosure on all backup documentation that is verifiable to program budgets. NUI will also implement a rolling 12-month allocation plan to ensure that all funds received are being spent appropriately and that there will not be a fund deficiency. This 12-month allocation will be reviewed monthly and allocations will be adjusted as needed. In the event that previous allocations need to be changed, NUI will shift costs per 2 CFR 200.405 (c) and (d) and provide additional backup documentation showing the change and why the change was made.

Finding 2022-004 ? Unallowable Use of Public Housing Program Funds Public Housing Program ? Assistance Listing No. 14.850a, Grant Period: Fiscal Year-End June 30, 2022 Corrective Action The Authority review allowable Public Housing Program versus COCC expenditures in HUD Handbook 7575.1 and refrain from charging COCC expenditures to the Public Housing Program. The Authority?s Executive Director, Africa Porter, has assumed the responsibility of executing this corrective action as of April 1, 2023.

Significant Deficiency in Internal Control over Compliance and Other Matters 2022-004 Unallowable Costs U.S. Department of Health and Human Services Child Care and Development Fund Block Grant (CCDF) ? CRSSA (Coronavirus Response and Relieve Supplemental Act) Assistance Listing Numbers: 93.575 Recommendation: We recommend the program work closely with ASD to ensure expenditures are tracked and mapped to the appropriate federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The ECECD ASD Director, CFO and Grants Manager will work with the Federal Program Team to develop formal policies and procedures for grant management to ensure compliance with programmatic grant requirements and track expenditures to ensure costs charged to grants are allowable, necessary, and reasonable. Name(s) of the contact person(s) responsible for corrective action: Ron Lucero, ASD Director; Carmel Pacheco-Aragon, Chief Financial Officer; Grants Manager (TBA); ECECD Program Managers. Planned completion date for corrective action plan: June 30, 2023

Finding 2022-003: Activities Allowed or Unallowed Federal Agency: U.S. Department of Education Special Education Cluster (IDEA) Federal Assistance Listing Number 84.027, Special Education ? Grants to States Federal Assistance Listing Number 84.173, Special Education ? Preschool Grants Condition One of the eight payroll samples selected for testing had incorrect salary percentages applied to the grant when compared to the tasks completed and approved budget for the grant. Corrective Action Planned The District will put procedures in place to verify all expenditures, including payroll, that flow through the federal grants for accuracy. Anticipated Completion Date November 2022 Individual Responsible for Corrective Action Plan Lisa Raymond, Assistant Superintendent of Business

The Organization billed the federal government for amounts of costs that had not yet been incurred and is at-risk for noncompliance with allowable activities and allowable costs, as well as cash management requirements. Statement of Concurrence or Nonconcurrence: Flower Hill has been billing the US Department of Agriculture 100% of its annual expenses in equal monthly amounts whether the total amount billed was expensed or not. According to audit, this is not allowable under a cost reimbursable contract. The organization agrees with, understands this finding and has already implemented corrective action to this finding. Questioned Costs $186,089 Corrective Action: Corrective action has been taken. FHI has discussed this finding with grantor (USDA Department of Agriculture) as has Auditor. To date, there has been no action taken by the USDA. As of July 2023, FHI has been billing only reimbursable amounts for direct costs incurred and for the approved 10% indirect rate. Name of Contact Person: Person responsible for completing the corrective action plan is Nicole Mast, Director of Operations, nmast@flowerhill.institute. Projected Completion Date: July 2023 Oversight: Billings will be monitored on a monthly basis to ensure full implementation through the end of the current contract (currently March 2026).

Corrective Action Plan: VDH has updated its accounting structure and cost allocation plan to ensure that costs not otherwise eligible under federal grant awards are not attributed to the VDH administrative cost pool and allocated to federal grant programs. Scheduled Completion Date: 10/1/2022 Contacts for Corrective Action Plan: Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

Recommendation: We recommend that the District implement procedures to review that expenditures claimed under the program are allowable and are not already claimed. Action taken: Cathy Meher, treasurer, reviewed this with the external auditors and those questioned costs had not been claimed for reimbursement and will be reviewed prior to submission to Grants Finance for reimbursement. Dr. Christopher Wojeski, Assistant Superintendent, will also review the expenditures to ensure they are allowable costs. With the addition of a new staff member in the Business Office, this will be addressed and corrected immediately. Anticipated completion date: 11/1/22

COVID-19 EDUCATION STABILIZATION FUND ? ASSISTANCE LISTING 84.425U PASSED THROUGH THE PENNSYLVANIA DEPARTMENT OF EDUCATION; GRANT PERIOD ? YEAR ENDED JUNE 30, 2022. Management Response: An invoice was accidently allocated to both federal programs but was corrected before ARP final reporting was done. Corrective Action Plan: All final reporting will be reviewed, and any duplicate dollar figures will be reviewed to ensure expenditures are not duly list. Person Responsible: Christina Bason, Superintendent Anticipated Completion Date: Immediately

Management?s Response: FSA have selected ADP as a third-party payroll services that allows for Human Resource and Payroll to use the same employee information that will be entered by the Human Resource Department and does not had to be replicated by Payroll. This will ensure that all updates in payroll to be updated in real time with no documentation delays. FSA went into an agreement with ADP May 2022 to begin implementation development of a system that would meet our needs to prevent this delay between MIP system when the staff updates the NOVA time system after the personnel action form is reviewed and approved.

Management?s Response: In January 2022, during the processing of FSA payroll, the system had a major error that caused for an emergency payroll processing to take place to meet the Labor and Wages standards, so this payroll was processed not knowing that it was paid based on home allocation rather then time sheets allocations. However, the majority of FSA employees were allocated to one department program or grant. Reassigning of location only occur within staffing emergencies within the same program. Due to this occurrence, FSA started to investigated a third-party payroll servicing company that uphold our standard of functional time keeping and allocation and selected ADP. Gross pay information for each employee is extracted from the Payroll Journal and entered into the Labor Distribution. Periodically, time sheet information is entered into the Labor Distribution and percentages developed or functional time which are used to allocate gross pay to each program based on total time worked. The Labor Distribution is used to post the allocated payroll costs to the General Ledger, or billing worksheet, and the related costs then posted to the billing or reporting document.

Management?s Response: Effective fiscal year 2022-23, the Association will follow section 2 of the CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. The costs, for which the benefit can be directly identified, will be charged to the benefiting grant and category. Shared/Joint costs will be charged based on employees? time reported (timesheet and labor distribution), units of services (meals, care management units, number of-participants, hours of service, etc.), square footage, or other method that will result in an equitable allocation of costs. Currently, direct-shared costs for the Child Care and the Senior Services Programs are pooled by program area. The direct-shared cost pool and pooled facilities costs are then allocated to each funder within the respective program. We have immediately implemented a change in procedures to recalculate our Cost Allocation Plan on a quarterly basis, based on using the previous quarter's payroll labor distribution report by program to calculate the FTE for the upcoming quarter cost allocation. However, if a funder disallows a particular expense item, after the determination of their portion, it is applied to Unallowable and paid with unrestricted funds of program or agency.

Panthera implemented Chrome River which is a platform that enables electronic review and approval of invoices as part of Panthera?s expense management process. As Panthera expands its operations internationally we plan to implement more controls and procedures to ensure foreign affiliates are properly maintaining all required expenditures documentation and approvals on spending.

Significant deficiency in internal controls over compliance and instances of noncompliance related to allowable costs. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: Paylocity, third party payroll processor, was implemented in October FY23. In FY23 we have reviewed payroll for each month to ensure the charge to the awards are the same as the actual allocation percentage to each grant, and have strengthened the internal controls over the complete, timely and accurate recording of payroll expenses for each payroll. The new internal controls include reconciling the Paylocity system reports to the bank reconciliations and the final journal entries to record the payroll expenses. Anticipated completion date: Completed September 2023.

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer