Corrective Action Plans

In response to finding number 2021-SA3, management agrees with the finding and will design, implement, and maintain policies and procedures that ensure expenditures are reviewed for allowability before being charged to Federal awards. Management will also design, implement, and maintain policies and procedures that ensure costs are reviewed for allowability before being charged to Federal awards. Further, management will perform budget-to-actual analysis on a periodic basis to ensure costs do not exceed limitations.

Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.

JFT does have all the board minutes on file. However, because we were a small agency, salary rates were not often changed. Additionally, all salary rates and changes were always driven by the ability to obtain the funding needed. Since we were small and there was not always a lot to discuss with the board our board only met twice a year. Therefore, all salary was discussed with the board president, then taken to the board unfortunately there is no formal documentation at this time. As of 2023 our board now meets quarterly. Therefore, the following policy will be included in the fiscal manual: the JFT board of directors will hold a public meeting quarterly. All matters of pay rates and salaries will be approved at the start of each grant cycle. State and county grants will be discussed prior to the July 1 start dates, all federal will be discussed prior to October 1. Any changes in salary must be approved by the board and documented in official board minutes. All board minutes will be placed in a lock file in the Fiscal Coordinator’s office.

Starting in 2023 all employees of the Organization will complete formal time sheets. These sheets will be signed by the Administrative Coordinator and by the Fiscal Coordinator and then entered into the system each pay period to rectify this finding.

Deficiencies in Activities Allowed, Allowable Costs, and Period of Performance Controls over compliance with Payroll - Significant Deficiency Recommendation: The auditor recommends that the Entity implement controls for documenting and retaining information to indicate the Entity follows the requirements over 2 CFR section 200.430(i), and that alll pay rates be reviewed for approval and propriety. Action Taken: EPHCC will implement additional controls to ensure the following: 1. All employees must submit an approved timesheet or time and effort for each pay period. 2. All payroll transactions for staff from staffing agencies need to be reviewed by the accounting manager to ensure invoice has correct rate and that staff is paid for all hours worked on timesheet. 3. Upon hiring staff from staffing agencies, EPHCC shall document and retain information that all pay rates are reviewed byt the CEO for approval and propriety. Responsible Official: Chief Financial Officer, Lizabeth Romero Timeline for Implementation: Effective by May 2023

Management Response: Due to turnover program pay records such as timesheets and equivalent documentation could not be located. The missing files had been stored on a drive maintained by a former employee and could not be recovered. The City implemented a records retention policy in 2023 and established a system to ensure that all documentation supporting expenditures is properly gathered, organized, and retained in compliance with federal requirements.

In a previous period and by previous auditors, PAX was told that because we were using a percentage of effort calculation in budgeting that time sheets were no longer needed for this purpose. At that time, we abandoned the time sheet process (which was arduous). Based upon current auditor’s advice, PAX will, going forward, establish an effort verification reporting system. This system will accurately capture the effort spent by each employee on specific grants, ensuring proper allocation of wages and salaries to the respective federal awards. Dije Kucana, Comptroller, effective immediately

Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently enforce its internal controls over nonpayroll expenditures to ensure all expenditures are approved by the appropriate supervisor. Repeat Finding No Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and Payrate Review and Approval: • Standardize timesheet submission and approval process • Utilize an electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, reviews, and approvals by supervisors. • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors NonPayroll Expenditures: • Evaluate and improve upon existing processes to ensure internal controls over nonpayroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail. • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors.

Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently enforce its internal controls over nonpayroll expenditures to ensure all expenditures are approved by the appropriate supervisor. Repeat Finding No Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and Payrate Review and Approval: • Standardize timesheet submission and approval process • Utilize an electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, reviews, and approvals by supervisors. • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors NonPayroll Expenditures: • Evaluate and improve upon existing processes to ensure internal controls over nonpayroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail. • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors.

Finding 2020-009 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Jonathan Lomack, Acting Tribal Administrator Corrective Action Plan: The finance department was notified of this finding during the audit and immediately corrected the method of converting timecard totals to hours. Personnel files have been reviewed and updated for all current employees. Proposed Completion Date: Complete as of December 2023

Corrective Action Plan: During the remaining of the year 2023, job descriptions will be sent to all employees for their review and signature. Contact Person: Edgardo Gonzalez, Human Resource Director Anticipated Completion Date: No later than December 31, 2023

Finding 2019-009 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Edward George, Tribal Administrator Corrective Action Plan: The finance department was notified of this finding during the audit and immediately corrected the method of converting timecard totals to hours. Personnel files have been reviewed and updated for all current employees. Proposed Completion Date: Complete as of December 2023