Corrective Action Plans

Finding Number 2022-211: The Schedule of Expenditures of Federal Awards (SEFA) closing package originally submitted to the Office of the State Controller did not properly identify COVID-19 Emergency Acts expenditures for multiple programs.Federal Programs:93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises10.551 - Supplemental Nutrition Assistance Program (Snap)84.181 - Special Education - Grants for Infants and Families93.497 - Family Violence Prevention and Services/ Sexual Assault/Rape Crisis Services and Supports93.590 - Community-Based Child Abuse Prevention Grants93.958 - Block Grants for Community Mental Health Services93.977 - Sexually Transmitted Diseases (STD) Prevention and Control Grants10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, And Children10.561 - State Administrative Matching Grants for The Supplemental Nutrition Assistance ProgramRelated to Prior Finding: 2021-206Agency?s view: The Department agrees with this finding.The Department agrees with this finding but it is important to highlight that our internal controls and review processes are designed to detect and correct material inaccuracies or omissions of required information within the annual SEFA. As this does not constitute a material error, but rather a significant deficiency, the Department?s controls for this process worked as intended.This was a new requirement and Department personnel failed to identify a significant risk related to it and enhance the review procedures accordingly. This requirement will be monitored while we spend down the remaining COVID-19 emergency funding we have already been awarded.Corrective Action: This corrective action plan is complete. Effective immediately, we willmonitor awards for any new COVID-19 funding, but we don?t believe that there will be any newCOVID-19 awards. All existing awards have been confirmed as being reported as COVID-19funding.Anticipated Corrective Action Date: Corrective action has been taken as of April 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding Number 2022-204: $196,247,971 was not properly identified as covid-19 funds on the statewide Schedule of Expenditures of Federal Awards (SEFA).Federal Programs:10.551 - Supplemental Nutrition Assistance Program (SNAP)10.557 - WIC Special Supplemental Nutrition Program for Women, Infants, and Children10.561 - State Administrative Matching Grants for the Supplemental Nutrition Assistance Program64.005- Grants to States for Construction of State Home Facilities84.181 - Special Education - Grants for Infants and Families84.425R - Education Stabilization Fund - Emergency Assistance for Non-Public Schools93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises93.497 - Family Violence Prevention and Services/ Sexual Assault/Rape Crisis Services and Supports93.590 - Community-Based Child Abuse Prevention Grants93.958- Block Grants for Community Mental Health Services93.977 - Sexually Transmitted Diseases (STD) Prevention and Control Grants97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters)Related to Prior Finding: N/AAgency?s view: The Office agrees with this finding.Corrective Action: Since the State began receiving COVID-19 funding, we diligently provided training and resources to the agencies regarding the funding and how it should be reported on the SEFA closing package. This includes a discussion in our annual closing package training, online resources regarding COVID-19 funds, an FAQ document, and being available to discuss questions and concerns. In addition to the steps we are currently taking, we will reiterate the importance of designating COVID-19 related expenditures on the SEFA closing package during our annual closing package training. We will review STARS activity in the COVID-19 related funds and compare to the agency submitted closing packages for reasonableness. Recognizing that not all agencies utilize these specific funds, we will also review COVID-19 related expenditures on an external online source that reports federal grant expenditures. We will then use this information to compare to what is reported on agency closing packages for reasonableness.Anticipated Corrective Action Date: Errors identified were corrected prior to issuance of the Single Audit report. We will work with agencies to ensure all COVID-19 funds are identified for FY23 reporting.Responsible for Corrective Action: Ethan Draves, Reporting and Review Bureau ChiefEdraves@sco.idaho.gov 208-334-3100

Office of the State ControllerFinding Number 2022-203: Errors in the elimination process between state agencies resulted in misstatements to the Schedule of Expenditures of Federal Awards (SEFA) totaling $14,656,928 for direct awards and $14,278,362 for expenditures provided to subrecipients.Federal Programs:21.027 - State and Local Fiscal Recovery Fund84.334S - Gaining Early Awareness and Readiness for Undergraduate ProgramsRelated to Prior Finding: N/AAgency?s view: The Office agrees with this finding.Corrective Action: We will improve our elimination and reporting process by adding the following steps:? We will add an additional tab to our SEFA Master file to cross check all COVID-19 related funding to ensure agencies are not double reporting expenditures.? We will add additional steps to our SEFA preparation and review checklist outlining specific steps for completing the subrecipient elimination process, and identify higher risk areas that require the most scrutiny.? We will also improve our current elimination tab (awards received from other state agencies) and reconciliation procedures for subrecipients.Anticipated Corrective Action Date: Errors identified were corrected prior to issuance of the Single Audit report. Changes to the subrecipient reporting process will occur for FY23 reporting.Responsible for Corrective Action: Ethan Draves, Reporting and Review Bureau ChiefEdraves@sco.idaho.gov 208-334-3100

Finding Number 2022-207: The amount reported as passed through to subrecipients on the Schedule of Expenditures of Federal Awards (SEFA) closing package was overstated by $331,500.Federal Programs:15.605 - Sport Fish Restoration15.611 - Wildlife Restoration and Basic Hunter EducationRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.Corrective Action: The Department will provide additional training and update its procedural documentation to ensure that expenses are thoroughly vetted before they are reported as subrecipient expenditures on the SEFA. Each expenditure identified as a subrecipient expense will be tied back to a specific subaward, further limiting the possibility of non-subaward expenses being reported in the subrecipient portion of the SEFA.Anticipated Corrective Action Date: This corrective action plan will be implemented by the end of August 2023.Responsible for Corrective Action: Michael Pearson, Chief, Bureau of Administrationmichael.pearson@idfg.idaho.gov(208) 287-2800Jon Oswald, Financial Managerjonathan.oswald@idfg.idaho.gov(208) 287-2820

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Please note that the ELC program has been reported in the FY 2022-23 SEFA. Additionally, we will update the procedures to document the SEFA reporting for the ELC program. Estimated Implementation Date: September 2024 Contact: Jennifer Chan, Accounting Administrator II Federal Reporting Unit, Financial Management Division California Department of Public Health

EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (Database). In addition, the onset of the COVID-19 pandemic created additional issues which ultimately impacted the EDD’s ability to submit timely year-end financials. However, the EDD continues to make progress to gain ground in the department’s efforts to follow the State’s deadlines for submitting year-end financials and entering the cash basis expenditures into the Database. During fiscal year 2022-23, the EDD completed a restructuring within the accounting area which realigned workload amongst the units and provided additional resources in critical areas. These changes will have a lasting effect and help the department to be better positioned going forward in processing the accounting workload and ultimately be able to catch up and submit year-end financials and enter the cash basis expenditures into the Database by the State’s deadlines. In addition, the EDD took lessons learned from the financial audits from the prior two fiscal years to update processes and procedures and applied that knowledge going forward. Also, staff continue to participate in various trainings offered by the Department of Finance and the Department of FI$Cal. In addition, staff work with the control agencies when issues arise that would impact our accounting functions. While the EDD has been behind in submitting year-end financials for prior years, the department is making great progress on catching up. The EDD submitted the last of its fiscal year 2021-22 financials in May 2023 and submitted the last of its fiscal year 2022-23 financials in January 2024. The department is now working on identifying the ineligible payment data needed in order to accurately reflect the cash basis expenditures to enter into the Database. The EDD’s goal is to submit fiscal year 2023-24 financials in November 2024. Similar to the 2020-21 financial audit, the EDD will take the knowledge learned during prior audit seasons and continue to engage with the control agencies, and continue to train and develop staff in order to keep progressing towards the department’s goal of becoming timely with the submission of the year-end financials and the entering of the cash basis expenditures into the Database.

During 2022, there was a change in accounting staff which led to difficulty in tracking and preparing the SEFA. Once management became aware of the issues, changes have been made to internal processes to allow for proper SEFA tracking moving forward.

Finding 2022-002: Emergency Watershed Protection Program - Reporting Program: AL 10.923 - Emergency Watershed Protection Program - Reporting Corrective Action Planned: The County will ensure County personnel obtain training to ensure there is a proper understanding of the Federal reporting requirements and preparation of the Schedule of Federal Awards. Anticipated Completion Date: Ongoing Responsible Party: Dixon County Board of Supervisors: Don Andersen, Deric Anderson, Roger Peterson, Neil Blohm, Lisa Lunz, Terry Nicholson, and Steve Hassler

2022-002 – Completeness and accuracy of the Schedule of Expenditures of Federal Awards- Significant Deficiency Cluster: Not applicable Federal Granting Agency: Department of Homeland Security and Emergency Services Award Name: COVID-19 – Disaster Grants- Public Assistance (Presidentially Declared Disasters) Pass-Through from New York State Department of Homeland Security and Emergency Services Assistance Listing #: 97.036 Assistance Listing Title: COVID-19 - Disaster Grants- Public Assistance (Presidentially Declared Disasters) Pass-Through from New York State Department of Homeland Security and Emergency Services Award Year: January 1, 2022- December 31, 2022 Management of Maimonides Medical Center did not correctly interpret the rules in regards to the review and approval process by FEMA and New York State Department of Homeland Security and Emergency Services for the requirement to record FEMA funds. Management has consulted with their auditors on the proper timing to recognize and record the revenue. The Medical Center has reviewed the FEMA portal to ensure all FEMA project funds obligated and expended are reported in the proper period. Responsible Individual: Robert Palermo, Executive Vice President Chief Financial Officer

The District will review the Uniform Guidance requirements and ensure all expenditures are accurately reported on the Districts federal schedule.

Action Taken: During 2023, Range Mental Health Center, Inc. and Subsidiaries had experienced turnover in key financial functions. In response to this we have outsourced its CFO function and hired internal staff with a greater level of expertise to facilitate improved reporting. As a result, we anticipate an improvement in timeliness of our financial records.

Finding 2022-002 Federal Program Information: Federal Grantor: United States Department of the Treasury Pass-Through Entity: Smith County, Texas and the City of San Marcos, Texas Assistance Listing No.: 21.027, Coronavirus State and Local Fiscal Recovery Funds Pass-Through Award Numbers: Trinity Mother Frances, Pass-through Smith County: Not available Santa Rosa, Pass-through the City of San Marcos: Not available Award Periods of Performance: Trinity Mother Frances, Pass-through Smith County, October 1, 2021 – November 30, 2021 Santa Rosa, Pass-through the City of San Marcos, March 03, 2021 through December 31, 2026 Corrective Action Planned: Management agrees that the Department of Treasury awards passed through Smith County and the City of San Marcos were not included in the Schedule of Expenditures of Federal Awards. However, grant management identified the oversight and took corrective action to inform external auditors immediately upon the discovery. We have reviewed our processes that led to the initial oversight. We have instituted a new process to obtain confirmation from each CFO that their Ministry’s reported amounts on the Schedule of Expenditures of Federal and State awards is complete and accurate. Responsible party: Lee Sonne, Vice President of Finance and Controller, jointly with the Melissa Crenwelge-Nedbalek, Accounting Director responsible for Grant Reporting Implementation Date: January 2024 prior to the final reissuance of the FY 22 Uniform Guidance Reporting Package.

Finding Number: 2022-001 Condition: The original SEFA prepared for audit purposes did not include all federal expenditures that should have been reported under ALN 66.443. Planned Corrective Action: All programs that have both Federal and State/Local funding will be examined to ensure correct expenditure by funding source is properly recorded. Contact person responsible for corrective action: Curt A. Reppuhn, CPA Deputy Comptroller Anticipated Completion Date: Fiscal Year Ended June 30, 2023

The School System does not concur with the auditor’s findings and recommendations. The total expenditures for all federal programs recorded in the Schedule of Expenditures for Federal Awards are accurately presented and tie to the general ledger. The payroll sub-ledger is corrected before posting to the general ledger every two weeks. The resulting differences are most often immaterial, but can be traced to corrections made by the Accounting Office after payroll is reviewed by the grants Restricted Funds Supervisor to ensure payroll is not posted to expired grants. To ensure all employees are paid according to pay dates established in our various labor agreements and recorded correctly in the general ledger, we will continue the payroll transaction validation process that assures the payroll expenses recorded are allowable and accurately stated in the SEFA and balance to the general ledger. BDO Response – We have reviewed management’s response and our finding remains as indicated, since we could not validate the details of the differences.

2022-006: Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with CFR Section 200.502(a) and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Planned Corrective Action: County management will develop a closing process to ensure all federal expenditures are identified, recorded, and reconciled on the SEFA. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2024

Federal Agency: U.S. Department of Agriculture, U.S. Department of the Interior, U.S. Department of Transportation, U.S. Department of the Treasury, Environmental Protection Agency, U.S. Department of Health and Human Services, and U.S. Department of Homeland Security. Program Name: Schools and Roads – Grants to States; PILT – Payment in Lieu of Taxes, National Forest Acquired Lands; Highway Planning and Construction; National Priority Safety Programs; COVID-19 - Coronavirus Relief Fund; COVID-19 – Coronavirus State and Local Fiscal Recovery Funds; Diesel Emissions Reduction Act; Superfund State, Political Subdivision and Indian Tribe Site-Specific Cooperative Agreement; Help America Vote Act; Homeland Security Grant Program. ALN Number: 10.665, 15.226, 15.438, 20.205, 20.616, 20.703, 21.019, 21.027, 66.039, 66.802, 90.401, 97.036 and 97.067. Responsible Official: Donal Firebaugh, County Clerk. Views of Responsible Individuals: The County Clerk takes responsibility. COVID-19 money and ARPA money had me confused.

(A) CDHS agrees to enhance internal controls over monthly P-EBT reporting to better ensure accuracy. P-EBT is a new program derived from pandemic funding. Being a new program with a lack of federal guidance at implementation, and urgency to get the funds disbursed program staff had to learn about the nuances of the program and the reporting requirements as it was being implemented. During implementation we recognized that there are some inherent differences with P-EBT from other benefit programs which caused processes to have to be adjusted slightly. Additionally, timing of federal report filing for the P-EBT program is not in synch with our other processes and associated federal reporting requirements and deadlines. This makes it impossible to ensure reconciliation procedures are performed before filing occurs, which is one of our typical internal controls. As a compensating internal control CDHS will ensure that supervisory review processes are performed over P-EBT reporting, and that P-EBT reporting is reconciled to other sources (CBMS and CFMS) as soon as possible after reporting is available. If changes are discovered CDHS will make adjustments to filed P-EBT reports as needed based on reconciliation findings, and communicate changes to necessary parties. (B) CDHS will work to ensure better coordination between program activities and the accounting section relating to federal reporting changes. Accounting will iterate the importance of timely informing the accounting staff when changes are made to program filed federal reports. This message will be delivered in periodic fiscal meetings and identified on the closing calendar. The P-EBT program will ensure that corrections are communicated to accounting on any updates completed on the FNS-292-B report upon discovery, and no later than 30 days after the reporting period. (C) CDHS will ensure that review and approval processes are occurring as designed at various points in the process leading up to entry into CORE. As part of the Requisition (RQS) approval process program and accounting staff independently approve that the correct direct or subrecipient object code is used. These approved RQS transactions are then transitioned into encumbrance documents that drive which object code future expenditures will be booked to. For CCDF transactions related to this finding, both the OEC and Accounting teams inadvertently approved an incorrect object code in 4 RQS's. Staffing shortages coupled with a large increase in workload related to pandemic funding contributed to this oversight. To correct OEC and Accounting will train new staff, periodically familiarize themselves with the appropriate object codes, and perform quality assurance review over object codes before applying approval in CORE. The K1 is compiled from balances derived from expenditure data recorded in CORE. The compilation of the K1 relies on the fact that expenditure balances are accurate, and that prior reviews and approvals of individual transactions have occurred as designed. The K1 currently goes through various levels of review focusing on balance level validation coupled with analytical procedures. To enhance the review process, CDHS will ensure analytical procedures include line level expenditure comparison at the direct and subrecipient levels.

Finding: 2022-001 Agency: U.S. Department of Health and Human Services ? ALN 93.558 ? TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Name of contact person and title: David Drawl, CFO Anticipated completion date: December 2023 MYCAP?s response: Concur MYCAP agrees with this finding and provided the following response for corrective action: U.S. Department of Health and Human Services ? Material Weakness ? Internal Controls over Compliance ? Reporting Plan of Action: The material weaknesses identified by the auditor is correct as presented. Upon learning of the omission, MYCAP immediately adjusted the SEFA and presented the requested information to the auditor in such time that the program mentioned is included in the audit. MYCAP will accept the recommendations presented by the auditor and incorporate them into their fiscal procedures as well as incur additional training in GAAP conversion and preparation for audit.

Finding Number: 2022-002 Condition: The Corporation did not prepare a complete and accurate SEFA for the year ended June 30, 2021. Planned Corrective Action: While technically considered a significant deficiency and audit finding in accordance with CFR guidance for federal award audit compliance purposes, management considers this finding to be an isolated incident. Management had prepared and provided a SEFA summary that properly identified all federal funding, including all of the CARES Act funding, received as of June 30, 2021. Management also prepared and provided information regarding amounts of the CARES Act funding expended and recognized as revenue within the financial statements for the years ended June 30, 2020 and 2021. However, there was interpretation that the amount that was supposed to be reported for the CARES Act funding on the SEFA for the period ended June 30, 2021, should be the amount expended and recognized as revenue as of the financial statements ended June 30, 2020, to align with the Period 1 portal reporting. As such, the amount reported for the final SEFA used for the June 30, 2021 compliance audit excluded $1,271,104 that was appropriately reported as deferred grant revenue liability as of June 30, 2020. The amount of CARES Act funding for the Period 1 portal reporting correctly included the $1,271,104. There was a significant amount of collective confusion regarding the Period 1 CARES Act portal reporting which was for the period ended June 30, 2020, in relation to the SEFA reporting and compliance audit reporting for that same period of time, which was unusually deferred by the federal government from June 30, 2020 to June 30, 2021. The results of the auditors procedures demonstrated that all the information management populated in the CARES Act portal for the June 30, 2020 reporting compliance Period 1 was accurate and that there were no other findings. Contact person responsible for corrective action: Bob Stillman, Chief Financial Officer Anticipated Completion Date: March 31, 2023

Corrective Action Plan Finding No. 2022-001: HRSA COVID-19 Claims Reimbursement for the Uninsured Program Corrective Action Plan Since the inception of the program, the Organization reported the HRSA COVID-19 for the Uninsured based on payment date rather than on date of service/ incurred date. Once the error was identified, management properly reported and corrected the SEFA for the year ended June 30, 2022 to reflect the total amount of claims for services provided during the year ended June 30, 2022 for the Uninsured Program. Corrective Actions Taken Management has implemented the above corrective action. The VP of Patient Financial Services is providing the HRSA COVID-19 for the Uninsured based on date of service/incurred date, therefore the SEFA is properly reported for the year ended June 30, 2022. Completion Date: June 30, 2022 Contact Persons: Deborah Gaugler, Controller Jeffrey Hinkle, VP Patient Financial Services

Finding Number: 2022-005 Condition: The SEFA was not appropriately reconciled to federal grant revenues and expenditures recorded in the financial statements. Planned Corrective Action: The City will work to improve closing processes and communications with various departments and consultants to ensure the SEFA is complete and accurate. Contact person responsible for corrective action: Finance Director and Treasurer Anticipated Completion Date: 6/30/2023

Finding 2022-003 Grantor: Department of Agriculture and Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Schedule of Expenditures of Federal Awards Award Year: Fiscal year 2021 1/1/2022 ? 12/31/2022 Award Number: Various Management agrees with the recommendation. Management will implement the following changes to the management of the Schedule of Expenditures. Corrective Action Plan and Anticipate Completion Date Management?s corrective action plan includes: ? Review and validate that grants are listed under the correct cluster. Responsible Person: Aaron Ufferman, Director, Sponsored Projects, Natasha Collins, Director of Research Accounting Completion Date: December 31, 2023

2022-004 - Aging Cluster - Significant Deficiency in Internal Controls over Compliance Recommendation: We recommend that Metro Meals on Wheels track when Federal funds are disbursed to subrecipients and report these expenditures on the SEFA in the period of disbursement. Planned Action Metro Meals on Wheels will track when Federal funds on a cash basis.

Finding Number: 2022-013 Federal Program, Assistance Listing Number and Name: ALN 21.023, Department of Treasury, COVID-19 Emergency Rental Assistance Program (ERAP); ALN 20.205, Department of Transportation, Highway Planning and Construction Cluster, Highway Planning and Construction (Federal-aid Highway Program); ALN 20.505, Department of Transportation, Metropolitan Transportation Planning and State and Non-Metropolitan Planning and Research; ALN 93.323, Department of Health and Human Services, COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC); ALN 97.036, Department of Homeland Security, COVID-19 Disaster Grants - Public Assistance (Presidentially Declared Disasters) (FEMA) ALN 93.268, Department of Health and Human Services, Total Immunizations Cooperative Agreements, ALN 93.145, Department of Health and Human Services, HIV Related Training and Technical Assistance; ALN 93.686, Department of Health and Human Services, Ending the HIV Pandemic: A Plan for America ? Ryan White HIV/AIDS Program Parts A and B Condition: Original Finding Description: The schedule of expenditures of federal awards (SEFA) was not complete, accurate or prepared timely Contact Person Responsible for Corrective Action: Regina Greear and Keisha Pierce Anticipated completion date: July 2023 Planned Corrective Action: As part of the City Audit finding Corrective Action Plan (AFCAP), in fiscal year 2022 the City developed a checklist to help ensure all Federal expenditures are properly reported. The City will implement additional preparation and review procedures that will include specific timelines and guidelines to ensure completeness, validity and accuracy of the final SEFA reporting. In addition, the City will implement the AFCAP plan to further document the procedure requirements and train the appropriate staff.

Program: Various, including AL 93.767 ? Children's Health Insurance Program, AL 93.778 ? Medical Assistance Program ? Reporting Corrective Action Plan: State Accounting will continue to work with State agencies on correct coding and business unit setup in an effort to reduce agency errors. Contact: Philip Olsen Anticipated Completion Date: Ongoing