Corrective Action Plans

2021-004: Single audit data collection form not filed by due date. Recommendation: We recommend the WDBEA continue its efforts in bringing audits to an up-to-date status. Action Taken: Management is working with current auditors to bring audits up to date. Name of Person Responsible for Corrective Action: Frances Tribble-Adams, Finance Manager. Anticipated Completion Date of Corrective Action: December 31, 2024.

Finding 2021-004 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Acting Executive Director Corrective Action Plan: The Native Village of Point Hope shall adhere to the Uniform Guidance reporting requirements. Proposed Completion Date: The 2022 audit is already late and the 2023 audit will be late since that audit has not begun. However, we hope to submit the 2024 audited financial statements by the September 30, 2025 deadline.

Management has implemented policies and procedures to ensure the timely submission of single audit reporting package.

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024

Management response- Management has engaged independent auditors to complete audits of the Center's annual financial statements and expenditures of federal programs for each fiscal year until they are current.

As we mentioned in the SA 2020 Corrective Action Plan, we expected to finish SA 2021 in FY 2023, as well as SA 2022. We were not able to achieve this goal as face-to-face work had not yet been fully normalized due to a Pandemic Covid-19.Normality in terms of face-to-face work was fully implemented in 2022-2023. We currently have a contract to achieve the SA 2022 which will start in April 2024. We will continue to enter into a unified contract to achieve SA 2023 and SA 2024 completion on or before December 31, 2024. We have worked hard planning for this goal.

2021-009—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024

CDChoices was under the assumption that the guidelines for a single audit were based on Federal expenditures of greater than $750,000. CDChoices management reached out to our former auditors, as well as the Health Resources and Service Administration, and the Federal Audit Clearinghouse for clarification as to the requirement for a single audit based on the receipt of the Provider Relief Funding rather than Federal expenditures and were told that a single audit was only required if an organization spent more than $750,000 in a calendar year. We now know that the requirement for Provider Relief Funding is based on the receipt of the funds in a year. Should CDChoices receive federal funding in the future, the Controller, Brian Frasier, will research deadlines for submission and implement procedures to ensure the completion of a timely audit. This action will be completed should CDChoices receive federal funding in the future

Reportable Condition: The Institute did not submit the Data Collection Form and Reporting Package to the Federal Audit Clearinghouse of the fiscal year in June 30, 2021 during the required period. Recommendation: We recommend the institute to maintain adequate accounting records related to the non-federal and federal funds in order to properly prepare the financial statements accurrate and in a timely manner. Action Taken: As previously stated, our new accounting system (MIP) will keep our accounting records on a precise manner, improving our internal controls and providing us the opportunity to prepare the financial statements with fulll correctness and accuracy, also complying with the terms established and regulated.

Finding 2021-001 – Reporting - Submission of the Data Collection Form Contact: Terry L. Weaver, CFO Telephone Number: (301) 539-3629 Estimated Completion Date: June, 2024 Charles County Nursing and Rehabilitation Center, Inc. hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of September 30, 2022. The Organization will file the reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with our audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline. Anticipated Completion Date The Organization anticipates submission of the audit and data collection form immediately upon completion on May 16, 2024.

Management has implemented new policy and procedures.

Federal Agencies: US Department of Treasury and Department of the Interior Federal Programs: CARES Act (CARES), ARPA, ERA and BIA Compact, respectively Assistance Listing Numbers: 21.019, 21.027, 21.023 and 15.022, respectively Award Numbers: None, None, ERA0672, GT-OSGT043-16, respectively Award Years: 2021 (CARES), 2021 (ARPA), 2021 (ERA) and 2021 (BIA Compact), respectively Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to turnover in the finance department, there have been unplanned delays in preparing for and scheduling the annual audit. All efforts are focused on the timely completion of the year-end closing and scheduling of the audit in advance of the nine-month deadline. Proposed Completion Date: December 31, 2024

We agree that we have not been reporting on a timely basis current findings and results. We have established a calendar to ensure that the submission of all required annual reporting, be strictly followed by our newly created job position (Federal Funding Accounting Coordinator). The plan will be approved by the Board and implemented no later than April 26th, 2024.

The Roosevelt Fire District was late in filing their Single Audit for the Fiscal Year Ending 12/31/21 due to limitations caused from COVID. We are a small office with part-­time staff and fully volunteer fire & ambulance service.

2021-002 – Reporting – Submission of the Data Collection Form Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management acknowledges that the reporting package and data collection form for the year ended June 30, 2021, was not filed with the Federal Audit Clearinghouse on or before the extended deadline of September 30, 2022. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.

1. In process of getting caught up on prior year audits will result in timely submission of data collection form going forward.

2021-004 – Late Audit Report Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will continue in its recruiting and will hire the various accounting positions as defined in the corrective action plan for finding 2021-001. • CBNHC will implement the corrective actions described in the corrective action plan for finding 2021-001 to assure compliance with its regulatory requirement for completing its timely audits. • In the event that the CBNHC experiences changes in its staffing levels again, it will actively seek interim support through an accounting consultant in order to maintain its accounting records. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring the scope of work as defined in CBNHC’s Annual Funding Agreement (AFA) with the Indian Health Service (IHS) is administered accordingly. • Human Resource Director (Christina Chavez) – Will participate by actively recruiting for CBNHC’s vacant positions within the hiring requirements defined by the Navajo Nation. • Interim Finance Director (Volelle Zamora) – Is responsible for ensuring the timely completion of the CBNHC’s annual financial audits in accordance with the requirements defined by the Single Audit Act (2 CFR Part 200.512). Completion Date: June 30, 2024. CBNHC will be back on track with additional accounting support and expects to have its audit reports completed on time for fiscal year 2023.

See the Corrective Action Plan for chart/table.

Finding 2021‐005 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will ensure beginning balance reconciliations and year‐end adjustments will be complete by September, and will work with external auditors to have a financial statement draft prior to their fieldwork. Expected Completion Date Fiscal year 2025.

Description of Finding: Significant weakness in internal control over financials reporting, other matters. A single audit was not filed within 9 months after the year end. In addition, an annual audited financial statement was not filed within the required timeframe, including extensions, 2 CFR 200.512. Statement of Concurrence or Nonconcurrence: As a part of the recovery from the pandemic, new programs were added to the DCSOS menu of services. In 2021 it included a new federally funded program which brought the collective total of federal funds to over the $750,000 threshold. Due to covid setbacks in preparing the annual audit, management was unaware of the requirements of a single audit. Therefore, DCSOS agrees with the audit finding. Corrective Action: The DCSOS has hired additional staff in the finance office and prepared a plan to ensure the filing of the 2022- and 2023-year end statements will be prepared and filed prior to the September 30th, 2024 deadline. With a new work plan in place, subsequent year filings for single audits will comply with the single audit filing deadlines. Proposed Completion Date: Immediately Person Responsible for Corrective Action: Financial Officer

View of Responsible Officials and Planned Corretive Action Responsible Party: Executive Director The single audit requirement was new to KMNH as a result of ESG CV funding. KMNH completed the procurement process as required by HUD, but did not receive any response from qualified service providers despite proactive outreach on our part. We were informed that many of the audit firms were overwhelmed by the need to complete audits due to the increased level of federal funding due to COVID. KMNH has since been able to secure an audit firm to complete the audit after the stipulated due date. The same audit firm has been engaged to complete our audit for year ended December 31, 2022. The benefit to using the same audit firm is that their understanding of KMNH’s financial reporting and grant compliance processes learned during the 2021 audit should contribute to an expeditious 2022 audit. KMNH will work diligently with the audit firm with the goal of completing the audit as soon as possible.

Views of Responsible Officials and Corrective Action: With the completion and submission of the FY 2021 audit in January 2024, the organization is on track to complete December 31, 2022 and 2023 audits by September 30, 2024.

Contact person(s) responsible: Executive Director Vanessa Timmons; Associate Director Keri Moran-Kuhn; Accounting Manager Linda Koonce Corrective Action Planned: During this time OCADSV went through several temporary fiscal staff and one permanent hired staff that had made mistakes, with the effect of having to make adjustments in order to attempt to close accounting records. Controls have been put into place and permanent accounting manager is in place. Anticipated Date of Completion: 01-24-2022

Transitions in WCSC financial personnel during and after year-end resulted delays to the audit process for this audit period (FY2021) and the subsequent audit period ending September 30, 2022. To address this problem, WCSC hired a fiscal consultant in August 2022 to oversee the fiscal office, prepare and complete all grant reports, and to coordinate all fiscal audits. WCSC also hired a full-time bookkeeper in October 2022 to conduct day-to-day financial transactions and to assist with audit and grant reporting. WCSC has already engaged its Auditors to conduct the FY2022 audit, which will commence immediately following the completion of the FY2021 audit. This would put WCSC on track to complete the FY2023 audit by June 2024, thus meeting the requirement to submit the audit to the Federal Audit Clearing House within nine months after year-end. The timeline for the completion of the two subsequent audits is as follows: Estimated Completion Date: June 30, 2024

Corrective Action Plan Finding 2021-001 – Reporting - Submission of the Data Collection Form Air Force Retired Officers Community – Washington, D.C. DBA Falcons Landing (the Organization) hereby acknowledges the Organization’s audit reporting package was not submitted by the filing deadline of September 30, 2022. The Organization will file the reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with our audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline. Anticipated Completion Date The Organization anticipates submission of the audit and data collection form immediately upon completion. Individual Responsible for Corrective Action Plan Hardy Lister, Chief Financial Officer