Corrective Action Plans

Finding Reference Number: MW2021-002 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2021: CUAHSI’s current accounting and finance staff successfully completed the 2021 SEFA. However, revisions to the version initially shared with auditors were necessary to correct expenses improperly categorized by prior contracted accounting staff during a migration from a failing legacy system to an enterprise accounting system. Some expenses had to be reclassified to convert the book of accounts from cash basis to accrual basis. These errors stemmed from the loss of staff familiar with the original terms of a legacy agreement, poor document management practices, and inadequate oversight during the 2022 migration to the new accounting system. Corrective actions to processes and responsibilities impacting subsequent years: This finding is considered resolved through the hiring of new CUAHSI employees in September 2023, who have the capability to manage single audit preparation, oversee grants and agreements, and maintain appropriate internal controls. In addition, policies and documentation practices have been updated to strengthen oversight. The current accounting system—fully implemented in 2023—now supports all required grant tracking, segregation, and reporting. Name of Contact Person: 􀁸 Jordan S Read, Executive Director 􀁸 Telephone: (339)933-4660 􀁸 Email: jread@cuahsi.org Projected Completion Date: NA; is complete

2021-003 - All Federal Programs - Compliance - Data Collection Form Corrective Action Plan: The County intends to submit the data collection form upon completion of the 2021 Audit and will continue to work towards getting up to date on all subsequent submissions. Responsible Party: Julie Morton, County Treasurer Back Up - Malynda Richardson, Comptroller Estimated Date of Completion: – April 4, 2025 for FY 2021 Submission; Late Spring 2025 for FY 2022 Submission; Late Summer 2025 for FY 2023 Submission Signature: [Handwritten Signature. See CAP.] Title: County Treasurer & Comptroller

Our Finance Department was unable to provide timely financial information to your audit firm and provide the financial statements by the filing deadline due to the COVID pandemic and the problems this also caused with the difficulty in hiring and maintaining qualified individuals. To prevent recurrence of the late filing of financial statements, we have contracted with a temporary staffing agency, Robert Half, for additional qualified accountants to provide the following services: to assist with preparing timely monthly financial information for presentation to the governing board; timely reconciliation of all bank statements to the general ledger each month; timely reconciliation of receivable and payables subsidiary ledgers to the general ledger each month; preparation any necessary adjusting entries for posting; attend the monthly board meeting when financial information is presented; and provide the necessary assistance to prepare audit financial statements on a timely basis.

a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding The Corporation will file the December 31, 2021 financial statements as soon as possible and will ensure the annual financial report is filed within 30 days after the date of the auditor’s report and within 9 months of fiscal year end.

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 01/31/25.

Finding Reference: 2021-001 Compliance with Reporting Under the Uniform Guidance Description: The data collection forms for the years 2018 through 2023 have not been submitted timely. Recommendation: The Town should follow federal guidelines by submitting the data collection form to the FAC in a timely manner. Corrective Action: The Town of Guilderland Comptroller’s Office suffered significant turnover in key positions during the fiscal years of 2019 and 2021 including the retirement of the Town Comptroller and Fiscal Officer. The Town also implemented a new accounting software during 2018 that caused significant delays in the monthly and year-end reporting. Lastly, the COVID-19 pandemic had significant impact to the Town, particularly during 2020 when remote work was encouraged. This combination and sequence of events made it impossible to meet the required external audit reporting deadlines. Since these events, the Town has filed the vacant positions and has scheduled all remaining audits. The auditors are working as expeditiously as possible to complete the remaining audits. The required reporting noted in the guidelines above cannot be completed until each prior year audit is finished, therefore causing a delay in each fiscal year’s reporting. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The data collection forms for years 2018 through 2021 have been filed. The remaining audits that are left to become fully in compliance have been tentatively scheduled with the external auditors since 2022. The Town of Guilderland works as efficiently as possible with the auditors to complete these remaining audits. The remaining data collection forms will be filed upon completion of the audits.

Recommendation: We recommend the organization work closely with the audit firm to ensure that the single audit reporting package is issued by the deadline or within a federally approved extended date along with submitting the required data collection form with the Federal Audit Clearinghouse. Response: The delinquent single audit reporting package and data collection form will be filed in December 2024. Going forward, we will work with the external audit firm to ensure that their required grant testing is completed, and the single audit reports included with the single audit reporting package, as well as the required data collection form is submitted to the Federal Audit Clearinghouse within the required or extended due date each year.

Management’s Response and Action Plan Accounting 501 was brought onboard in fall of 2023 to expand the finance department. A significant amount of work was done to bring the current and historical financial reporting to a timely and accurate position. Financials and supporting schedules are currently being produced on a monthly basis. The 2023 audit is on track to be completed on a reasonable timeline. Personnel Responsible: Gabriel Maldonado, Chief Executive Officer Anticipated Completion Date: September 2024

Contact Person Megan Rath 2021-002 Corrective Action Plan The Association’s audited financial statements are now up to date. Proper checks and balances have been put into place to ensure ongoing complete and accurate financial data to avoid delinquent audits and data collection forms. Completion Date The data collection form will be submitted to the Federal Audit Clearinghouse by September 30, 2024.

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.