Corrective Action Plans

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

In May 2022, a new CFO was hired and new procedures put in place. All reporting requirements are tracked by both the CFO as well as the Accounting Manager and reviewed on a monthly basis.

In May 2022, a new CFO was hired and new procedures put in place. All reporting requirements are tracked by both the CFO as well as the Accounting Manager and reviewed on a monthly basis.

View of Responsible Officials Covid-19 delays coupled with staffing shortages and turnover on the part of the audit firm resulted in the late submission of the audit. The Cooperative will work with the firm to establish appropriate deadlines to ensure timely completion of all upcoming audits. Respectfully Sara Tempel, Director Bear Paw Cooperative

Finding 2021-006 Reporting - Timely Submission of Financial Reports – Material Weakness in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager Corrective Action Plan: The Borough is currently in process of catching up on audits with the goal of completing the FY 2023 audit timely. Completion Date: March 2024

2021-006: Audit Completion and Submission to the State and Federal Government - Material Weakness and Non-Compliance Views of Responsible Officials: Management agrees with this finding as the Data Collection Form was not submitted to the Federal Audit Clearinghous within nine months after fiscal year-end. However, the Board does not agree that the late filing of the Data Collection Form rationalizes a qualified opinion over Reporting for the Airport Improvement Program. Corrective Action Plan: The Board will fire a contract accountant to assist the Accounting Manager in the timely finanical close to report and audit preparation to ensure timely completion of their finanicial and compliance audits. Anticipated Completion: December 31, 2023 Responsible Party: Tamie Wick, Accounting Manager. Amy Terrell, Airport Director.

With resolution of accounting procedures in 2020-001 and reconciliations in 2020-002 we will move toward a timely close and be able to file this on time. This is also dependent on audit catch-up. Amy Cunningham, Carla Carvalho-Degraff. Target Completion Date: 06/30/2025.

MANAGEMENT WILL ENSURE THAT FUTURE AUDITS ARE SUBMITTED TIMELY. MANAGEMENT IS CURRENTLY PREPARING FOR THE 2022 AUDIT AND WILL BE SUBMITTING THE 2023 AUDIT TIMELY.

Finding 2021-002 Program: Various, including AL 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) – Reporting Corrective Action Planned: To make sure and have proper education and obtain training to ensure County personnel are aware of the Federal reporting requirements and understanding of the schedule of expenditures of Federal awards. Anticipated Completion Date: Fiscal Year End 2023-2024 Responsible Party: Garfield County Board Scott Krause Garfield County Board Chairman

Strengthen internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implement a detailed closing schedule and tracking process to monitor deadlines, beginning with monthly financial close procedures and year-end close preparation by March 31, 2026. Ensure adequate staffing or external support during the financial statement preparation and audit process, including retention of qualified accounting consultant by April 30, 2026. Conduct periodic reviews to confirm compliance with federal Single Audit submission deadlines, with Executive Director oversight of audit progress reports by May 31, 2026. Prioritize completion of outstanding audit reports for fiscal years 2021-2024 with aggressive timeline: 2021 audit by June 30, 2026; 2022-2023 audits by September 30, 2026; 2024 audit by December 31, 2026. Establish year-round audit preparation procedures, including monthly reconciliations, quarterly financial reviews, and ongoing documentation organization to prevent delays.

PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission. Dije Kucana, Comptroller, and Bradley Smith, CEO, effective immediately

Management has started the audit preparation process for 2021, 2022, 2023 and 2024 and will ensure that the 2024 audit is completed within the required timeframe.

FINDINGS - FEDERAL AWARDS FINDINGS 2020-001: Single Audit Data Collection Form Not Filed by Due Date Recommendation: We recommend a system of control be enacted to ensure data is submitted in a timely manner. Action Taken: Management has discussed and agreed to initiate audit procedures earlier in the year. Name of Person Responsible for Corrective Action: Cathy Hardin Harrison, County Judge. Anticipated Completion Date of Corrective Action: April 30, 2024.

Finding Reference Number: MW2020-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2020: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is currently delinquent on the filing of audits from fiscal years 2020-2023. The organization is treating audit filings as the top priority and is working carefully through the audit backlog with qualified auditors that are currently engaged for audits 2020-2022. The delays in filing will continue into calendar year 2025, at which time it is expected that the audit package for the year ended December 31, 2024 will be filed on time to the Federal Audit Clearinghouse. Changes to CUAHSI’s accounting system, personnel, duties, and processes help ensure future audit preparation and support are streamlined, accurate, and timely. Name of Contact Person: 􀁸 Maureen S. Ako, Director of Finance 􀁸 Telephone: (339)221-5400 􀁸 Email: msabino@cuahsi.org Projected Completion Date: 2025-09-30

Finding Reference Number: MW2020-002 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2020: CUAHSI replaced prior contracted accounting staff with knowledgeable employees and were able to complete the 2020 SEFA. A lack of organized grant documentation and mistakes by prior contract staff to adequately segregate qualified expenditures from two grants (phase I and phase II of similarly named subawards) required a revision to the initially submitted SEFA to correct the statement of expenses for audit year 2020. Corrective actions to processes and responsibilities impacting subsequent years: We consider this finding to be addressed by new CUAHSI employees hired in September 2023 capable of supporting single audit preparation and updates to policies and documentation storage practices. CUAHSI’s current accounting system – the result of completing a migration from a poorly performing system in 2023 – supports all necessary grant tracking, segregation, and reporting requirements. Name of Contact Person: 􀁸 Jordan S Read, Executive Director 􀁸 Telephone: (339)933-4660 􀁸 Email: jread@cuahsi.org Projected Completion Date: NA; is complete

Audit Finding #2020-001 / CFDA 93.224 – Delinquent Filing Auditors Recommendation: We recommend that the Corporation document the annual financial statement close process so this process could be performed by anyone inside the Corporation with the proper skills, knowledge and understanding and spread the responsibilities over monthly reconciliations to multiple individuals within the Corporation. Action Taken: The Corporation has begun putting in policies and procedures to ensure the monthly financial statement close process is completed in a timely manner. See separate report for planned corrective action. Should you need anything further or have any questions regarding management's plan of correction response you may contact me at Central Mississippi Health Serivices. (601-353-5820) or by email at matcpa@yahoo.com.

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 vents, 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 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.