Corrective Action Plans

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Health and Senior Services (DHSS) Audit Finding Number: 2024-009 - CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Bureau Chief Anticipated completion date for corrective action: Corrective action planned is as follows: The agency does not agree with the audit findings and therefore no corrective action is required. Explanation and specific reasons are as follows: DHSS disagrees with this finding. While the USDA partially sustained the previous finding in the FY2023 SWSA, the corrective action plan and supporting documentation submitted by DHSS was accepted by USDA and deemed adequate. On April 17, 2025, the USDA recommended final action to close the FY2023 audit finding.

THE IDAHO COALITION WILL IMPLEMENT STRENGTHENED INTERNAL CONTROLS OVER THE ALLOCATION OF NON-PAYROLL EXPENSES TO FEDERAL PROGRAMS, CONSISTENT WITH 2 C.F.R. PART 200 AND THE DOJ GRANTS FINANCIAL GUIDE. SPECIFICALLY, THE ORGANIZATION WILL: 1. DOCUMENT ALLOCATION METHODOLOGY: ESTABLISH AND MAINTAIN WRITTEN PROCEDURES THAT CLEARLY DESCRIBE THE ALLOCATION METHODOLOGY FOR NON-PAYROLL EXPENSES, ENSURING COSTS ARE 1402 W GROVE STREET BOISE, IDAHO 83702 WWW.IDAHOCOALITION.ORG ALLOWABLE, REASONABLE, AND ALLOCABLE TO EACH FEDERAL AWARD. 2. APPROVAL & REVIEW: REQUIRE CONTEMPORANEOUS REVIEW AND APPROVAL OF ALL NON-PAYROLL ALLOCATION JOURNAL ENTRIES BY THE FINANCE STEWARD (OR DESIGNATED FINANCE STAFF) AND THE EXECUTIVE DIRECTOR. 3. SUPPORTING DOCUMENTATION: MAINTAIN SOURCE DOCUMENTATION (E.G., INVOICES, ALLOCATION SCHEDULES, APPROVAL RECORDS) IN THE FINANCIAL SYSTEM TO DEMONSTRATE COMPLIANCE WITH UNIFORM GUIDANCE STANDARDS. 4. QUARTERLY MONITORING: CONDUCT QUARTERLY RECONCILIATIONS OF ALLOCATIONS TO ENSURE COMPLIANCE WITH FEDERAL COST PRINCIPLES. 5. TRAINING: PROVIDE TRAINING TO FINANCE STAFF AND MANAGERS ON ALLOWABLE COST REQUIREMENTS UNDER 2 C.F.R. § 200.403–405 AND OVW/HHS AWARD CONDITIONS TO REINFORCE COMPLIANCE.

Finding 2024-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division updated its FFATA procedure effective March 2025 and has been working to correct the inaccurate FFATA reporting for the Refugee and Entrant Assistance State/Replacement Designee Administered Programs subawards. All of LEO’s open subawards are reported correctly in SAM and LEO completed corrections to the closed subawards in April 2025. Going forward, LEO will ensure that future subawards are reported both accurately and timely in accordance with FFATA requirements. Anticipated Completion Date Completed Responsible Individual(s) Heidi Parker, LEO

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an issue in the future.

RE: Audit Finding-Missing EIV Reports Montpelier Housing Authority Audit Finding Response: The auditor reviewed the finding with me and the following action plan was put in place to ensure that key EIV reports are run on a scheduled basis and appropriate actions are taken: • Policies and procedures surrounding EIV were reviewed. •We implemented the use of a chart to prompt EIV reports within 90 days for new moveins. (see attached chart) •We already monitor EIV monthly and quarterly to ensure that EIV reports are run for all move-ins and re-certifications. This action plan is effective immediately, as of the date of this letter, February 17,2025.

2024-018 Oregon Department of Human Services Strengthen Medicaid fraud hotline reporting mechanismsManagement Response: We agree with this recommendation and will work to develop a more effective public facing referral process.. Anticipated Completion Date: July 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

2024-018 Oregon Department of Human Services Strengthen Medicaid fraud hotline reporting mechanismsManagement Response: We agree with this recommendation and will work to develop a more effective public facing referral process.. Anticipated Completion Date: July 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

Corrective Action Plan HCAP’s current procedures require the selection of auditors at least every five years. The request for proposal and selection of auditors for the fiscal year ended March 31, 2024 audit caused unexpected complications and delays in completing the audit and ultimately the filing of the single audit report to the Federal Audit Clearinghouse. The single audit for the fiscal year ended March 31, 2024 is expected to be submitted prior to March 28, 2025. The lessons learned during the 2024 audit will contribute to an expeditious and timely 2025 audit. HCAP will work diligently with its audit firm to ensure that future single audit reports are filed timely with the Federal Audit Clearinghouse. Completion Date: Completion date of the CAP is expected to be prior to March 28, 2025. Contact Person Responsible: Lynnelle Hasegawa, Director of Finance.

RE: Audit Finding-Missing EIV Reports Montpelier Housing Authority Audit Finding Response: The auditor reviewed the finding with me and the following action plan was put in place to ensure that key EIV reports are run on a scheduled basis and appropriate actions are taken: • Policies and procedures surrounding EIV were reviewed. •We implemented the use of a chart to prompt EIV reports within 90 days for new moveins. (see attached chart) •We already monitor EIV monthly and quarterly to ensure that EIV reports are run for all move-ins and re-certifications.

Reference Number: 2024-026 Prior Year Finding: 2023-023 Federal Agency: U.S. Department of Agriculture U.S. Department of Health and Human Services State Agency: Department of Finance and Management Federal Program: SNAP Cluster Temporary Assistance for Needy Families CCDF Cluster Assistance Listing Number: 10.551, 10.561, 93.558, 93.575, 93.596 Award Number and Year: 4VT400406 (10/1/2022 – 9/30/2023) 4VT402513 (10/1/2023 – 9/30/2024) 2301VTTANF (10/1/2022 – 9/30/2023) 2401VTTANF (10/1/2023 – 9/30/2024) 2301VTCCDD (10/1/2022 – 9/30/2025) 2401VTCCDD (10/1/2023 – 9/30/2026) Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend that Finance review and enhance its internal controls and procedures over the CMIA Annual Report to ensure that it verifies the correct interest rate is applied and that State and Federal interest liabilities are properly calculated in accordance with 2 CFR section 200.514. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: The current available rate at the time of calculation, review, entry, and moving to draft were all accurate to what U.S. Treasury had available at the time. The rate was updated on December 3rd, after our submissions had already been locked via the draft process in the CMIAS portal done on November, 26th. The process was not fully submitted due to issues with the CMIAS portal not allowing us to submit which has been extensively documented via multiple email chains with U.S. Treasury CMIA over the past two years. Finance and Management will take a screenshot of the CMIA interest rate page dated on the review date of the CMIA Annual Report submissions from departments to ensure that we maintain the historical rate posted to the U.S. Treasury CMIA page at the time of review. Additionally, AHS will take their own screenshots of the CMIA Interest Rate page from U.S. Treasury website on the date of their Annual Report Summary submissions for record and to show that the rate from this time was checked and applied to the current year’s program. If during the review, there is any discrepancy between the review screen of the rates and the calculations screenshot of the rates; the calculation spreadsheets will be kicked back to AHS to be updated. Scheduled Completion Date of Corrective Action Plan: November 30, 2025 Contacts for Corrective Action Plan: Jordan Black-Deegan, Statewide Grants Administrator jordan.black-deegan@vermont.gov Sarena Boland, Financial Manager III sarena.boland@vermont.gov

Program: AL 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) – Subrecipient Monitoring Corrective Action Plan: NEMA has implemented a process, effective immediately, to review the information submitted by subrecipient organizations regarding their 2 CFR Single Audit Certification. Responses will be cross-referenced with our own records of Federal funds passed through NEMA to the subrecipient. Any subrecipient responding that it was not required to conduct a single audit will prompt NEMA to validate against payment data. Any subrecipient’s noncompliance will be followed up by NEMA staff. Contact: Erv Portis Anticipated Completion Date: February 11, 2025

Controls will be implemented for future reporting and the School will have the opportunity to correct the reporting errors in the subsequent periods.

To ensure fiscal compliance and operational efficiency, grant activities will undergo enhanced monitoring through the addition of monthly reviews of review revenue and expense recognition, regular comparisons against budget and award terms, and provide targeted training for new grant managers and accounting staff on expenditures to meet grant spend down schedules. This finding relates to one legacy grant.

Controls will be implemented for future reporting and the Organization will have the opportunity to correct the reporting errors in the subsequent periods.

Name of Contact Person: Melanie Imholte Finance Director mimholte@soldotna.org 907-714-1224 Finding 2024-001 Reporting – Significant Deficiency in Internal Control Over Compliance Corrective Action The City of Soldotna will revise policies and procedures to ensure review and approval of grant reports being submitted. Expected Completion Date: Fiscal Year 2025

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy’s side. The Finance Director is now responsible for the renewals going forward, and this will not be an ongoing issue in the futur

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy’s side. The Finance Director is now responsible for the renewals going forward, and this will not be an ongoing issue in the future.

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy’s side. The Finance Director is now responsible for the renewals going forward, and this will not be an ongoing issue in the future.

Condition - The data collection form was not submitted within the required time as required by 2 CFR 200.512 for the year ended June 30, 2023. Planned Corrective Action - The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an ongoing issue in the future. Anticipated Completion Date: November 15, 2024 Point of Contact: Mary Ann Johnson

The Organization has remedied its controls and procedures to ensure the single audit is completed within the required timeline.

All future federal expenditures will be reconciled to the disbursement ledger.

We agree with this finding. The Chief Financial Officer in collaboration with the Assistant Director for Finance and the Assistant Director for Financial Compliance will set a calendar at the end of the fiscal year to ensure timely closeout of the books that will allow ample time to engage and complete the audit prior to the deadline for the FAC filing.

View of Responsible Officials and Corrective Action Plan – The Academies will develop a reliable system that will lead to the timely processing of the financial records by reviewing existing procedures to identify bottlenecks and areas of improvement. Feedback will be gathered from team members involved in the financial record keeping process so that standard procedures can be development and implemented. Furthermore, opportunities to automate processes and use software to assist with data entry, record reconciliation, and reporting can be used. This will significantly decrease manual workload and improve accuracy and timeliness.

The Board of Directors hired Gorman Management Company (GMC) on March 1, 2024, to operate the property, Ardmore Village. GMC has extensive experience in the on-site and financial management of properties like Ardmore Village. Specifically, GMC has procedures in place to maintain compliance with the regulations applicable to the Section 8/202 program and the FHA Section 223f program. GMC is well versed with CFR §200.512 (single audit data collection form), HUD Handbooks 4350.3, 4370.2 and 4381.5. GMC manages over 40 properties that have similar reporting and auditing requirements. All of the issues related to these findings will cure through GM C's policies and procedures.

Schedule of Corrective Action Plan For the Year Ended June 30, 2023 Finding 2023-003: Significant deficiency over Procurement and Suspension and Debarment Responsible Official’s Response and Corrective Action Plan We concur with the finding. BCI has an informal process of reviewing vendors and determining if they have been suspended or debarred. However, there is not a formal process where proper documentation such as screenshots of the search are saved. Due to the transition in the accounting department, we were not aware of these specific criteria at the time. We were notified of these requirements after the end of fiscal year 2024. To address these issues, we will implement a comprehensive process during fiscal year 2025 to ensure proper documentation and compliance with procurement regulations. This process will include: 1. Ensuring that all sole source vendor selections are properly documented and justified. 2. Verifying and maintaining records that confirm vendors are not debarred or suspended from doing business with the Federal Government before entering into contractual agreements. We are committed to improving our procedures and ensuring compliance with all applicable regulations moving forward. Planned Implementation Date of Corrective Action Plan September 1, 2024 Person Responsible for Corrective Action Plan Caryn York, Executive Director