Corrective Action Plans

December 12, 2022 Finding: 2022-001 Procurement, Suspension and Debarment US Department of Agriculture ? ALN # 10.555/10.559/10.582 ? Child Nutrition Cluster Green Mountain Unified School District Single Audit ? Material Weaknesses Responsible Official - Cheryl Hammond ? Business Manager Anticipated completion date: December 12, 2022 The school district agrees with this finding and will implement the following: ? Review the procurement policy and procedure ? Distribute the policy and procedure to the food service and business staff ? Train staff on what needs procurement documentation ? Beginning this process immediately

Action Plan: We will work with our departments to ensure that controls for grants are documented with written procedures. These procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, re-performable manner with the name of the responsible individuals, the specific control(s) they performed over compliance for the grant, and the date(s) the controls were performed. Contact Names Responsible for the plan - Marcia Saulo Anticipated completion date of the plan - September 20, 2024

Finding No. 2022-006 Department(s) New York City Department of Health and Mental Hygiene Program(s) Assistance Listing Number 93.069, Public Health Emergency Preparedness Corrective Action(s) DOHMH?s Office of Emergency Preparedness and Response (OEPR) and Division of Finance are in agreement with the recommendations. Non-compliance with the level of effort requirement occurred because the agency received additional federal funds as part of the American Rescue Plan and utilized those funds to cover city tax levy costs in FY22. This was a one-time offset. In addition to strengthening and maintaining internal controls, DOHMH plans to revisit how maintenance of effort is calculated for the PHEP award, as it is currently calculated using a 15-year-old formula that has not been tweaked to ensure it accurately captures health care preparedness and public health security spending. DOHMH will close out a 5-year project period on the PHEP award in 2024 and plans to revisit the current maintenance of effort formula in advance of applying for the new project period. Anticipated Completion Date June 2024 Person(s) Responsible for Implementation Monica Marquez Assistant Commissioner, OEPR (347) 396-2730 Wai ting Yu Assistant Commissioner, Central Finance (347) 396-6214

2022-003 Accuracy of Federal Reports Throughout the Single Audit process, management discovered that the pandemic caused issues concerning the organization of cash disbursement receipts. In lieu of this finding, management has decided to develop and implement the following procedures: 1. Management will develop a written policy and procedure for a cloud-based document saving subscription, that will be utilized to scan and to upload all invoices/statements/bills/receipts into specific grantor, vendor, and program folders. 2. Management will create a unique email address strictly used as a landing site for pay request, vendor invoices, and receipts. 3. Management will train all current staff and provide training to new hires as a part of orientation in use of the system. 4. Management will monitor the site on a weekly basis, at which time request, payments and receipts will be allocated to the appropriate budget lines.

93.767 Children' s Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Reporting 2022-026 Ensure Compliance with Reporting Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: DOM Concurs. DOM identified this issue during reporting of the March 31, 2022 federal expenditures. Per 45 CFR ?95.1, DOM has two years (seven quarters following the occurrence of the expenditure) to make adjusting entries to claim additional expenditures. DOM Does not Concur. DOM has fully corrected finding 2021-041 on the Schedule of Prior Year Findings. This finding is based on OSA's belief that DOM should be using state tax data to determine eligibility of applicants. However, DOM does not have statutory authority to access this information. DOM utilizes all available tools, in accordance with the CMS approved state plan, to evaluate the eligibility of applicants; thus, this finding is Fully Corrected as DOM is complying with all CMS regulations and the approved state plan. Further, DOM performed training and made operational changes for all other issues noted in finding 2021-041. There are internal controls in place to limit the number of errors and annual training is conducted that includes examples of issues noted, along with preventive and corrective solutions. Human error is a part of any manual process and cannot be completely eliminated. DOM Corrective Action Plan: a. DOM made adjustments to the costs identified in this audit finding in the June 30, 2023 federal reports. In addition, a reconciliation has been added to the spreadsheets used for reporting of federal expenditures to ensure all expenditures are reported properly going forward. b. Christine Woodberry c. Completed July 24, 2023

Views of responsible officials and Corrective Action Plan: The School will implement an additional internal control to review the reimbursement meal claim to underlying support prior to submission, with evidence of review.

Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal requirements to ensure subrecipients of the Block Grants for Community Mental Health Services program and the Block Grants for Prevention and Treatment of Substance Abuse program received required single audits, and that it appropriately followed up on findings and issued management decisions. Questioned Costs: Assistance Listing # 93.958 93.958 COVID-19 93.959 93.959 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Authority concurs with the finding. The Authority will: ? Follow established procedures related to the agency-wide monitoring of subrecipients? single audits. ? Issue management decision letters for findings subrecipients received related to programs that are funded by the Authority?s pass-through federal funding. ? Evaluate corrective actions to ensure subrecipients adequately address audit recommendations. Completion Date: Estimated July 2023 Agency Contact: William Sogge, CPA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with requirements to issue management decisions for audit findings to subrecipients of the Low-Income Home Energy Assistance Program. Questioned Costs: Assistance Listing # 93.568 93.568 COVID-19 Status: Corrective action complete Corrective Action: The Department?s internal control officer is responsible for completing the monitoring of federal reporting and issuing management decisions for subrecipients who receive federal audit findings for programs funded with the Department?s federal pass-through funding. Beginning in December 2021, the internal control officer documented all findings, corrective action plans, and communication with subrecipients in a monitoring spreadsheet. This enabled the Department to ensure all efforts in monitoring subrecipients were taken. In May 2022, all management decisions were added to the monitoring spreadsheet which documented the Department?s management decisions. To ensure compliance with federal requirements for subrecipient monitoring, the Department has implemented the following process: ? Review all audit findings issued to Department subrecipients. ? Review each subrecipient?s corrective action plan. ? Review and discuss all findings and corrective action plans with subrecipients to identify and understand the basis for the deficiency and planned corrections. ? Create a management decision for each subrecipient finding, receive leadership approval, and formally communicate the decision to our subrecipient. ? All management decisions will be formally communicated to our pass-through subrecipients within the six-month federal deadline. Completion Date: September 2022 Agency Contact: Gena Allen Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

Finding: The University of Washington did not have adequate internal controls over and did not comply with federal requirements to ensure subrecipients of the Global AIDS program received required single or program-specific audits, and that it followed up on findings and issued management decisions. Questioned Costs: Assistance Listing # 93.067 93.067 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The University maintains that there are adequate internal controls to ensure the Global AIDS program complies with the requirements for pass-through entities as outlined in Uniform Guidance 2 CFR ? 200.332 and the university policy incorporated in Grants Information Memorandum 8. As noted in the finding, the University uses a certification process to obtain information and documentation needed, such as audited financial statements, from each subrecipient and perform a risk assessment using standard risk criteria. For the one exception identified by the auditors, the University misinterpreted the response provided by the subrecipient regarding whether it expended $750,000 or more in federal awards during the fiscal year. Although the single or program specific audit report was not obtained and reviewed, a risk assessment was performed on the subrecipient. With a medium risk rating, the subrecipient was subject to monitoring at the program level throughout the project during the period in question, in accordance with University policy. The University will: ? Update the certification process with all subrecipients to confirm if federal expenditures during a fiscal year exceed the $750,000 threshold to require a single or program-specific audit. ? Issue written management decisions for all applicable audit findings. ? Ensure subrecipients develop and perform acceptable corrective actions to address all audit recommendations, if applicable. Completion Date: Estimated September 2023 Agency Contact: Erick Winger Controller 4300 Roosevelt Way NE Seattle, WA 98195 (206) 543-5322 erickw@uw.edu

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding. The Chief Financial Officer in collaboration with the Finance Associate and the Financial Consultant will set a calendar at the end fof 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.

Through the assistance of the Oklahoma State Auditors and Inspectors Office, we have received appropriate instruction on how they wish the appearance of the SEF A to be. We believe this issue to be resolved and will be reported as instructed from this point forward.

The BOCC will work to design and implement internal controls to ensure accurate reporting of federal expenditures on the Schedule of Federal Awards (SEFA) and ensure compliance with federal requirements.

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.

1) Identify high risk areas 2) Reconcile accounts 3) Document process 4) Maintain once current 5) Work through list until all accounts are bring reconciled on a schedule 6) Develop month end check lists 7) Use checklists to close 8) Enhance checklists throughout the year . Responsible Party: Amy Cunningham, Carla Carvalho-Degraff. Target Completion Date: 06/30/2024