CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 COGNIZANT OR OVERSIGHT AGENCY U.S. Department of Health and Human Services INDEPENDENT PUBLIC ACCOUNTING FIRM Karlsson & Lane, An Accountancy Corporation 4725 First Street, Suite 226 Pleasanton, California 94566 AUDIT PERIOD - For the year ended June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs are discussed below. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT 2022-001 The Organization should implement a procedure and control to determine program participant eligibility on at least an annual or six month schedule as required by the program. Action: The Organization agrees with the finding, and will implement procedures to implement the recommendation. Conclusion: If the U.S. Department of Health and Human Services has questions regarding this plan, please contact Charlie Meade at: 3170 23rd Street San Francisco, CA 94110 (415) 625 5220 cmeade@shanti.org CORRECTIVE ACTION: Following this audit finding, Shanti?s HIV Programs performed an internal review of all clients served during FY 2021-present to identify active clients out of compliance with Ryan White eligibility. Shanti?s HIV Programs will rectify the auditor?s findings in the following ways: All clients with outstanding eligibility documents will be reached out to regarding their compliance status and HIV Programs staff will attempt to obtain proper documentation. If a client is unable to provide Ryan White eligibility documents, they may sign an attestation stating that they are a San Francisco resident and their income is at or below 500% of the Federal Poverty Level. When eligibility documentation is received, HIV Programs will update the ARIES database, the client?s chart and Shanti?s internal tracking document. Shanti will communicate status updates regarding client eligibility and will inform the appropriate parties if any clients served during the FY 22-23 contract period were not able to prove Ryan White eligibility. Previously reported UOS and UDC that remain undocumented will be restated with February 2023 reporting. POLICY & PROCEDURE CHANGES: HIV Programs? Policies and Procedures will be updated to reflect that clients who are not in compliance with Ryan White eligibility should not receive services or be billed for until documentation is provided. o The Director of HIV Programs will review a listing of all clients out of compliance monthly. o HIV Care Navigators and/or the HIV Program Coordinator will follow-up with clients out of compliance to obtain documentation. o The Director of HIV Programs will review the clients reported monthly into ARIES and sign off that all clients are eligible and documented to have received services during the month. o The Director of HIV Programs will sign off on all UOS and UDC reported monthly to finance for inclusion on the monthly invoices to the City. PROJECTED COMPLETION DATE: Shanti?s HIV Programs Department is working diligently to update Ryan White eligibility documents for all clients served during the FY 21-22 and FY 22-23 contract periods. The corrective action plan is anticipated to take until the end of the FY 22-23 contract period (2/28/23).