Corrective Action Plans

The Finance and Business Department, with the Chief Information Officer, will need more training for procedures for cash drawdowns and expenditure's reconciliation per records and accounts on a timely basis.

Corrective Action Plan – The current Finance Director and Housing Director have implemented an updated system that tracks, collects, and assembles the proper documentation for the monthly grant expenditure reports during the last week of the month to ensure timely submissions to the grantor. Even though Athens Land Trust is a small organization with less than 25 employees, several staff members are being cross trained on the reporting process to ensure reporting is not disrupted by any potential future staffing changes. The updated system is reviewed periodically at biweekly director meetings to ensure oversight by the Executive Director.

As part of the on-boarding process with the virtual accountant, Cleveland UMADAOP will document its financial procedures to ensure consistent execution of financial activities.

ACCOUNTING FOR GRANTS - MATERIAL WEAKNESS Condition The grants accounts receivable account was not reconciled at year end to properly reflect grant activity. It was noted that grant funds drawn down from the G5 system in April, May, and June 2023 were not recorded in the general ledger. When the College made a journal entry to correct the missing deposits, a clearing account was used not the grants accounts receivable account where the entry should have been posted. Cause The College did not have a written year end closing process for grants or cash accounts. The lack of written procedures, the turnover within the grant accounting staff, and lack of proper oversight from management did not allow grants to be properly accounted for. Recommendation Proper accounting for grants is an integral function for the College. The timely and accurate reporting of expenses and the related cash receipts allows for proper grant management of available funds to be expended in the period of availability. The College should review the responsibilities of the staff within the accounting department to ensure that an individual is dedicated to maintaining accurate grant reconciliations and in contact with the various grant managers. The College also should ensure proper oversight is in place to oversee the grant reporting process. Management Response We agree with the auditor's comments. The College is reviewing standard operating procedures for all grant activity. Guidelines for ensuring proper accounting of grant funding, drawdowns, reconciliation, and entry into the general ledger are being reviewed. Procedures and training will be implemented by the end of the FY 2025.

Federal Program COVID-19 Education Stabilization Fund (ALN 84.425 C, F, & M) and Student Financial Assistance Cluster (ALN 84.033, 84.063, and 84.268) Condition The College did not locate evidence that the lost revenue calculation was performed before drawdown was completed in the G5 system. Evidence of approval to drawdown funds form the G5 system was also not located by management. Cause Turnover within the accounting office and lack of proper oversight from management led to the lack of evidence to support the timing of drawdowns reported to be located and provided to the auditor. Recommendation The College should revisit its internal control procedures to ensure that direct and material compliance requirement are being followed and controls are implemented to ensure the processes are followed and assign accountability for completion. The procedures should be documented to allow new employees an understanding of the grant requirements and how they are fulfilled. Management Response We agree with the auditor's comments. The College is actively recruiting to fill critical vacancies. Procedures for documenting approvals and drawdowns in the G5 system are currently being reviewed. Documentation of procedures for drawdowns and monthly cash reconciliation will be implemented by the end of FY 2025.

Management will undertake the following corrective actions to address the material weakness identified: 1. Provide additional training to staff involved in payroll processing. 2. Establish procedures and implement more precise controls to ensure that expenditures are properly reviewed and approved before being charged to a federal award.

Finding 2023 – 001: Restatement to Fund Balance Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct the recording of GASB 87. Plan: The Village Finance Director will implement internal controls to review all GASB 87 Agreements and record accordingly prior to audit fieldwork. Anticipated Date of Completion: December 31, 2024

The corrective action to be taken will be to created formal policies and procedures to ensure there is a second person involved in the reporting process. Expected Completion Date: December 31, 2024. Contact Person: Nicole McGee, Finance Director

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County design controls to ensure the accounting records reconcile to the reimbursement request and documentation be retained. Reconciliations should be reviewed and approved by an individual other than the preparer at the time of the request and this documentation should be retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements. Community Resources staff have been trained on keeping proper detailed records of all cash draws. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

SIGNIFICANT DEFICIENCY 2023-002 Deposit of surplus cash to residual receipts more than 90 days Recommendation: Management should continue to evaluate their internal policies and procedures to ensure surplus cash is deposited within 90 days of year-end. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management adopt policies of earlier deposit or switch to electronic methods. Name of the contact person responsible for corrective action: Nicole Chwala, CEO Planned completion date for corrective action plan: December 2024

Airport Improvement Program – Assistance Listing No. 20.106 Recommendation: We recommend the City designate a responsible and qualified grant manager and establish internal controls for matching requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City is in the process of establishing interal controls for reporting and will review and file all future required reports in a timely and accurate manner. Name(s) of the contact person(s) responsible for corrective action: Melody Sauerhafer Planned completion date for corrective action plan: 09/30/2024

FINDING 2023-003: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will immediately transfer the delinquent surplus cash to the residual receipts reserve account and implement robust internal controls to ensure all future deposits are made promptly and in compliance with the Regulatory Agreement. Action Taken: Management has transferred the overdue amount to the residual receipts reserve account and implemented enhanced internal controls to prevent future non-compliance.

FINDING 2023-002: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement internal controls to ensure timely monthly contributions to the replacement reserve and will address the shortfall by making up the missed deposits in the subsequent period alongside the normal required contributions. Action Taken: The Organization will make the necessary required deposits to bring the balance of the reserve for replacement in alignment with requirements of Section 811 Capital Advance Program Regulatory Agreement.

Consolidated Health Centers Grant — Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has reviewed all of our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a drawdown can be requested in the payment management system

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2023, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Public Health (ADPH) passed through a portion of the Immunization Cooperative Agreement federal award to subrecipients. During our audit, the ADPH’s Office of Program Integrity (OPI) notified us that based on its investigation a subrecipient was not submitting adequate supporting documentation for reimbursement requests. A total of thirteen subrecipients requested and received reimbursement of program expenses during the fiscal year. Based upon procedures performed, we noted that of the 13 subrecipients who received federal award reimbursements, six did not provide adequate detailed documentation to support their requests for reimbursement. In addition, forty-eight of the sixty-three invoices submitted for reimbursement by the subrecipients did not have adequate documentation resulting in questioned costs of $8,478,032.39 and one of the invoices included an improper payment of $2,600.00 for a total question cost of $8,480,632.39. The ADPH did not have adequate policies and procedures in place to ensure that all requests for reimbursement were supported by adequate detailed documentation to ensure all coast are allowed under the federal award. This is a material weakness in internal controls. Recommendation: The Alabama Department of Public Health should take action to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and to ensure costs are allowable under the federal award. Response/Views: We agree with the Examiners' finding; adequate documentation did not exist at the time of the audit to substantiate payments that resulted in questioned costs and improper payments. However, we do not concur with the total amount of the questioned costs cited in the report. ADPH's Office of Program Integrity initiated its own ongoing investigation. As this process continues, we are requesting additional documentation from the subrecipients, which will affect the questioned costs of this program. Corrective Action Planned: As noted, ADPH's Office of Program Integrity (OPI) has initiated its own internal on-going investigation. As part of that investigation, the Federal Grantor was notified of the situation and OPI is requesting supporting documentation from the sub grantees. ADPH is strengthening the internal control system for grants management. ADPH has and will continue to develop internal grant training for all employees who handle any phase of grant activities or have managerial responsibility for a grant. ADPH is working to make this training mandatory. In addition, the Centers for Disease Control has grant training available which will be utilized. The Bureau of Financial Services is establishing a Grants Management Office and has distributed grant tools such as a standard Risk Assessment Form for grant program use. Corrective action within the Immunization Division will include hiring additional staff to support the grant review and monitoring process. Immunization will implement the following procedures: • Grant guidance will be reviewed semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation for source documents will be reviewed against grant guidance as received by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied. • Grant monitoring staff will ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • Invoices or vague requests requiring additional documentation will be held until the necessary information is provided. • Ensure all program grant staff have access to and attend all available Finance and Grant training courses. • Engage assigned Grant Accountant quarterly or as needed. • Conduct a Risk Assessment on all new subrecipients within 30 days of a signed grant agreement which will be forwarded to OPI for review. • Immunization staff will conduct a Risk Assessment on all current subrecipients within 60 days which will be forwarded to OPI for review. • Immunization staff, along with Finance and OPI, will develop a subrecipient monitoring plan based on the Risk Assessment of each subrecipient. The monitoring plan will be completed within 30 days of the receipt of the completed Risk Assessment. • Copies of all completed monitoring activities, as outlined in the monitoring plan, will be forwarded to OPI. Anticipated Completion Date: April 1, 2025 Contact Person(s): Immunization: Denise Strickland, Immunization Division Director; Daniels, Immunization Operations Manager; Harrison Wallace, Director, Bureau of Communicable Disease; Bureau of Financial Services: Shaundra B. Morris, Chief Accountant; Office of Program Integrity: Debra S. Thrash, Director

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2023, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Transportation (the “Department”) passed through a portion of the Formula Grants for Rural Areas and Tribal Transit Program federal award to subrecipients. One of the subrecipients requested and received reimbursement of program expenses. Subsequent to the payments of the invoices, the Department received information alleging that falsified or altered documents related to expenditures submitted by a subrecipient. Upon receipt of these allegations, the Department initiated a review of the supporting documents which had been submitted by the subrecipient. The review consisted of obtaining documents from vendors and comparing those documents to the ones submitted by the subrecipient. The results of this comparison indicated that the amounts owed and the description of goods and services provided columns had been changed. Nine of ten supporting documents for meeting expenses submitted for reimbursement by the subrecipient during the audit period were altered and were not true and accurate. These altered supporting documents totaled $94,123.56. The Alabama Department of Transportation reimbursed the subrecipient based on the altered documents and, therefore, improperly expended Formula Grants for Rural Areas and Tribal Transit Program federal award funds. Recommendation: The Alabama Department of Transportation should take actions to ensure that all reimbursements of expenses are adequately documented, based on true and accurate supporting documentation, and to ensure costs are allowable under the federal award. Response/Views: We agree that there appears to have been falsified supporting documentation submitted by a subrecipient. Corrective Action Planned: Once we were made aware of the allegation, we began a thorough review of the subrecipient’s invoices. Based on the information discovered during our review, we notified the Federal Transit Administration, Alabama Attorney General’s Office, Alabama Ethics Commission, and the Alabama Department of Examiners of Public Accounts. The Office of Inspector General for the U.S. Department of Transportation is currently investigating the case. The subrecipient involved in this matter is no longer associated with our Transit Program. The duties that they performed were either moved to another subrecipient or in-house. We have modified our invoice review process, and the changes have been applied to all subrecipients for the Transit Program. Anticipated Completion Date: We have taken the steps outlined above as of August 28, 2024. Contact Person(s): Jeff Hornsby, Chief Financial Officer

Federal Agency: U.S. Department of Transportation Program/Cluster: Metropolitan Planning and Research Federal Assistance Listing Number: 20.505 Pass‐through: California Department of Transportation Award No. and Year: 74A0821, 2022/2023 Compliance Requirement: Reporting Type of Finding: Significant Deficiency over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Delay in Caltrans approving the first quarter request for reimbursement and progress reports until January 24, 2023, as well as additional staff time needed to prepare the narrative information, resulted in the submittal of the second quarter reports nine days after the due date of January 30, 2023. Caltrans District 2 staff were notified early that there would be a delay in the reporting and indicated this was acceptable. This is an extraordinary occurrence, as it is SRTA’s common practice to submit all required reports before the deadline. Corrective Action Plan: The Agency will send a memorandum to all staff to ensure timely reporting of required quarterly reports in accordance with the agency’s established policies and procedures and compliance with the Master Fund Transfer Agreement that is active at the time of submittal. The Agency will also create reminders on the shared agency calendar that will be set to automatically alert the executive director, CFO, OWP manager, and relevant staff, of the deadline to submit the quarterly narratives to further eliminate the risk of late reporting. Responsible Individual(s): Sean Tiedgen, Executive Director and Jessica Carlson, Chief Fiscal Officer Anticipated Completion Date: June 30, 2024

West Community Development Corporation (dba BuCu West Development Center) is revising its financial procedures to ensure all federal grant transactions are recorded on an accrual basis. We are working closely with our financial team and external consultants to realign our reporting practices by the next fiscal year. This includes enhanced staff training and system upgrades to support accrual-based tracking and reporting.

Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Shelby Mahoney, State Alliances Accounting Manager Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

Views of Responsible Officials and Planned Corrective Action: Management acknowledges the terminations. The Board of Directors of the Neighbor Network of Northern Nevada determined not to seek an appeal of the Department’s decision. No corrective action was requested, required, or deemed necessary.

2023-005. Match Source Documentation United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: Source documentation was not maintained to support costs applied to the match. Recommendation: The Organization should maintain an accounting for all funds expended attributed to meeting the match requirement, as well as the source documentation. Corrective Action: The Organization will implement procedures to ensure accounting for funds expended, as well as source documentation, is maintained for costs attributed to meeting the match requirement. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

2023-003. Written Intake Procedures United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: The Organization was unable to provide written policies and procedures with respect to intake and the calculation of rent. Recommendation: The Organization should complete the written policies and procedures to comply with the written intake documentation and rent calculation. Corrective Action: The Organization will maintain the written intake policies and procedures, as well as rent calculations. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

Views of Responsible Officials and Action Taken: FCE implemented new internal controls in the fourth quarter of 2023 and has continued to document all draw down requests, review thereof, and approvals.

Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal control process to verify all requisition slips get signed. Anticipated Completion Date Fiscal Year 2024