Corrective Action Plans

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged through to and was reimbursed by PHB under their CDBG Grant. Corrective Action: Since the time of this we have made some changes to have the appropriate funding code on each client’s folder/information so that it is easy to see where to charge when making a purchase and the CBP manager is reaching out to PHB on resolution to this instance.

Corrective action has already been taken. Appalachian Headwaters requests and receives detailed invoices for all employee reimbursements which include amounts, descriptions of items purchased, and delivery locations, when possible. Appalachian Headwaters pays vendors directly whenever possible.

Management disagrees with the finding. Their position is that funds are disbursed when checks are cut, regardless of when they are mailed. (As of 2023, this is no longer an issue due to changes to the program and compliance supplement)

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

None. This matter, as stated above, was properly addressed.

The Academy signed a Promissory Note with Washington Parks Academy on February 8, 2024, to return all the ESSER dollars transferred to the Academy plus interest back to Washington Parks Academy over the next 60 months.

The Academy will monitor the budget to actual numbers on a monthly basis and review with the Board. We will also put in place tighter budgetary controls. The building leaders' and all other administrators' budgets will be monitored monthly, and budget overages will be resolved immediately. The Academy will follow the currently approved deficit reduction plan and submit revisions if needed.

Management will ensure experienced staff is recruited, retained, and trained to support grant revenues, which are accurately drawn and reported to an appropriate accountant for recording.

Management has reaffirmed their commitment to following and enforcing current policies.

Management has reaffirmed their commitment to following and enforcing current policies.

Federal Award Findings and Questioned Costs Finding 2022‐002: Inaccurate Staff Timesheet Support Corrective Action: At monthly staff meetings, we will review current contracts, including terminating contracts and new contracts that are beginning. We will inform and train staff regarding the proper recordkeeping of their time allocation on their timesheets. We will also inform and train managers on more thorough oversight of staff time allocation to contracts as part of the timesheet approval process. Name of Contact Person: Heather Hays, Associate Director Proposed Completion Date: Immediately

2022-004 Cash Management Federal Program – All federal programs Criteria – Advances received on federal awards should be expended within 30 days of being drawn down to comply with relevant cash management requirements. Condition and Context – During the performance of our audit, we noted that the Organization had a significant amount of refundable advances on federal awards and had cash on hand that exceeded the anticipated expenses over the next 30 days. As a result of a conversion to a new accounting system, the impact of COVID-19, cash advances were not routinely reconciled during the year ended December 31, 2022. Questioned Costs – None. Effect – The Organization was not in compliance with the Uniform Guidance cash management requirements. Cause – With the conversion to a new accounting system, combined with the COVID-19, new accounting staff, refundable advances were not reconciled timely. Recommendation – The refundable advances of the Organization should be reconciled on a monthly basis, which will permit more accurate draws on federal awards. Views of Responsible Officials and Planned Corrective Actions Management partially agrees with this finding as, in certain instances, the Organization must comply with the payment schedules of our grantors, which typically are on a quarterly basis. In some cases, there are strict schedules of draws in our grant agreements and no requests to draw funds are made. In situations when the Organization has the ability to draw funds, we agree not to make additional draw requests until the Organization has expended the funds already received. In 2022, due to the pandemic and the uncertainty of when programs would continue, many programs were suspended while waiting for travel restrictions to be lifted so that the Organization’s programs could be implemented. We will take the following steps: We will improve procedures to ensure that the drawdown of funds, from those grantors who require drawdowns will not exceed the Organization’s immediate use and we will develop additional procedures, as necessary, to assist in monitoring cash management. Anticipated Completion Date: December 31, 2023 Contact Person: Natalia Arno, President, 202-549-2417

FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October 2022. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels. A Case Manager managed all aspects of an individual patient’s care. Once a patient’s care was complete, the case was closed by the Case Manager in the online portal. Completed cases were compiled by the Clinical Manager into a data sheet, which was then submitted to the Manager of Administration. The Manager of Administration based on the compiled data sheet prepared and submitted a reimbursement request to the State without an oversight, review, or approval process to ensure the reimbursement request was complete and accurate. Recommendation: We recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate.” Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: Option 2: “We disagree with part of the finding.” Explanation and Reason for Disagreement: The County already has an established process of review and evaluation. The Case Manager’s reports on work are reported to their superior, the Clinical Manager. The Clinical Manager reviews data, enters report data into the program portal as required. A spreadsheet with case start date, patient ID number, home address and payment is submitted to the Manager of Administration who acts as secondary review and completes the invoice and submits it to the State where an additional process of review is then executed before approval and federal funds are drawn. Once the invoice is submitted, the Manager of Administration makes two copies of the invoice and the spreadsheet, one copy is sent to the Clinical Manager and the other to the Auditors office. This is an excellent procedure for checking and balance. Description of Corrective Action Plan: The Elkhart County Health Department receives elevated blood lead levels from the State. The Lead Case Manager determines if criteria are met to initiate a case. They conduct a home visit and make appropriate referrals. The lead case manager enters case information into NBS. INDIANA STATE BOARD OF ACCOUNTS 38 Ongoing case management for children with elevated blood leads levels includes coordination of blood lead tests, education, and appropriate referrals. The Lead Case Manager submits a list of cases each month to the Clinical Manager that meet the criteria for submission for reimbursement. The criteria are a completed home visit, a completed nutrition assessment, a referral for developmental assessment and documentation in NBS. The Clinical Manager reviews the cases in NBS and compiles a list and submits the data sheet to the Fiscal Manager. The Fiscal Manager prepares the invoice and submits it along with documentation to the State and Timothy Conley for review and approval. The Elkhart County Health Department will continue to have collaborative compilation of data which will be reviewed by field specialists before being submitted to the Manager of Administration for invoice reimbursement. The data and records are reviewed by the Manager of Administration and the invoice total will be confirmed and documented with the Clinical Manager prior to being submitted to the State for review and approval. Confirmation emails of secondary review will be retained as documentation. The State must approve invoices with supporting documentation and is the external party requesting reimbursement with Federal funds once approved. A copy of supporting documentation is supplied to the Elkhart County Auditor’s Office to be retained on file and to be used for receipting records once reimbursement is received and deposited into its unique 8000 series fund. Anticipated Completion Date: August of 2023 (Note: Provide the projected date of completion of major tasks for the planned corrective actions.)

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

College will implement training for staff to ensure compliance with future federal awards

The College is reviewing processes in place with third party financial aid servicer and internal policies to implement controls over compliance

Plan of Action: Drafted new procedure that will be implemented 5/15/24 and will develop a tracking system in Microsoft Forms for the Project Director or Authorizing Officer requesting and approval funds by 6/1/24. Date of implementation: 6/1/2024

Views of Responsible Officials and Planned Corrective Actions: This unallowable expense was charged inadvertently, and corrections have been made. Astraea is in discussion with the Federal agency about appropriate adjustments to account for this and will take subsequent action per Federal agency instructions. In addition, Astraea is in current discussions with USAID to update the current agreement so that a 10% de minimis overhead cost allocation will be explicitly allowed. Further, Astraea is seeking a NICRA in FY2025. Anticipated Completion Date: June 30, 2024 Responsible Officials: Associate Director, Grants Management and Compliance; Associate Director, Partnerships

September 28, 2023 The Blackstone – Millville Regional School District respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Robert E. Brown II, CPA Certified Public Accountant 25 Cemetery Street P.O. Box 230 Mendon, Massachusetts 01756 Audit period: The finding from the June 30, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule of expenditures of federal awards. Department of Education Other Matters Related to Internal Control over Compliance of the Major Program Finding 2022-001 – Child Nutrition Cluster – AL No.’s 10.553 & 10.555; Grant period: Year Ended June 30, 2022 Criteria: The School is required to submit requests for reimbursement based on meals served during the given month. As such the school needed to keep records of the meals disbursed to the students as well as the students being served meals onsite. Condition: During our testing of the requests for reimbursement in one instance documentation could not be provided to support the meals distributed to students for the period of October 2021. Questioned Costs: None Context: The School was unable to provide meal counts for the meals distributed to Students who received meals for October 2021. Effect: No audit evidence could be provided that supported the meals that were reported on the requests for reimbursement. Cause: Tracking hand written meal counts on paper for each school. Paper copies not filed correctly and lost. Identification as a Repeat Finding: N/A Recommendation: We recommend the Blackstone – Millville Regional School District follow procedures to ensure that all meals served are properly accounted for and recorded on the request for reimbursement. Responsible for Corrective Plan: Jennifer Paradis Estimated Completion Date: August 1, 2023 Action Taken: All documentation required for the reimbursements are kept in a labeled folder in the Food Service Director’s office. These documents will also be scanned onto the Nutrition Shared drive so that the District can access them as needed.

December 27, 2022 Valley Community Services Board respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2022 The findings from the June 30, 2022, Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT If the Federal Audit Clearinghouse has questions regarding this plan, please call Devin Foster, Director of Finance, or Dereck Criner, Director of Human Resources and Interim Chief Financial Officer during the audit period, at (540) 887-3200. 2022-007: Emergency Solutions Grant Program - AL #14.231, Controls over reimbursements and program monitoring (Material Weakness) Condition: The Community Based Services Supervisor is the only person involved with submitting reimbursement requests and monitoring the budget and expenditures for the program. A separate review of reimbursement requests is not performed. The accounting department is not involved with managing the program budgets. Criteria: More than one staff person should be involved for accountability and monitoring of the program. Expenditures used to recognize revenue in accounting should correspond to expenses reimbursed or identified for federal and state award programs. Cause: With turnover in accounting staff during the year, items were not reviewed or monitored for the program. Effect: Errors in reporting or misuse of funding could potentially go undetected due to lack of separation of functions and proper oversight. Recommendation: We recommend implementing internal controls over the reimbursement requests and budget monitoring process by involving another person prior to submitting the request. Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or Assistant Director or accounting. Views of Responsible Officials and Planned Corrective Action: Effective February 2022, all requests for reimbursement under this program are submitted by the fund manager to the program's Assistant Director prior to submission to Accounting. Reimbursement filings are provided to Accounting in a timely manner and a fund reconciliation spreadsheet will be created to share with the fund manager and Assistant Director on a monthly basis. Additionally, Accounting now receives a copy of the submitted reimbursement requires and will be including a review of expenses, requests for reimbursement, and reimbursements received as part of the monthly reconciliation. 2022-008: Emergency Solutions Grant Program-AL# 14.231, Controls over cash management and reimbursement requests (Material Weakness) (Continued) Condition: Requests for reimbursement were not submitted timely, with multiple months submitted 80 days after the expenditure had incurred. Amounts recorded for revenue did not accurately reflect final requested reimbursement. Criteria: Reimbursements should be submitted timely and should be provided and reconciled to financial data in general ledger by accounting team. Differences should be resolved, and reimbursement received should ultimately reflect total program revenue in general ledger. Cause: With turnover in staff during the year, items were not always available timely. In addition, management was not always aware of reporting requirements or aware of activity under program reimbursements. Effect: Errors in reporting could ultimately lead to differences in financial accounting vs program activity. Accurate and timely reporting and requests can improve cash flows and ensure program is able to meet funding needs. Recommendation: Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or another individual in the finance department. These spreadsheets should ultimately identify amounts that were submitted for request for reimbursement and be recorded in the general ledger. Amounts recorded for revenue in the general ledger should agree between the two, with monthly or quarterly reconciliations performed to ensure financial reporting accurately reflects spending and reimbursement activity. Views of Responsible Officials and Planned Corrective Action: VCSB will amend the reconciliations process for CHERP to include a documented review and approval of all expenses, reimbursement requests, and reimbursements received. Additionally, the Accountant and Director of Finance are working with the program fund manager to submit requests for reimbursement in a more timely manner. Sincerely yours, Derek Criner Director of Human Resources

December 27, 2022 Valley Community Services Board respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2022 The findings from the June 30, 2022, Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT If the Federal Audit Clearinghouse has questions regarding this plan, please call Devin Foster, Director of Finance, or Dereck Criner, Director of Human Resources and Interim Chief Financial Officer during the audit period, at (540) 887-3200. 2022-007: Emergency Solutions Grant Program - AL #14.231, Controls over reimbursements and program monitoring (Material Weakness) Condition: The Community Based Services Supervisor is the only person involved with submitting reimbursement requests and monitoring the budget and expenditures for the program. A separate review of reimbursement requests is not performed. The accounting department is not involved with managing the program budgets. Criteria: More than one staff person should be involved for accountability and monitoring of the program. Expenditures used to recognize revenue in accounting should correspond to expenses reimbursed or identified for federal and state award programs. Cause: With turnover in accounting staff during the year, items were not reviewed or monitored for the program. Effect: Errors in reporting or misuse of funding could potentially go undetected due to lack of separation of functions and proper oversight. Recommendation: We recommend implementing internal controls over the reimbursement requests and budget monitoring process by involving another person prior to submitting the request. Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or Assistant Director or accounting. Views of Responsible Officials and Planned Corrective Action: Effective February 2022, all requests for reimbursement under this program are submitted by the fund manager to the program's Assistant Director prior to submission to Accounting. Reimbursement filings are provided to Accounting in a timely manner and a fund reconciliation spreadsheet will be created to share with the fund manager and Assistant Director on a monthly basis. Additionally, Accounting now receives a copy of the submitted reimbursement requires and will be including a review of expenses, requests for reimbursement, and reimbursements received as part of the monthly reconciliation. 2022-008: Emergency Solutions Grant Program-AL# 14.231, Controls over cash management and reimbursement requests (Material Weakness) (Continued) Condition: Requests for reimbursement were not submitted timely, with multiple months submitted 80 days after the expenditure had incurred. Amounts recorded for revenue did not accurately reflect final requested reimbursement. Criteria: Reimbursements should be submitted timely and should be provided and reconciled to financial data in general ledger by accounting team. Differences should be resolved, and reimbursement received should ultimately reflect total program revenue in general ledger. Cause: With turnover in staff during the year, items were not always available timely. In addition, management was not always aware of reporting requirements or aware of activity under program reimbursements. Effect: Errors in reporting could ultimately lead to differences in financial accounting vs program activity. Accurate and timely reporting and requests can improve cash flows and ensure program is able to meet funding needs. Recommendation: Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or another individual in the finance department. These spreadsheets should ultimately identify amounts that were submitted for request for reimbursement and be recorded in the general ledger. Amounts recorded for revenue in the general ledger should agree between the two, with monthly or quarterly reconciliations performed to ensure financial reporting accurately reflects spending and reimbursement activity. Views of Responsible Officials and Planned Corrective Action: VCSB will amend the reconciliations process for CHERP to include a documented review and approval of all expenses, reimbursement requests, and reimbursements received. Additionally, the Accountant and Director of Finance are working with the program fund manager to submit requests for reimbursement in a more timely manner. Sincerely yours, Derek Criner Director of Human Resources

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Service Grants Contract No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies regarding expense reimbursement grants and ensure support for costs submitted for reimbursement comply with 2 CFR Subpart E. Corrective Action: To ensure expense reimbursement and support of cost submitted by subrecipients comply with 2 CFR Subpart E, The Resource Group will annually verify the subrecipient’s cost allocation plan. To verify costs are allowable and allocable to the grant, The Finance Director will conduct fiscal monitoring of subrecipients. The fiscal monitoring will be conducted at least annually in accordance with all state and federal statues, regulations and terms and conditions. As a component of the monitoring, The Resource Group will verify costs submitted for reimbursement are allowable, reasonable, approved and accurately submitted. This includes verification of the cost allocation plan and underlying documentation of associated expenses. The Finance Director is responsible for oversight and administration of fiscal monitoring. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. In the event the Finance Director position is vacant more than 90 days, The Resource Group will contract with an appropriate financial contractor to conduct annual monitoring as needed. In the event of extenuating circumstances and the subrecipient is not reviewed annually, The Resource Group will determine the appropriateness of all costs under the cost allocation plan through the submission of alternate supporting documentation. This will be verified prior to the close of the grant period. Progress to date 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson; Executive Director, Tiffany Shepherd, MPH Date to be Corrected: August 2024

U.S. Department of Housing and Urban Development - COVID-19 - Emergency Solutions Grants Program (ALN 14.231) Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements and that IDIS drawdowns are performed timely and accurately. Action Taken: Grant compliance administrators will review each invoice for eligibility prior to the invoice being paid. The Grants Manager will approve the eligible activities prior to the drawdown in IDIS. This will be completed by June 30, 2024.

2022-002 Inadequate Supporting Documentation Material Weakness The Chairman of the Tongue River Valley Joint Power Board will make two copies of all invoices. One set of invoices will be retained by the Chairman and the other will be retained by the treasurer to improve the necessary documentation. This process began June 2022 and is ongoing.

Finding Number: 2022-001 – Reporting Programs: U.S. State Department. Award Listing Number 19.517 Overseas Refugee Assistance Programs for Africa: Sunrise Project, Cairo Urban Refugees VII U.S. State Department. Award Listing Number 19.517 Overseas Refugee Assistance Programs for Africa: Sunrise Project, Cairo Urban Refugees VIII U.S. Agency for International Development. Award Listing Number 98.003 Ocean Freight Reimbursement Program U.S. Agency for International Development. Award Listing Number 98.006 Foreign Assistance to American Schools and Hospitals Abroad (ASHA) - Don Bosco Sobre Ruedas (Don Bosco on Wheels) U.S. Agency for International Development. Award Listing Number 98.006 Foreign Assistance to American Schools and Hospitals Abroad (ASHA) - Walking Anew - El Salvador Planned Corrective Action: The planned correction plan is to file annual data collection forms upon the issuance of the Uniform Guidance financial statements and ensure that future data collection forms are filed timely. Person Responsible: Daniel DeFilippis, Controller Expected Completion Date: May 2024