Corrective Action Plans

Tri-County North will make sure that we follow the proper controls on wage requirements and standards to make sure that the contractor is in compliance with prevailing wage rate.

2022-001 - Deposit of Surplus Cash into a Residual Receipts Account Corrective Action Plan No later than 60 days past the end of the fiscal year, we will identify surplus cash in the project funds account and deposit into the residual receipts account. Person(s) Responsible: Greg Shinn, Agency CPA Timing for Implementation: Immediate

2021-001 ? Internal Control Finding over Reporting Auditor Description of Condition and Effect: Internal control procedures are required to ensure the reporting requirements for the Homeland Security Grant Program are being met. The County is required to submit standardized EMD reimbursement reports to report expenditures under Federal Awards. During our testing, we identified $11,884 of expenditures that were not included on the EMD reimbursement reports. As a result of this condition, the County is exposed to an increased risk of not being reimbursed for eligible expenses. Auditor Recommendation: The County should review and reconcile the EMD reimbursement reports to the County?s detailed accounting system records to ensure completeness of the reimbursement requests. Corrective Action: We agree with the finding and will implement this procedure going forward. Responsible Person: Anticipated Completion Date: September 30, 2023

FINDING 2022-004: ESSER - REPORTING CONTACT PERSON: Jessica Garnica, Business Manager CORRECTIVE ACTION: Management will ensure all necessary reports related to federal grants are filed in a timely manner and that PDE requirements are reviewed. Management has already filed the required cash on hand reports for ARP ESSER for the most recent fiscal quarter. Management is confident that the issue can be resolved immediately. PROPOSED COMPLETION DATE: Immediately

Finding Number 2022-002 SPECIAL TESTS AND PROVISIONS- INSURANCE PROCEEDS - COMPLIANCE- INTERNAL CONTROL DEFICIENCY Agency Name FEDERAL AGENCY: PUBLIC AND INDIAN HOUSING, DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 ? PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Special Tests and Provisions ? Insurance Proceeds - As stated in the April 2022 Compliance Supplement, a Public Housing Agency (PHA) is required to use insurance proceeds to promptly restore, reconstruct, and/or repair any damaged or destroyed property of a project, except when a PHA has written approval from HUD to do otherwise. Unspent insurance proceeds normally are recorded as restricted cash or restricted investments on the Financial Data Schedules (FDS) up to the amount of the repair. In cases of unforeseeable and unpreventable emergencies that include damages to the physical structure of the housing stock, PHAs are allowed to use their Operating Funds to cover the expenses associated with the damages. A PHA?s insurance may cover the damages fully or partially, however, it usually takes time for the PHA to receive the insurance proceeds. Once received, the PHA must reimburse its operating account for any expenses that were initially covered with Operating Funds up to the amount received. If the amount of the insurance proceeds is less than the cost of the repair and the PHA elected to use Operating Funds to cover the difference, the PHA is not allowed to draw down capital funds to reimburse the Low Rent program. Condition/Context The Authority received insurance proceeds to cover catastrophic loss affecting a myriad of locations. The insurance recovery was promulgated on emergency repairs and post-events, many of which were not initiated or needed due to internal fixes. During our review of the insurance proceeds compliance, we noted that the Authority did not document repair expenditures for loss affecting myriad locations and could not correlate one-to-one expenditures to the insurance proceeds in a timely manner from when the insurance proceeds were received. Recommendation We recommend that the Authority correlate one-to-one expenditures to the insurance proceeds received on a timely basis Corrective Action Plan All good faith efforts to correlate emergency expenditures from insurance proceeds will be made in order to capture vendor work on a timelier basis. Catastrophic events (resulting in insurable claims such as the Hurricane Ida related claim selected in Deloitte?s testing) are complicated as the focus is primarily on restoring critical services in many developments, usually located in all five boroughs. The proceeds thus far received were estimated via inspection and the insurance claim remains open for more permanent pricing and repair. Such a claim often takes years to finalize as work scope is prepared and agreed to by insurers? representatives and the Authority. The emergency proceeds received have been used as needed for more repairs requiring them. As identified in the audit, much of the emergency work to date on Hurricane Ida was performed internally by staff at the sites, which did not generate transparent repair expenses. Management will take action, within limitations described above, to improve the correlation of expenditures to the insurance proceeds received on a timelier basis. In order to accomplish, will rely on the Authority?s Asset & Capital Management Department to provide timely work scope to assist in the correlation of more permanent expenditures Action Date Ongoing Final Implementation Ongoing Name And Phone Number Of Person Responsible For Implementation Arlene Orenstein Director of Risk Management 212-306-6682

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review of wage rates for eight employees selected for testing. There was no formal documented review for the calculation of indirect costs submitted for reimbursement for four months selected for testing. There was no formal documented review for seven reimbursements requests selected for testing. Washburn Center has designed internal controls over these areas; however, the controls were not formally documented. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: Management will review the current active review process and implement a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: December 2023

View of Responsible Officials The State concurs in part with the premise of the findings identified, but it does not concur with the characterization of the Governor?s Office for Emergency Relief and Recovery (GOFERR), the process for authorizing the relevant subaward and relevant amendments, the nature of the subaward and amendments, or the recommended corrective action. Moreover, the full $49,250,000 identified in the finding was not provided to the subrecipient in one lump sum. The State was allocated $50,000,000 from U.S. Treasury for the purposes of designing and facilitating the State?s HAF program. The State received $5,000,000 from U.S. Treasury up front and received the remainder after approval of the State?s planned program. As a result, the State?s subrecipient received an initial subaward for administrative and planning purposes from within the initial $5,000,000 delivered to the State. The subrecipient was advanced only a portion of those initial funds and then was provided the remainder upon request and justification. A subsequent amendment to that subaward provided additional funds to the subrecipient as needed for the same purpose and as part of the U.S. Treasury required process of designing and then attaining approval for the State?s HAF program. The State ultimately received approval from U.S. Treasury for the State?s HAF program plan, which is a complex multi-faceted program that provides various forms of assistance to homeowners, and then received approval from State officials to launch the program. The State?s program is run entirely through a single subrecipient, New Hampshire Housing Finance Authority, which is the only entity of its kind as a statewide housing authority. This subrecipient facilitates a variety of larger-scale, federally funded housing programs. While developing the State?s HAF program and as it neared the launch date, the State began receiving preapplications through its subrecipient. Additionally, during this time, the State was facilitating its Emergency Rental Assistance (ERA) program, which has provided assistance to renters as opposed to homeowners and is facilitated by the same subrecipient of the State. Within the context of having received nearly 200 preapplications for the HAF program and witnessing a heavy and increasing demand in the rental assistance program, the decision was made to advance the remainder of the State?s HAF allocation ($45,000,000) to its subrecipient in order to provide prompt and adequate assistance, believing the program would experience high demand at the outset and funding shortfalls would be problematic for its success. Moreover, the amount of funds provided to the subrecipient was consistent with past advances to the same subrecipient under the ERA program, and as with prior delivery of funds, the subrecipient placed the funds in an appropriate account. However, demand for assistance did not unfold as anticipated due to the features of the program and the areas of need ultimately demonstrated by applicants after review and processing of initial applications. As part of the State?s monitoring protocols, and in part because of a lower initial expenditure rate than expected, the subrecipient began providing biweekly reports on the usage of funds, which the State has used as a measure of cash on hand. Moreover, the State also engages in standing, calendared, weekly calls with the subrecipient to discuss these reports. The State has provided documentation to support the process outlined above as well. Finally, as a result of the State?s remaining HAF allocation having already been provided to the subrecipient, the recommended corrective action is not feasible. However, the State acknowledges the need to more formally memorialize its review of the subrecipient?s cash on hand. As a result, the biweekly reports received and reviewed by the State will now include a specific section providing such information; review and discussion of that data will be incorporated into the weekly calls with the subrecipient, and the process and protocols will be documented in the State?s transaction processing memo for the program. Corrective Action Incorporation of cash on hand related data in biweekly reports received and reviewed by the State, documentation of that review as part of the weekly calls with subrecipient, and memorialization of the process and protocols in the State?s transaction processing memo for its HAF program. Anticipated Completion Date: Cash on hand data into biweekly reports and documentation of review said data as part of weekly calls with the subrecipient is being is actively being incorporated as of this response. The State will ensure that the transaction processing memo is updated with the requisite processes and protocols during the next update before the end of Q1 2023. Contact Persons: Chase Hagman, Lisa Cota-Robles, and Michele Zangri-Crean

When the project started, the National Trail Local School District was not fully aware of all needed requirements when using federal grant dollars. At that time, the information and directions had not been clearly issued by the State of Ohio and the District was learning about the uses and regulations when it came to COVID dollars. However, once we were aware we immediately made the needed changes. In the future, the District will put controls in place to address this issue to ensure we properly follow the guidelines when using federal grant dollars.

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There has been turnover in the finance department and the past employees who would have been responsible for this are no longer here. There are already internal controls in place to ensure that the monthly sponsor claims submitted match the school?s meal count reports. The Treasurer will continue to ensure that everything is correctly entered before submission. Anticipated Completion Date: March 2023

Name of auditee: Faith Housing New Hope Apartments HUD auditee identification number: 122-HD127-WPD-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2022 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition # 2022-001 Comments on Finding and Recommendation: The Corporation's required deposit of $12,057 to the residual receipts account per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Action(s) taken or planned on the finding: Management deposited $12,057 into the residual receipts fund on November 8, 2021.

Name of auditee: Silver Lake New Hope Courtyard Apartments HUD auditee identification number: 122-HD047-WPD-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2022 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition # 2022-001 Comments on Finding and Recommendation: The Corporation's required deposit of $53,828 to the residual receipts account per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Action(s) taken or planned on the finding: Management deposited $53,828 into the residual receipts fund on November 12, 2021.

Finding 2022-002:Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development Compliance Requirements: Cash Management, Eligibility, Reporting Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: This is not a "non-compliance" finding, however, management and the Board understand that internal controls and best management practices need to be strengthened. Management will review job descriptions and evaluate the number of staff needed to strengthen internal controls. Policies and procedures will be reviewed and adopted to segregate duties for best management practices in internal controls given the size of the organization we are. If the U.S. Department of Housing and Urban Development have questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Karla Shriver Managing Board Member Tri-County Senior Citizens and Housing, Inc.

March 17, 2023 Department of Health and Human Services: Martinsville Henry County Coalition for Health and Wellness respectfully submits the following corrective action plan for the year ended June 30, 2022. Independent public accounting firm: Foti, Flynn, Lowen & Co., Roanoke, VA Audit period: Year ended June 30, 2022 The findings from the year ended June 30, 2022 Schedule of Findings and Questions Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING ? MAJOR FEDERAL AWARD PROGRAMS AUDIT ? Significant Deficiency Finding No. 2022-002: Lack of review of underlying expenses supporting federal grant drawdowns/revenue. Recommendation: Martinsville Henry County Coalition for Health and Wellness should assign an employee with suitable knowledge and skill to review the underlying expenses supporting federal grants drawdowns/revenue to ensure that no expenses are supporting more than one drawdown or being double counted within the same drawdown. This employee should be someone other than the employee who prepared the drawdown. Additionally, we should provide external and on-the-job training of staff to further develop their financial accounting acumen. Action Taken: We concur with the recommendations and are in the process of implementing the recommendations.

Recommendation: : We recommend that management compute surplus cash on an annual basis and make the deposit within 90 days after year end, as required by the Regulatory Agreement. Views of responsible officials: : Management originally did not remit surplus cash within the 90-day requirement due to the Project not having a finalized calculation of surplus cash until the financial statement audit as completed. The Project remitted the funds top the residual receipt escrow account during November 2021.

Program: COVID-19 Education Stabilization Fund ALN 84.425F Higher Education Emergency Relief Fund ? Institutional Portion Compliance Requirement: Cash Management Criteria: Pursuant to 2022 Compliance Supplement ESF Section 2 III Cash Management, the College is required to disburse funds within three days of draw from G5. Condition: The College had approval from the Department of Education to transfer allowable activities to other expenditures that were applicable under the grant guidelines and replace debt forgiveness outside the period of performance. This caused cash management to become out of compliance with the three days to apply expenditures from the date of drawdown. Context: The College originally applied funds to debt forgiveness in which the parameters of the three days to apply funds did apply. The debt forgiveness was not approved by the Department of Education for items before March 13, 2020. The Department of Education gave written approval to the College to reclass invoices that were applicable under the grant guidelines. This produced the draws being over three days from drawdown for majority of the items. Cause: On September 23, 2022, the College was asked to contact the Department of Education for guidance on debt forgiveness or obtain a waiver. The College?s request for a waiver was denied on November 29, 2022. The Department of Education gave written approval to the College to apply invoices that are within the guidelines of the grant as grant expenditures instead of the original debt forgiveness. Transferring allowable activities resulted in noncompliance with the criteria of expending funds within three days of draw. Effect: The College could be asked to return funding if draws are viewed as out of compliance after the reclassification. Questioned Cost: None Repeat Finding: No Recommendation: The College needs to ensure they understand high-risk grant requirements by reviewing the compliance supplement, the Department of Education?s website and making contact with the Department on questions of concern. Views of Responsible Officials: The College requested a reclassification of expenditures for the grant year. The request was approved by the Department of Education. The College will request any clarification on items from the Department when in question to ensure they understand the requirements of the grant. No further action is required.

Recommendation: Management should do a thorough review of all contracts to ensure they are not drawing funds prior to incurring expenditures to ensure they are properly following cash management regulations for Federal contracts. Action Taken: Codman Square Health Center, Inc. (the Health Center) received a two-year $4.053 million HRSA Workforce Development grant from April 1, 2021, through March 31, 2023. The funding was provided to support staffing recruitment and retention efforts as summarized by HRSA ? ?On Thursday, April 1, 2021, HRSA awarded more than $6.1 billion in funding provided by the American Rescue Plan Act (ARPA) to 1,377 HRSA-funded health centers (activity code H8F). The purposes of the ARPA funding are to prevent, mitigate, and respond to Coronavirus disease 2019 (COVID-19) and to enhance health care services and infrastructure. Consistent with these purposes, funding may support a wide range of in-scope activities, which may change as COVID-19 circumstances and related community, patient, and organizational needs evolve over the two-year period of performance?. We began program implementation on September 6, 2021, and management drew down $1 million on November 17, 2021, to cover eligible spent monies for that period. An additional $1 million was drawn down on June 1, 2022, to cover eligible expenditures as of May 2022, in the amount of $1,176,844. It was anticipated that there was a total of $1.9 million in eligible expenses to be spent in the month of September 2022 which included items such as retention bonuses, leadership training, staff recruitment, and placement costs. These expenses were never realized prior to August 2022 draw down. The remaining HRSA ARPA funds were expended by March 31, 2023. The Health Center was consistent with adhering to the proper grant billing procedures for the first two drawdowns. The Health Center will follow HRSA Compliance requirements detailed in Compliance Requirements - Cash Management and will draw down HRSA grants on an incurred cost reimbursement basis. If the Department of Health and Human Services has questions regarding this plan, please call Sandra Cotterell at 617-822-8212.

Finding Reference Number: 2022-002 Reporting Allowable/Allocable Costs Description of Finding: During the audit testing, the auditor noted cost allocations included on submitted grant reports did not reconcile directly back to underlying supporting documentation (payroll records, etc.). Therefore, there was no accounting trail between costs reported and supporting records. Statement of Concurrence or Nonconcurrence: The Uncas Health District agrees with the audit finding. Corrective Action: Each employee that receives funding as part of a grant will note the time spent/ grant time spent on each day in the NOTES section of their timesheet. This information will be used to enter information into Quickbooks and for the required reporting. This process will be outlined in the District's Cost Allocation Plan. Name of Contact Person: Patrick R. McCormack, MPH, Director of Health, {860} 823-1189 x112, doh@uncashd.org; Laura Boudah, Office Manager, {860} 823-1189 x111, ofcmgr@uncashd.org Projected Completion Date: This change will be implemented immediately.

Views of Responsible Officials of the Auditee Management agrees with this finding and will take corrective action. Corrective Action Plan The Deputy Director or Comptroller will verify and initial the amounts before drawn via ACH by the Grants and Contracts Manager. This will ensure that funds are drawn in a timely manner and are not in excess of expenditures. Anticipated Completion Date: This policy is effective May 15, 2023 Contact Person(s): David A. England, Deputy Director Sherry Horton, Grants & Contracts Manager

Finding 2022-003: Failure to Return Residual Receipts to HUD Name of Contact: Kendrick D. Blais, President Management's view: Management agrees with the finding. Corrective Action: The Organization is working with its management company to return the residual receipts to HUD. Proposed Completion Date: June 30, 2023

Finding 2022-002: Failure to deposit Surplus Cash in the Residual Receipts accounts Name of Contact: Kendrick D. Blais, President Management's view: Management agrees with the finding. Corrective Action: Management will transfer surplus cash to the residual receipts account. Proposed Completion Date: June 30, 2023

Finding: An Administrative Review for Dierks School District was completed by the Arkansas Division of Elementary and Secondary Education, Child Nutrition Unit (DESE, CNU) in February 2022. The review noted the high school meal counts for breakfast and lunch were not consolidated and daily rosters for lunch at the elementary school were inaccurately counted on the January 2022 claim for reimbursement. This resulted in an under claim of $3,354 for breakfast and $12,494 for lunch. In addition, the review noted the District was talking lunch counts in the classroom prior to the lunch service rather than at the point of service. During our examination of the March and May 2022 claims for reimbursement, we noted the number of meals reported was overstated by 34 for breakfast and 42 for lunch resulting in a combined over claim of $280. The District will thoroughly review the data during the posting of monthly account eligibility reports and daily record forms to the monthly claim for reimbursement. Person responsible for the Corrective Action Plan: Kayla Jones Business Manager, Federal Programs Manager 870-286-2191, 227 Kayla.jones@dierksschools.org

2021-01: Approval for expenditures Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: A member of management of the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.

2019-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregated certain duties are not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.

FINDING 2022-004 COMMENT: Under Uniform Guidance requirements, the County may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity. Each individual project under this program has a specified work deadline, which may be extended at the discretion of FEMA. RESPONSE: The County has requested an extension related to the FEMA work, but as of the date of the report, the extension has not been approved. Effective June 26, 2023, Rett Daniels, Deputy County Administrator, and Sarah Sun, Budget Director, will continue to seek and obtain the proper extensions needed for the FEMA project in question.

Finding Number: 2022-001 Condition: Controls in place did not minimize the time elapsing between the transfer of funds and disbursement to a GTI Energy subrecipient. Planned Corrective Action: The one exception noted related to a disbursement made in January 2022, prior to the full implementation of the corrective action plan in May of 2022. GTI Energy management believes the prior year?s corrective action plan successfully addressed this finding, as the remainder of the transactions tested were paid within 30 calendar days. Contact person responsible for corrective action: Michael Momot, Sr. Manager, Accounting and Contract Administration Anticipated Completion Date: Fully corrected as of May 31, 2022