Corrective Action Plans

Condition: The District?s school lunch office maintains production records and manual count sheets instead of using the point of sale system for tracking student meat counts. Corrective Action Planned: Due to a staffing shortage the district is unable to run the point of sale system. We are currently advertising weekly for new staff to hire. We have a low starting salary and the turnover is very high. We are in negotiations with the union to increase the starting pay and are trying to get creative to see if there is a way to add more duties to the new employees to increase the hours of the job to make the positions more attractive. We are also in the process of purchasing a new point of sale system that will help streamline the process and won?t be as staff intensive. Anticipated Completion Date: Hiring of new staff - March 2023 New POS System - September 1, 2023 Contact: Ann-Marie Geyster

Legal Services Corporation CFDA #09-742018 Legal Services Corporation -Basic Field - General CFDA #09-742018 Legal Services Corporation - Basic Field - Native American Eligibility Significant Deficiency in Internal Control over Compliance 2022-005 Condition: One instance identified in which the Grant Compliance Checklist wasn't completed as required by DPLS policy. Additionally, one instance identified in which Form 1644 Disclosure of Case Information was not completed timely, resulting in the case information not being reported to the Corporation. Auditor's Recommendation: We recommend DPLS review policies and procedures with applicable employees and remind them of the importance of established review and monitoring processes. Management's Response: All employees have received additional training on compliance procedures and new employees will receive the same. All files being closed are now reviewed first for accuracy by the case handler of that file. The files are double checked by the office secretary for accuracy. At the end of the quarter, all files are sent to compliance for a third review. Any needed corrections are noted by compliance and the file is then sent back to the office where it originated from to be corrected. Then the corrections to the file are reported back to compliance to verify that they have been made. Responsible Individuals: Dawn Marshall, Compliance Officer, Tom Mortland, Executive Director, Annemarie Michaels, Deputy Director. Anticipated Completion Date: December 31, 2023.

Finding # 2022.002 View of Responsible Officials: The Project will request payment from the affiliate and will continue to monitor related party activity to ensure the Project does not pay reimbursements or advances to affiliates in excess of allowed expenditures or allowable distributions of surplus cash. Responsible Party: Tom Henry Estimated Completion: December 31, 2023

Finding 2022-006 Beginning June 1, 2022, grans accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023

Finding 2022-001 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023

Beginning immediately, the executive staff to include the Executive Director, HR/ Finance Coordinator and Grant and Compliance Coordinator for VFCCH, will review significant transactions monthly to ensure completeness and accuracy, including following up on outstanding grant receivables . The executive staff will also review all account balances at year-end to ensure proper cutoff and accrual-based reconciliations agree to the general ledger. The VFCCH Board Treasurer will review accounts receivables on a monthly basis and account balances at year end to ensure proper cutoff and that accrual-based reconciliations agree to the general ledger. VFCCH will engage an outside Non-Profit Management Consultant to review and prepare journal entries, reconcile all grant expenditures and complete the audit schedule as well as grant listings for the year.

Finding Number: 2022-002 Planned Corrective Action: If the district is required to return to tally sheets for the calculation of site claim forms, more stringent reviews will be put into place between the tally sheets and the entering of the site claim form data. The 2021 ? 2022 school year had special procedures in place due to the ongoing pandemic. Anticipated Completion Date: March 16, 2023 Responsible Contact Person: Mandy Hildebrand, Treasurer

Item 2022-004 -Delinquent Claim Filings. Recommendation: Filing claims report should be incorporated as part of the month-end close process. Action Planned: CFO will create Month end close schedule, ensuring claim filings are prepared monthly, as applicable. Anticipated Completion Date: June 30, 2023 Responsible Party: Ann Nelson, Chief Financial Officer

Corrective Plan Management should ensure CFDA numbers are included on all grants and file the report with the Federal Audit Clearinghouse in a timely manner.

Finding 2022-001 Personnel Responsible for Corrective Action: President/CEO ? Darlene Sowell Anticipated Completion Date: November 1, 2023 Corrective Action Plan: The Organization has modified it?s internal control procedures to include a monthly review of actual hours incurred compared to the estimated amounts by individuals assigned to federal grant projects prior to requesting reimbursement from the funding source. The review will be performed by an individual, other than the preparer of the reimbursement request, with knowledge of the federal grant program and will be formally documented.

Due to administrative errors and staff turnover, the drawdowns were incorrectly performed. We will ensure that all the drawdowns support is reviewed and approved by the department head before any drawdowns are made.

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

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 2022-002 Federal Agency Name: Department of Homeland Security & Emergency Management Program Name: Disaster Grants ? Public Assistance Federal Financial Assistance Listing # 97.036 Finding Summary: Equipment costs were claimed for reimbursement and match that used the 2019 FEMA equipment rates for combination rate vehicles instead of the applicable 2017 FEMA equipment rates for combination rate vehicles. In addition, the Cooperative submitted equipment costs for reimbursement and match that duplicated usage of certain vehicles. Responsible Individuals: Jon Wunder, Chief Financial Officer and Jay Cleveland, Accounting Manager. Corrective Action Plan: The Cooperative met the threshold for a single audit for the first time in several years. To make the process as efficient as possible, the Cooperative developed an excel template that summarizes the Cooperative?s accounting data into formats that are summarized for FEMA submission, review and audit. Once the errors were identified by the auditors, a revised claim was calculated and submitted for reimbursement. The Cooperative used this template for two FEMA submissions in 2022 and continues to refine the output measured by input from reviewers and auditors. In addition, the Cooperative will develop a written process that details the preparation and review of the excel template and submitted costs. Anticipated Completion Date: June 30, 2023

March 30, 2023, Southwestern Virginia Transit Management Company [SVTMC] respectfully submits the corrective action plan for the Year Ended June 30, 2022. Name and address of Independent Accounting Firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road, Roanoke, Virginia 24018 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. B. FINDINGS - FINANCIAL STATEMENT AUDIT 2022-001: Segregation of Duties and Management Oversight (Material Weakness) Condition: Due to staff turnover, duties handled by the Director of Finan ce included incompatible duties such as: ? Collection of cash, post receipts to general ledger, and prepare bank deposit slips Criteria : A fundamental concept of internal controls is the separation of duties. No one employee should have access to both physical assets and the related account in g records, or to all phases of a transaction. In addition, all significant transactions and controls should involve reconciliations and supervisory, or management level, reviews of those processes. An effective and timely review process is intended to prevent and detect both fraud and errors. Cause: Turnover in key positions can result in individuals performing duties that are not appropriately segregated. In addition, turnover can also create challenges in the oversight or review function. Effect: Internal controls are designed to safeguard assets and detect losses from employees dishonesty or error. Recommendation: Steps should be taken to eliminate conflicting duties and implement compensating controls, where possible. View of Responsible Officials and Corrective Action Plan: In August 2022, a new Director of Finance updated procedures to remove the aforementioned duties from the position. Currently, two Accounting Associates and the Money Room Shift Leader process bus station and accounts receivable receipts. Cash fares are counted twice weekly by a minimum of three staff members, not including the Director of Finance. With minimal exceptions, all monies received are kept in a locked safe and transported to the bank by an armored cash handling company. 2022-002: Grant Management and Operating Assistance (Material Weakness) Condit ion: During 2022, various functions related to financial management were not performed timely resulting in difficulties and delays in completion of the annual audit, including the need to prepare material adjustments to both the current year financials and a restatement to prior year balances. Criteria: Internal controls related to financial management should be designed to ensure timely reconciliations are performed, including submission of reim bursement requests and reconciling grant and local revenue. Timely and effective reconciliations ensure the financials provided for the annual audit are provided based on the agreed upon sch edule with the auditors which allows timely inclusion in the City's financial report as well as to meet federal reporting deadlines. In addition, these reconciliations will ensure that financials do not require adjustments. Cause: Turnover in financial positions, increased levels of federal and state gran ts , and implementation of a new financial software caused significant delays in performance of and reduction in effectiveness of certain financial duties. Effect: Current and prior period audit adjustments were required to prepare the financials in accordance with Generally Accepted Accounting Principles. In addition, there were significant delays in completion of the annual audit . Recommendation: We recommend that the Company establish financial management procedures to ensure th at timely reconciliations and submissions of reimbursement request s. We would recommend these procedures be performed monthly and include tracking and reconciling grant activity by type (federal, state, and local). Views of Responsible Officials and Planned Corrective Actions: During FY2022, a new Director of Finance and Accounting Supervisor were hired. They are in the process of reviewing operating procedures and have created a monthly close checklist to create consistency in the timing and manner of recording financial activities. Beginning in FY2024, staff will be assigned specific monthly close duties and monthly activity should be fully recorded by the 20th of the subsequent month. Members of the Accounting Team have been receiving financial system training on various topics from the system vendor and management is researching additional outside training opportunities. 2022-003: Bank Reconciliations (Material Weakness) Condition: Monthly bank reconciliations were not prepared by an account ant and reviewed and approved by a supervisor in a timely manner. Criteria: Monthly bank reconciliations should be performed by the 15th of the next month. Cause: Staff shortage and lack of cash flow management. Effect: Poor cash flow management resulting in vendor and cont ractor invoices not being paid timely . Recommendation: We recommend bank reconciliations be prepared by an accountant and reviewed by a supervisor to ensure unreconciled or unusual items, or other matters noted in the reconciliation, are detected and addressed in a timely manner. Views of Responsible Officials and Planned Corrective Actions: Specific Accounting Team members have been assigned responsibility for reconciling individual bank account activity. Staff will receive the required system training and delinquent reconciliations will be completed by June 30, 2023. A new monthly close checklist has been developed, and includes preparation and review of these reconciliations. Beginning in FY2024, all monthly close items should be completed by the 20th of the subsequent month. 2022-004: Virginia Public Procurement Act Prompt Payment Requirement Condition: As discussed in later findings, the Company did not pay cert ain contractors for the construction of the bus transfer station on a timely basis. Criteria: Section 2.2-4352 of the Code of Virginia requires that every agency of local government that acquires goods or services shall promptly pay for the completed delivered goods or services by the required payment date. The required payment date shall be either {i) the date on which payment is due under the terms of the contract for the provision of the goods or services or (ii) if a date is not established by contract, not more than forty-five days after goods or services are received or the invoice is rendered. Cause: Due to a lack of cash flow and grant management, insufficient funds were available to pay certain contractors timely. Effect: A contractor upon delay of receipt of payment within a reas onable timeframe contacted the City of Roanoke requesting payment. Recommendation: All vendors are to be paid in a timely manner as defined by the Code of Virginia. Views of Responsible Officials and Planned Corrective Action s: Due to technical issues, staff was unable to submit grant draw requests to the Federal Transit Authority through their Electronic Clearing House Operation [ECHO] system, significantly effecting the company's cash flow. This system access issue is now resolved and management has targeted April 30, 2023 to complete eligible drawdowns. Additionally, detailed spreadsheets tracking grant activity have been developed, which will allow staff to better monitor reimbursement requests and a specific task related to ensuring payment to the transfer station construction vendor has been added to the newly-developed monthly close list. C. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT 2022-005: Federal Transit Cluster-AL# 20.507, Cash Management- Material Noncompliance/Material Weakness in Controls over Compliance Condition: A lack of cash flow and grant management oversight resulted in contractors not being paid timely for the construction of the bus transfer station. Criteria: All grant activities should include management level oversight to ensure timeliness, accuracy, and compliance with specified grant requirements. Cause: Lack of proactive cash flow and grant management occurred when invoices received. Effect: Contractors were not paid for over 30 days after receipt of invoice. Repeated delays in payments could result in work stoppage and project delays. Recommendation: A designated management level individual should have oversight to require timely drawdowns of capital grants and timely payment of invoices. Views of Responsible Officials and Planned Corrective Actions: Due to technical issues, staff was unable to submit grant draw requests to the Federal Transit Authority through their Electronic Clearing House Operation [ECHO] system, significantly effecting the company's cash flow. This system access issue is now resolved and management has targeted April 30, 2023 to complete eligible drawdowns. Additionally, detailed spreadsheets tracking grant activity have been developed, which will allow staff to better monitor reimbursement requests and a specific task related to ensuring payment to the transfer station construction vendor has been added to the newly-developed monthly close list. Greater Roanoke Transit Company P.O. Box 13247 ? Roanoke, Virginia 24032 ? Phone: 540.982.0305 ? Fax: 540.982.2703 ? www.valleymetro.com

Finding reference number: SA2022-01 Review of Required Reports Submitted To Grantor CFDA number 20.205 CFDA Title: Highway Planning and Construction Grant Name of Federal Agency: Department of Transportation Federal Award Identification number and year: 1. STPL-6084(206) 2016 2. CMLNI-6419(027) 2017 3. BRLS-5159(017) 2016 4. BRLS-5159(018) 2016 5. BPMP-5159(022) 2016 Name of pass-through Entity: Metropolitan Transportation Commission California Department of Transportation Name(s) of the contact person: Jeff Zuba, Finance & Administrative Services Director Corrective Action Plan: The Finance team and Engineering/Public Works department will implement a new procedure for preparing and reviewing reimbursement requests. Assistant Public Works Director prepares reimbursement request and Finance Director reviews it before the reimbursement request submission. Anticipated Completion Date: April 1, 2023

Finding: No. 2022-005- Cash Management Finding: An excess cash balance tolerance is allowed if that balance is less than 1% of the institution's prior-year drawdowns and is eliminated within the next seven calendar days (34 CFR 668.166(a) and (b)). The institution must return immediately any amount of excess cash over the one-percent tolerance and any amount of excess cash remaining in its account within the seven-day tolerance period. Condition: There was one drawdown from the G5 during the year for federal direct loans in which the College was in an excess cash position starting on June 29, 2022, through September 20, 2022. The maximum daily excess cash balance during this time was $51,701. Corrective Action Taken or Planned: Management will review and follow internal control to regularly monitor disbursements and reconcile to drawdowns to ensure applicable requirements are met. Corrective action has been taken to return any amount of excess cash, as of 09/30/2022 completed by the VP of Administration and Finance, William McDonald.

2022-003 ? Assistance Listing Number 10..558 ? Child and Adult Care Program: Provider Monitoring Performance and Documentation - Contact Person: Tavaughn Thomas, Completion Date: 3/15/23. Identified Problem: Out of nine Child Care Center and Home providers tested, the first monitoring report for one provider was not completed and monitoring report for one provider was not completed, and monitoring reviews for two providers were not performed timely causing a gap between reviews to be more than six months. Action: Creation of a master calendar that shows scheduled monitoring for each center and home that is approved by the Director of the program. All staff within program are tasked with ensuring that 100% of monitoring is completed within the required timeframes Director is to report to CEO each quarter compliance with monitoring timelines.

The District will review their current needs for equipment, charges for student meals, etc. and develop a plan for the reduction of cash balances in the lunchroom fund during the current year ended August 31, 2023.

June 21, 2023 Corrective Action Plan Finding Number: 2022-001 Condition: The Organization charged costs to the grant which were associated with individuals who were subsequently discovered to have insurance. In addition, the Organization did not timely refund private pay patients for payments that were paid by HRSA funding. Planned Corrective Action: Management has allocated for staff to review and process credit balances. Additionally, Management has contracted with an outside vendor to expedite these reviews and processing of credit balances in a timely manner. Contact person responsible for corrective action: Dudley Harrington, VP of Patient Financial Services Anticipated Completion Date: 7/31/2023

2022-03: Approval for expenditures Name of contact person: J.R. Davis, Chief Executive Officer 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.

2022-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer 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.

Item 2022-005 Condition: During the process of identifying expenses and capital costs that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included capital items for which there was a lack of supporting documentation. Planned Corrective Action: Management agrees with the noted finding. However, the Hospital had also incurred sufficient unreimbursed expenses that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred eligible expenses in excess of the PRF funds received, including interest earned on such funds. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources. Contact Person: Amanda Davidson, Chief Financial Officer Anticipated Completion Date: Ongoing

Item 2022-004 Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, certain expenses that were reported in the PRF submission were not reduced by amounts reimbursed by other sources. Planned Corrective Action: Management agrees with the noted finding. However, the Hospital had also incurred sufficiency lost revenue that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred eligible expenses in excess of the PRF funds received, including interest earned on such funds. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources. Contact Person: Amanda Davidson, Chief Financial Officer Anticipated Completion Date: Ongoing

Reporting views of responsible officials and planned corrective actions Management will ensure that security deposits are tracked so they can be recorded accordingly when there is a move in and/or move out. Management is also in the process of opening a new account for this HUD entity. Moving forward management will put in place controls to ensure that the calculation is done at the end of the fiscal year.