Corrective Action Plans

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The City submitted four P&E reports during the audit period; however, the controls in place were not effective to prevent, or detect and correct, errors. As a result, errors in reporting were identified. The current period and cumulative expenditures reported consisted of the amounts expended by the beneficiaries who were awarded funds from the City, rather than total amounts expended to the beneficiaries, resulting in current period expenditures and cumulative expenditures being incorrectly reported on all four reports as follows:  Quarterly Report: October 1, 2022 to December 31, 2022 Current period expenditures were overstated by $40,350. Cumulative expenditures were understated by $262,057.  Quarterly Report: January 1, 2023 to March 31, 2023 Current period expenditures were understated by $2,338,864. Cumulative expenditures were understated by $2,499,656.  Quarterly Report: April 1, 2023 to June 30, 2023 Current period expenditures were understated by $1,200,000. Cumulative expenditures were understated by $3,699,656.  Quarterly Report: July 1, 2023 to September 30, 2023 Current period expenditures were overstated by $2,126,306. Cumulative expenditures were understated by $1,573,349. Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number and Email Address: 812-948-5333 and lmoeller@cityofnewalbany.com Views of Responsible Officials and Explanation and Reasons for Disagreement:  We concur with the finding.  However, the issue and non-compliance deals with the interpretation of the federal rules regarding the appropriate amounts to report and when to report them by subrecipients of the monies. INDIANA STATE BOARD OF ACCOUNTS 19 Office of the Controller  New Albany City Hall  142 E Main Street, Suite 314  New Albany, Indiana 47150 Telephone: 812-948-5333  www.cityofnewalbany.com City of New Albany, Indiana Linda Moeller City Controller  The non-compliance is not related to policies or controls not being effective to prevent, detect or correct errors. In fact, the reporting system initially implemented by the City and put in the federal reports provided the actual expenditures for those periods by recipients of the grants.  However, the City does agree that after full examination and review of the federal rules the initial full amount of funds provided to the subrecipients should have been reported in full versus the actual expenditures during the periods. Description of Corrective Action Plan:  Current period and cumulative expenditures reported will consist of the amounts advanced to subrecipients. Anticipated Completion Date:  The City has already made this correction in its most recent Quarterly Report April 1, 2024 to June 30, 2024.

FA 2023-001 Strengthen Controls over Special Reporting Compliance Requirement: Reporting Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 235GA324N1199 Questioned Costs: None Identified Prior Year Finding: FA 2022-001 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the monthly Claims for Reimbursement process. Corrective Action Plans: The School District has returned to collecting Free and Reduce applications and recording the student meals accordingly. Estimated Completion Date: July 1, 2024 Contact Person: Chris Johnson, Director of Financial Services Telephone: 478-994-2031 Email: chris.johnson@mcschools.org

Recommendation: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits at year-end are deposited in a timely manner. Action Taken: To enhance the controls around residual receipt deposits during year-end close-out procedures, the Organization will implement a systematic action plan to ensure that residual receipt deposits are processed in a timely manner. The organization will implement a monitoring system that tracks the status of residual receipts and flags any deposits that are approaching or have passed their deadlines. Regular progress reviews will be scheduled to ensure that all residual receipts are processed promptly and any issues are addressed swiftly. Finally, a post-year-end audit will be conducted to evaluate the effectiveness of the new procedures, identify any areas for improvement, and refine the process for the following year. This action plan will ensure that residual receipt deposits are managed efficiently and contribute to the overall accuracy of the year-end financial statements.

The finding arose due to conditions created as a result of turnover experienced by the Center within the finance department, expense reimbursement requests were inadvertently completed incorrectly using incorrect allocation percentages and information. Additional preventative internal control procedures will be implemented, including an additional level of review of the reimbursement request prior to submission.

Management response/corrective action: The Nutrition Director will involve the Support Services Administrative Assistant in the claims process to review and check for accuracy.

Pre-Disaster Mitigation PDM Program – Assistance Listing No. 97.047 Recommendation: The Village should monitor the various reporting requirements and have the proper reporting documentation on file from the subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Village will revise their control process to ensure that they are monitoring the various reporting requirements and have the proper reporting documentation on file from the subrecipient. Name(s) of the contact person(s) responsible for corrective action: Laurie Cook, Village Treasurer. Planned completion date for corrective action plan: December 31, 2024

There was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approval process for the drawing of federal funding. In addition, it is important to establish a clear process and timeline for performing draws. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement an electronic approval system, and draws will be completed within 30 days of month end. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed with the September 2024 month-end close.

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2023-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations

Effective June 1, 2023 Texas Biomed implemented enhanced controls to ensure timely entry of subrecipient invoices into the financial system and timely approvals by Principal Investigators (PIs) of invoices. While these controls were operating effectively after the implementation date, turnover within the Accounts Payable team had not been anticipated and led to delayed payment processing. In mid-2024, Texas Biomed implemented a new electronic AP/invoice system as part of a comprehensive Enterprise Resource Planning system (and associated supporting systems) conversion to enhance efficiencies and functionality. With implementation of new systems, control enhancements enabled by the systems were implemented. This included setting up subawards as Purchase Orders, which enabled automation of a previously manual process to secure PI approval of invoices. Accounts Payable staff have been trained on how to properly enter subaward invoices into the system to trigger electronic routing to the PI for approval. While these steps will streamline the approval process, a further mitigating control will be implemented, with Accounts Payable staff periodically tracking approvals of pending subrecipient invoices and notifying the appropriate Sponsored Program Administrator for follow up with PIs in the event of delayed approvals. Responsible Parties: Eva Zepeda, Director, Finance; Michelle Hyde, Controller Completion Date: September 30, 2024

Finding 2022-05 Misallocation of Grant Funds Condition: The Organization claimed purchases under a reimbursement-based federal grant but then used these supplies for a different grant. This improper use of grant-funded supplies is a violation of the grant’s terms and conditions. Corrective Actions Taken or Planned: The Organizations’ Board and Executive Team consisting of the Chief Executive Officer (CEO) and the Chief Operating Officer (COO) and key Overdose Lifeline (ODL) Staff to include the independent bookkeeper and Grant and Finance Manager recognize the need to further significantly improve on the oversight and reconciliation of supply ordering and inventory. This is already underway with the QB inventory process described previously and an improved process for backup documentation. Additionally key staff will complete of a formal course that covers performing a single audit and engage in consultation with the Independent Public Accounting Firm (Pile CPAs)

2023-002 – ALN #14.218 Community Development Block Grant/Entitlements Grant; Recommendation: We recommend that the City return the duplicate drawn funds to HUD. We recommend all drawdown requests are completed by appropriately trained employees and that all drawdowns are reviewed and approved by an appropriately personnel prior to submission to HUD. Corrective Action Planned: The City agrees with this finding. The City will work with HUD to repay the duplicated funds and implement additional review and approval procedures for drawdown requests. Person responsible for corrective action: Brandon Phillips, Finance Director Telephone: (256) 549-4715 Anticipated Completion Date: Corrective action will be implemented for the fiscal year ended September 30, 2024.

Federal Agency Name: Department of Homeland Security Program Name: Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Finding Summary: The Cooperative utilized a fringe benefit spreadsheet provided by FEMA where the information was not calculated correctly. Responsible Individuals: Jeff Birkeland, CEO Corrective Action Plan: The spreadsheet we received from FEMA was protected and we could not verify formulas or make changes. We assumed the spreadsheet to work correctly. Through the audit, however, we found that there is an error in a formula(s) having to do with overheads. We will ensure we are using the most up-to-date spreadsheet for fringe benefits on FEMA projects going forward. Anticipated Completion Date: This has been resolved and Steph went back through and updated the spreadsheets accordingly in August 2024

Action Planned/taken in response to the finding: Kewaunee County agrees with the finding. An assessment of all grants, requirements, and related policy and procedures is in progress and will continue to: • Evaluate existing policy and procedures for needed revisions • Document revisions to policy and procedures as necessary • Communicate any new policies to employees responsible for awards • Identify awards covered by the Uniform Guidance • Set and document a schedule for periodic review and revision Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the Uniform Guidance. Progress continues into 2024. The Finance Director will continue to coordinate and provide assistance and guidance to departments receiving grants subject to the Uniform Guidance. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh Planned completion date for corrective action: December 31, 2024

Finding Number: 2023-003 Planned Corrective Action: The accounts payable clerk will double check all claims submitted to the state for accuracy. Anticipated Completion Date: 08/30/2024 Responsible Contact Person: Stacy Bolden

2023-003 TANF Voucher Controls The Administration of HONOR acknowledges the finding identified in our 2023 Financial Audit concerning the inadequacies regarding ''TANF Voucher Controls". The following response outlines the steps the HONOR Administration, Management and Direct Support Team will take to address these issues and prevent recurrence. Corrective Actions Taken: -Create a Policy and Procedure by 9/30/2024. HONOR has identified verification forms and processes to ensure accurate data is recorded. -Staff Training: A comprehensive training program has been initiated for all relevant staff, focusing on verifications forms, admissions/discharges, and bed nights. Training requirements will ensure these policies are covered and understood. Staff will receive in-depth training on nightly bed sheets and data entry of client attendance in the EMR system, (NETSMART), to generate an accurate attendance roster. This in-service will take place by 10/15/2024. - Revamping Verification Procedures: HONOR has designated a position, Administrative Response Coordinator, to be responsible for verifying the nightly bed sheets and roster at the end of the month. Any discrepancies are reported to the Case Management Supervisor for verification. If changes are to be made, documentation will be made on the bed sheets and data entry will be corrected in NETSMART and roster reprinted. - HONOR will re-engage, when determined and or required, with designated team members of the Orange County Department of Social Services. Any possible disputes and or concerns regarding possible inaccuracies with TANF vouchers will be reviewed and documented by the Shelter Manager. -Periodic Reviews. The Quality Assurance/Compliance Mgr will conduct a regularly scheduled review process to monitor documentation, ensuring ongoing compliance and addressing any issues proactively. Monitoring and Follow-up: -To ensure the effectiveness of the corrective actions, HONOR administrative team will be conducting a quarterly review of internal audits, trends and data. HONOR's Executive Director along with the Administration and Management teams take this audit seriously and are committed to strengthening our internal controls to prevent future incidents. The steps outlined above will help us maintain compliance and ensure the proper use of resources. HONOR thanks RBT for their due diligence and bringing these matters to our attention.

Boston Public Schools (BPS) Food and Nutrition Services (FNS) has implemented advanced policies including additional segregation of duties to ensure that all deposits made have clear and accurate cash receipt forms. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) Food and Nutrition Services (FNS) has implemented various procedures in order to accurately report meal counts and claims.  Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Management will ensure experienced staff is recruited, retained, and trained to support grant revenues. This includes recording the grants correctly in the G/L and also pulling the correct draws from the State website accurately and timely.

Management agrees that due to turnover in staff during 2022 and 2023, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 8/1/24 Staff: Don Reynolds, contracted CFO

FINDING 2023-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Kosciusko County Sheriff's Office applied for the Indiana Local Body Camera Grant (ILBC). The sheriff’s office was awarded this grant on January 1, 2023, with a grant cost amount of up to $31,920. This grant is a reimbursable grant through the Indiana Department of Homeland Security. The period of performance was from January 1, 2023, to December 31, 2023. The Kosciusko County Sheriff's Office ordered body-worn cameras and equipment on April 26, 2023. The invoice for the cameras and the camera equipment was paid on July 14, 2023. The Kosciusko County Sheriff's Office then submitted a Reimbursement Claim Form on September 11, 2023. The Reimbursement Claim Form shows the Sheriff's Office incorrectly requested the full $31,920. They received $31,920 from the Indiana Department of Homeland Security on September 27, 2023. However, the county had only spent $9,581 of the grant money towards the body camera purchase. Therefore, there is a remaining balance in the fund of $22,339 as of December 31, 2023. Due to the period of performance, the county should have reimbursed the Indiana Department of Homeland Security $22,339. On May 9, 2023, the Sheriff's Office grant administrator submitted a Program Report for the ILBC grant. This report was filed without an implemented internal control or evidence of a review. The report was completed and submitted by the Sheriff's Office grant administrator. The report incorrectly indicated that all expenditures had been completed. As of the date of the submission, the county had not purchased the bodyworn cameras and all federal funds had not been expended. Contact Person Responsible for Corrective Action: Alyssa Schmucker Contact Phone Number and Email Address: 574-372-2325 aschmucker@kosciusko.in.gov View of Responsible Officials: We concur with the findings identified. Description of Corrective Action Plan: The Kosciusko Sheriff’s Office, grant coordinator will contact IDHS for instruction on how to return the $22,339.00 and prepare a claim to be processed by the Kosciusko County Auditor’s office. The grant balances are submitted each month by departments these are checked and confirmed by the Auditor’s Office this one was overlooked in the review process. The person who applied for the grant no longer works for the county. It is believed the new person handling the grants was not aware that this grant even existed. The Grant Administrator(s) will have someone sign off on the grant report submissions and forward all reports to the Auditor’s Office. Anticipated Completion Date: It is anticipated that this will be completed as soon as the information to return the funds is received from the state and the claim is submitted to the Auditor for payment. This claim will be paid as soon as it is received. On or before 12/31/2024.

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended March 31, 2023. Finding 2023-001 Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements A/B - Activities Allowed or Unallowed and Allowable Costs/Cost Principles, C – Cash Management, E – Eligibility, L – Reporting, and N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management reported that the failure(s) involved records related to the period managed by the predecessor management company. We will request and keep all required documentation from HUD and establish processes and procedures to ensure compliance with the Regulatory Agreement. Anticipated Completion Date September 30, 2024

View of Responsible Officials: Based on the perspectives provided by management and officials, the finance department has initiated specific corrective measures to ensure strict adherence to reporting PRF and centralization of documentation. As our organization expands, we will evaluate our documentation processes to create clear standard operating procedures (SOPs). We have employed a grants analyst who will define distinct responsibilities for grants reporting, establish a central repository, and reconcile both FTE and non-FTE expenditures and receipts, including cash receipts, drawdowns and invoice allocation. Project codes will be crucial in driving this process within our financial system, Blackbaud. Management will report on progress of these actions to the Finance Committee of the Board of Directors at its monthly meetings.

Finding 2023-001: Allowable costs – significant deficiency in internal controls over compliance and compliance finding. Management Response CCGD was issued monitoring findings by HHSC for the monitoring period October 2021 (FY 21) -November 2022 (FY 22) in April 2023. As a result of that finding, CCGD received a finding in its 2022 audit. Because of the timing of the findings, as noted in the 2023 audit report, there was not time to resolve the issue before 2023. Therefore, even though the below described plan was implemented in 2023, immediately upon receipt of the initial finding, CCGD was still issued a finding in its FY2023 audit. The notification was received in the 7th month of fiscal year 2023, the following plan has been implemented. o Timesheet and GL mismatch i. Management Response: 1. Perform an audit of existing setup of HRIS-Paycom system to determinecause of mismatch 2. If needed, reimplement Paycom with required setup or change vendors 3. All departments along with respective service categories werereestablished in Paycom to only display employees applicable servicecategories based their respective grants. 4. Conduct quarterly audits of timesheets and GL to ensure there are nomismatches. 5. Time study was performed on quarterly basis to ensure individualperformance complies with funders mandate. ii. Progress Update - GL and Timesheet Mismatch: 1. Audit of existing setup to review the following: a. Department(s) - revised department names/descriptions i. Made changes to all applicable employees’ setup. b. Home Allocation(s) – revised home allocation(s)i. Revised/edited the default home allocation description ii. Assigned correct default home allocation to employees c. Service Categories i. Revised/edited service categories assigned to each department 2. Observations: a. Following Paycom updates, CCGD experienced technical challenges due to software glitches which continued to result in timesheet and GL mismatches. CCGD is continuing to work with Paycom to identify and eliminate the problem. b. CCGD subsequently sought assistance from Paycom in the troubleshooting process. 3. Departmental training of timekeeping process a. Personalized standard operating procedures used b. Real-time examples/instruction provided to staff in training session(s) 4. Post-training audits conducted to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheetsiii. Future Steps and Anticipated Timeline: 1. Continuation of post-training audits to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheets 2. With an anticipated deadline completion date of December 31, 2023, for adherence of full compliance, CCGD effectively implemented system updates prior to this deadline to ensure payroll processing is now based on the actual time and effort performed. iv. Progress Update – Performance Activity Report 1. To provide further back up to time and effort, an additional option in Paycom was enabled for staff to enter notes on day-to-day activity. 2. Departmental training on this goal was performed and completed as of March 31, 2024. 3. Continuation of post-training audits to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheets v. Post implementation plan and observation: CCGD is fully committed to complying with funders and audit standards. Furthermore, CCGD will continue to monitor and identify any potential errors in its payroll reporting to bring a timely solution if required. Furthermore, minor reporting errors occur in payroll GL reports on a random basis. The errors appear to be technical, and as such, we are currently working with Paycom to resolve this issue. Additionally, CCGD will continue to perform time study to ensure that all salary expenses and allocations are adhered to the respective program budget. Parties Responsible: Chief Executive Officer, Chief Financial Officer, and Director - Human Resources

Finding 2023-001: Condition and Context: For the year ended September 30, 2023, we reviewed the current period grant expenditures and found the HUD monthly monitoring reports to be incomplete. In addition, several material grant expenditures were not submitted for reimbursement within 120 days following the date of expenditure. Corrective action planned: Management of the City will implement additional control activities over the review of draw requests and monthly reports by reconciling them to the detail grant expenditures contained in the City’s financial accounting system. Contact person: Cheryl Zeto, Finance Director (409) 883-1041 Anticipated completion date: August 2024

The HIDTA Financial Manager, in conjunction with the City's Finance Assistant, will request smaller dollar amounts with new advances in order to liquidate the prescribed HIDTA guideline of 21 days.