Corrective Action Plans

Action taken in response to finding: The new CFO reviews and approves federal grant draw requests prior to the submission to the granting agency. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: August 31, 2024

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are incurred, charged appropriately and supporting documentation is maintained on file. Additionally, AP and Finance team review supporting documentation and ensure completeness. Name(s) of the contact person(s) responsible for corrective action: Floral Reed Planned completion date for corrective action plan: June 30, 2024

Action taken in response to finding: The new CFO reviews and approves federal grant draw requests prior to the submission to the granting agency. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: August 31, 2024

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will reconcile federal programs to the passthrough agencies 9 months into the fiscal year at a minimum as part of the preparation of the SEFA report.

To address these issues - UPCEE has hired a new Contract Manager (that comes highly recommended and has worked successfully with other TRIO programs) who will continue to do the following: • Oversee office management processes, budgets, and enhance our current way of working with federal timelines. • Ensure billings are kept timely and entered in the financial system for QuickBooks Online and now updates data entry after each completed month. These changes allow for the immediate completion and availability of data to be used for 990 completion and audit processing. • Work in tandem with the UPCEE Executive Director to ensure these tasks are done. With the implementation of these new processes, UPCEE feels very confident that this will prevent any further need for risk management.

The County has assigned a specific individual for grant and contract maintenance.

Tenant security deposit bank account. Contact person - Executive Director. Corrective action planned - The Project will maintain a tenant security deposit bank account in accordance with the regulatory agreement. Anticipated completion date - Within the next fiscal year.

FINDING #2023-002 RESERVE FOR REPLACEMENT Condition: The Reserve for Replacement account balance for Park Ridge Apartments, Phase 4 underfunded in the amount of $750. Recommendation: The management agent should ensure that all required deposits are made to the Reserve for Replacement account and that the balance in that account meets the minimum required balance in accordance with the regulatory agreement between the Entity and HUD. View of Responsible Officials and Planned Corrective Action: The management agent agrees with the finding and the auditor’s recommendations have been adopted.

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2023 through December 31, 2023 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of January through June 2023, resulting in $261,999 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization met with subrecipients prior to December 31, 2023 to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2023 as of February 2024.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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