Corrective Action Plans

TINDLEY ACTION PLAN 1. Develop and implement Procurement Policy (completed and on-going by CFO/Accounting Manager/Accountant/Grants Manager/Network President/Department Heads) a. Enhance written procedures for procurement and accounts payable. i. Purchases between $15,000-$25,000 will require two quotes for all new vendors; purchases between $25,000-$75,000 will require three quotes for all vendors; and purchases over $75,000 will require a competitive bid process for all vendors. ii. Establish a Master Vendor list. 1. Master Vendors may be used for up to $20,000 for regular services and products in the normal course of business with dual approval by the Network President and CFO. b. Require vendor bids/quotes for services. c. Segregate purchasing duties. 2. Research new vendors prior to utilization (implemented and ongoing by CFO/Accountant) a. Are these vendors commonly known in the industry or the community? b. Does the vendor have a valid website, phone number, address and email address? 3. Conduct Periodic/Continuous Fraud-Detection Monitoring (CFO – at every fiscal year end) a. Annually identify (1) Tindley’s top 20 vendors, (2) all Tindley vendors receiving annual payments totaling more than $10,000, and (3) any new vendors receiving annual payments totaling more than $5,000. i. Ensure there are valid and updated contracts for these vendors. ii. Ensure the description for services on the corresponding. invoices are detailed and complete. iii. Assess multiple corresponding invoices that have the same total amounts. 4. Refine and codify job descriptions/job duties for Network President, CFO, Grants & Compliance Manager, and Director of Development (HR/Board to be completed by 9/30/24) a. Keep these job descriptions in a database to ensure a smooth transition in the event of a departure or retirement. b. The job descriptions should highlight the financial compliance aspects of each position. 5. Change reporting structure for CFO (to be implemented by HR/Board 9/30/24) a. CFO will report directly to the Board with a dotted line to the Network President. 6. Provide anti-fraud training for Network President, CFO, Director of Development, Grants & Compliance Manager, and in-house accounting professionals (to be implemented by Network President/CFO and completed by 11/30/24) 7. Establish a Whistleblower/Ethics hotline to report suspected fraud (to be implemented by HR 9/30/24) a. Ensure employees understand that it is available to report suspected fraud. b. Develop procedures for responding to whistleblower allegations. PROCUREMENT POLICIES AND PROCEDURES I. INTRODUCTION AND PURPOSE Tindley should adhere to strict ethical and legal standards to prevent fraud and ensure accountability. This procurement policy should be cross-referenced with current local, state, and federal laws. II. CODE OF CONDUCT A. Conflict of Interest Tindley purchasers shall not participate in the selection, award, or administration of a contract if they have a real or apparent conflict of interest. Such a conflict arises when the Tindley purchaser; any immediate family member (spouse, child, parent, parent in law, sibling, or sibling in law); partner; or an organization that employs, or is about to employ, any of the above has a direct or indirect financial or other interest in, or will receive a tangible personal benefit from, a firm or individual considered for the contract award. An “organizational conflict of interest” is created because of a relationship that a Tindley employee has with a parent, affiliate, or subsidiary organization that is involved in the transaction such that the Tindley employee is or appears to be unable to be impartial in conducting a procurement action involving the related organization. B. Gifts, Money, Gratuities Tindley employees involved in the purchasing process shall not solicit or accept gifts, money, gratuities, favors, or anything of monetary value, except unsolicited items or services of nominal value from vendors, prospective vendors, parties to subcontracts, or any other person or entity that receives, or may receive compensation for providing goods or performing services to Tindley. All Tindley purchasers shall review and comply with Tindley’s procedures for disclosing, reviewing, and addressing actual and potential conflicts of interest. III. PROCUREMENT PROCEDURES A. Procurement Procedure See chart at the end of document B. Bid Procedures All procurement shall be conducted in a manner that provides, to the maximum extent practical, a full and open competition. Tindley bid procedures should always follow local, state, and federal requirements. Procurement Processes should include the following: 1. Assemble a Procurement Committee consisting of the Network President, CFO, Grant Manager, and the requestor of the product or service. i. In the event that the requestor of the product or service is the Network President, a Tindley Board member of the applicable committee that corresponds to the request will be asked to participate. 2. Pre-Bid Phase. i. If an outside vendor is needed to develop the bid specifications for a bid project, the vendor, or related parties to the vendor cannot participate in the bid. ii. The procurement committee should have specific criteria of the bid specifications including how bids will be judged based on price, quality, experience of vendors, etc. iii. All solicitations shall incorporate a clear and accurate description of the technical requirements for products or services to be procured. iv. Identify all requirements which offerors must fulfill and all other factors to be used in evaluating bids and proposals. v. If required by local, state, and or federal laws, Tindley should publicly announce in advance of projects that require a competitive bid process. vi. Vendors should not be allowed to interface with Tindley procurement committee members before any public bids are announced, and post-bid announcement, interactions should occur only as part of the formal bid process (questions and answers in writing, face-to-face walk-throughs, proposal phases, and actual bid submissions). 3. Bid Phase. i. All bidders should have adequate time to respond to a bid, including Q&A sessions, and a face-to-face walk-through if necessary. ii. The Tindley employee sending out bid packages including specifications, should not be the same person receiving the vendor bid submissions. iii. The Tindley employee receiving the bid submissions should time and date stamp each bid received and the committee should exclude any bids submitted after the bid deadline. iv. Tindley employees are forbidden to disclose to vendors information about other bidders, including bid proposal contents such as pricing. 4. Bid Selection Phase. i. The procurement committee should develop a bid template and checklist that ranks bids based on criteria developed by the committee and ensures bid procedures are followed. ii. If the procurement committee chooses the winning bid on criteria other than what is stated in the original specifications, the committee must document the reasons why. For example, if the winning bid was not the lowest price, the committee must justify in writing why the vendor was selected. C. Competition All procurement shall be conducted in a manner that provides, to the maximum extent practical, a full and open competition. 1. Procurements shall avoid noncompetitive practices that may restrict or eliminate competition, including but not limited to: a. Unreasonable qualification requirements. b. Unnecessary experience and excessive bonding requirements. c. Non-competitive pricing practices between firms or affiliated companies. d. Non-competitive contracts to consultants on retainer contracts e. Organizational conflicts of interest. f. Specifying “brand name” only instead of allowing “an equal to product.” 2. Procurements shall not intentionally split a single purchase into two or more separate purchases to avoid dollar thresholds that require more formal procurement methods. 3. Procurements shall include in any pre-qualified list an adequate number of current qualified vendors firms or products. 4. Procurements shall not preclude potential bidders from qualifying during the solicitation period. 5. Procurements shall not use any geographic preferences (state local or tribal) in the evaluation of bid proposals except where expressly mandated or encouraged by applicable federal statutes. 6. The procurement team must find, when possible, bidders to compete that were not provided by the Tindley requester. 7. The procurement committee must use independent judgment and notify the Board of Directors and ethics hotline if the requester of products or services is attempting to use undue influence for the team to select specific vendors. D. Considerations Tindley purchasers should take the following actions when procuring goods and services. 1. Conduct a lease versus purchase analysis when appropriate, including for property and large equipment. 2. Consolidate or break out procurements to obtain a more economical purchase if possible. 3. Use state and local intergovernmental or inter-entity agreements, or common or shared goods and services, where appropriate. 4. Use federal excess and surplus property in lieu of purchasing new equipment and property if it is feasible and reduces project costs. 5. Use time and materials contracts only if no other contract is suitable and the contract includes a ceiling price that the contractor exceeds at their own risk. If such a contract is negotiated and awarded, Tindley must assert a high degree of oversight to obtain reasonable assurance that the contractor is using efficient methods and effective cost controls. IV. PROCUREMENT METHODS A. All procurements made under this policy shall: 1. Be necessary, at a reasonable cost, documented, not prohibited by law or the applicable funding source, and made in accordance with this policy. 2. Avoid acquiring unnecessary or duplicative items. 3. Engage responsible vendors who possess the ability to perform successfully under the terms and conditions of a proposed procurement. 4. Tindley purchasers shall consider vendor integrity, public policy compliance, past performance record, and financial and technical resources. B. Procurement Parameters For all transactions, Tindley shall follow the applicable procurement method set forth in Appendix 1 C. Exceptions to Standards Methods Solicitation of a proposal from a single source may only be used if the following apply and are documented: 1. The item is only available from single source. 2. Public exigency or emergency will not permit any delay. 3. The Federal awarding agency or pass-through expressly authorizes the sole source in response to a Tindley request. 4. After soliciting a number of sources, competition is determined inadequate. V. DOCUMENTATION A. Records Tindley shall maintain records sufficient to detail the history of each procurement transaction. These records must include, but are not limited to: 1. A description and supporting documentation showing the rationale for the procurement method (e.g., cost estimates). 2. Selection of contract type. 3. Written price or rate quotations (such as catalog price, online price, e-mail or written quote), if applicable. 4. Copies of advertisements, requests for proposals, bid sheets or bid proposal packets. 5. Reasons for vendor selection or rejection, including Finance Committee and Board Minutes, rejection letters, and award letters. 6. And the basis for the contract price. VI. COMPLIANCE WITH THIS POLICY Program directors and, where applicable, the purchasing committee, shall maintain oversight to ensure that contractors and vendors perform in accordance with the terms, conditions, and specifications of contracts or purchase orders. Violations of this policy may result in disciplinary action, up to and including termination. VII. VENDOR SELECTION CRITERIA For vendors that have been selected in a competitive bid or that will provide critical services to the school, Tindley should evaluate them based on cost, quality, past performance, experience, and financial stability. Before providing services or products, the selected vendor can be asked to provide references, allow for background checks, and provide documentation such as certificate of insurance, certificate standing, adherence to anti-fraud policies, and contracts with right-toaudit clauses.

While discussing this issue with the USDA over email it was agreed that other expenses that were previously paid by the district and not covered by the USDA loan would be acceptable to use instead of the miscalculated, overage of the interest expense. The district had spent several hundred thousand dollars in funds above the originally budgeted district contribution towards the Water Storage Tank Project previous to acquiring the loan with the USDA.

CONDITION: The District did not maintain a general ledger system of accounting for its Cafeteria Fund which reports the financial activity of the federal National School Lunch and School Breakfast Programs. The financial activity occurring in this Fund is maintained in checkbook fashion during the fiscal year. This is a repeat finding (2021-004) from the previous fiscal year. CRITERIA: Prudent internal control over accounting for federal program funds requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the receipt and use of federal funds as stated in Section 2 CFR Part 200 of the Uniform Guidance. Best practices suggest that the use of a general ledger system of accounting would enable the District to aggregate financial information involving federal funds during the fiscal year in such a manner to properly manage, monitor, and report the financial activity in compliance with federal program guidelines. RECOMMENDATION: The District’s accounting software can readily account for the financial activity of all Funds in a manner like the District’s General Fund. I am recommending that the management of the School District utilize the accounting software to enter the financial activity (Receipts and Disbursements) of the Cafeteria Fund in a manner like the General Fund. This procedure will significantly enhance the District-wide internal controls over financial reporting for the Cafeteria Fund, as well as provide management the ability to produce meaningful financial reports reflecting the activity in the Cafeteria Fund for prudent oversight by the Board of Education. In addition, this procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200 of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is reviewing its current system of processing the transactions for the Cafeteria Fund to determine the most efficient and effective manner for implementation of a general ledger system of accounting for this Fund as opposed to its current manual process. It is anticipated that the conversion of this Fund into the District’s accounting software can be completed during the 2024-2025 fiscal year to enable the District to comply with the recordkeeping requirements for federal funds as specified in 2 CFR Part 200 of the Uniform Guidance.

CONDITION: During my sample review of the District’s completion of its federal grant program ‘Quarterly Cash On Hand Reconciliations’ for the 2021-2022 4th fiscal quarter for the ESSER II and ARP ESSER grants, I noted that the amounts reported to date for ‘total disbursements’ could not be ascertained from the coding of these expenditures in the District’s general ledger (See Finding 2022-005) and did not reconcile to the separate spreadsheets maintained by the School District. This is a repeat finding (2021-006) from the previous fiscal year. CRITERIA: Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance, to allow for the proper completion of the ‘quarterly cash on hand reconciliations’. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to effectively access the necessary federal expenditure totals, by individual grant program, to document and support amounts reported as ‘total cash disbursed’ on the quarterly cash on hand reconciliations. This procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations. This is a repeat finding (2021-005) from the previous fiscal year. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

U.S. Department of Agriculture Iron County Hospital District dba: Iron County Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 – June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 – 2023 Community Facilities Loans and Grants Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with latest USDA guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Medical Center will ensure that controls are put into place to ensure timely reporting in accordance with the USDA guidelines. Name of the contact person responsible for corrective action: Steve Weiss, Interim CFO Planned completion date for corrective action plan: July 1, 2022

On the 15th of each month the Residential Division Director will meet with the Director of Finance to review the prior months match and year to date match and sign off on the report. This will assist in ensuring all match (cash/inkind) are accounted for accurately and that MHACG meets the required 25% match.

Corrective Action Plan for Fiscal Year Ended June 30, 2022 Finding 2022-001 Condition The District did not meet the deadline for submission of its data collection form and reporting package to the Federal Audit Clearinghouse for the fiscal year ended June 30, 2021. The data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors? report or nine months after the end of the audit period. Therefore, the deadline for submission of the required information for the fiscal year ended June 30, 2021, was December 22, 2021. The data collection form and reporting package was not submitted by that date. Corrective Action Plan Corrective Action Planned: Establish procedures to verify that the data collection form and reporting package have been properly submitted on a timely basis. Name of Contact Person Responsible for Corrective Action: Matthew Moore, CPA, Chief Financial Officer Anticipated Completion Date: December 16, 2022

Finding: 2022-001 - Earmarking, Reporting (Performance Progress Reporting) – Material Weakness in Internal Controls Over Compliance and Instance of Noncompliance (Scope Limitation) Recommendation: We recommend that the Coalition develop policies and procedures for tracking actual expenditures related to earmarking requirements and maintain all supporting documentation for the calculation of the earmarking percentages that are reported in the semi-annual performance progress reports. Corrective Action Plan: The Coalition’s staff has developed policies and procedures for tracking actual expenditures related to these requirements, and maintaining all supporting documentation for the calculation of the earmarking percentages that are reported in the semi-annual progress reports. The Coalition has developed an internal control process for reviewing and approving calculations required by Section 50 of the grant agreement and has strengthened its reporting management review controls to ensure that the review is effective to ensure the completeness and accuracy of reports, and that all elements are appropriately supported, prior to submission the federal agency. Anticipated Completion: Late Summer and Fall of 2023 Responsible Party: WCADVSA Co-Directors, Tiffany Eskelson-Maestas and Susie Markus

2022-012 Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP shall recruit and hire a dedicated Data Analyst to oversee the PIC entries and to ensure that recertifications are uploaded in accordance with reporting requirements. The PIC uploads will be quality-controlled monthly by HCVP and quarterly by the OAC. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24.

2022-011 Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP shall recruit and hire a dedicated Data Analyst to oversee the PIC entries and to ensure that recertifications are uploaded in accordance with reporting requirements. The PIC uploads will be quality-controlled monthly by HCVP and quarterly by the Office of Audit and Compliance. The OAC will conduct monthly checks to ensure that the uploads are done to facilitate the required reporting. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24.

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN March 11, 2024 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2022-004 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management ensure that the data collection forms are submitted electronically to the FAC each fiscal year going forward. Action Taken: We agree with Finding 2022-004 and the recommendation described in the accompanying schedule of findings and questioned costs. The project was unable to pay the prior audit fees timely due to limited available cash flow causing a delay in the audits. Management will work to improve cash flow for timely payment of the required annual audits. If HUD has questions regarding this corrective action plan, please call (803) 873-2377. Sincerely yours, Dwayne Legrant President Omni Property Management and Development Managing Agent

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN March 11, 2024 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2022-003 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: We recommend that management monitor the annual surplus cash and all required payments from any surplus cash. Action Taken: We agree with Finding 2022-003 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will submit a request to re-evaluate payments due based on no surplus cash available. If HUD has questions regarding this corrective action plan, please call (803) 873-2377. Sincerely yours, Dwayne Legrant President Omni Property Management and Development Managing Agent

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN March 11, 2024 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2022-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2022-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting and financial procedures, system of internal controls and policies. If HUD has questions regarding this corrective action plan, please call (803) 873-2377. Sincerely yours, Dwayne Legrant President Omni Property Management and Development Managing Agent

Condition: Errors were identified during our testing of the Organization’s Form ED-209, Revolving Loan Fund Financial Report. In addition, supporting documentation was not available for review of some financial amounts reported. Criteria: 13 CFR 307.14 requires the Organization to submit a revolving loan fund financial report semi-annually. The report should reconcile with the Organization’s financial documents and account balances. Auditor’s Recommendation: Management has improved their process for reconciling balances and tracking relevant information for proper reporting. We recommend that management continue to improve internal control systems and processes to ensure compliance with reporting requirements. Management’s Response: Standard accounting procedures have been implemented to ensure accurate financial reporting. These procedures include improved reconciliation processes and schedules to capture relevant financial data to meet reporting requirements.

FINDING 2022-006 Information on the federal program: Subject: Title III-E – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Title III-E Family Caregiver, COVID-19 – Title III-E Family Caregiver Assistance Listing Number: 93.052 Compliance Requirement: Cash Management Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Context: We noted that for two claims in a sample of two, there was no formal review/approval of the FSSA Contract Claim Reimbursement form outside of who is preparing the form. The CFO prepared and submitted the claims without a secondary review. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: CICOA created an additional position in our Fiscal department to help add capacity and address various segregation of duties concerns. On April 3, 2023, CICOA hired a Senior Director of Financial Reporting to fill this new position. The CFO has done/will continue various training with the Senior Director and other staff to transfer knowledge and responsibilities currently held by the CFO, including future preparation and submission of the FSSA Contract Claim Reimbursement documents. The CFO will serve as either the primary or secondary reviewer of such Claim Reimbursements after preparation by other Fiscal staff. Key item to note: this finding was made as part of the audit for the fiscal year ended June 30, 2022, and the hiring of the Senior Director was not made until late in the fiscal year ended June 30, 2023. Due to this timing, necessary changes did not exist until fiscal year 2024. Responsible Party and Timeline for Completion: To be completed by CFO (with assistance from Senior Director of Financial Reporting and other Fiscal staff), beginning no later than Claims Reimbursements submitted for services provided starting in fiscal year 2024.

FINDING 2022-005 Information on the federal program: Subject: SSBG – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Social Services Block Grant Assistance Listing Number: 93.667 Compliance Requirement: Cash Management Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Context: We noted that for three claims in a sample of three, there was no formal review/approval of the FSSA Contract Claim Reimbursement form outside of who is preparing the form. The CFO prepared and submitted the claims without a secondary review. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: CICOA created an additional position in our Fiscal department to help add capacity and address various segregation of duties concerns. On April 3, 2023, CICOA hired a Senior Director of Financial Reporting to fill this new position. The CFO has done/will continue various training with the Senior Director and other staff to transfer knowledge and responsibilities currently held by the CFO, including future preparation and submission of the FSSA Contract Claim Reimbursement documents. The CFO will serve as either the primary or secondary reviewer of such Claim Reimbursements after preparation by other Fiscal staff. Key item to note: this finding was made as part of the audit for the fiscal year ended June 30, 2022, and the hiring of the Senior Director was not made until late in the fiscal year ended June 30, 2023/early fiscal year 2024. Due to this timing, necessary changes did not exist until fiscal year 2024. Responsible Party and Timeline for Completion: To be completed by CFO (with assistance from Senior Director of Financial Reporting and other Fiscal staff), beginning no later than Claims Reimbursements submitted for services provided starting in fiscal year 2024.

FINDING 2022-004 Information on the federal program: Subject: Aging Cluster – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Aging Cluster Assistance Listing Number: 93.044, 93.045, 93.053 Compliance Requirement: Cash Management Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Context: We noted that for four claims in a sample of four, there was no formal review/approval of the FSSA Contract Claim Reimbursement form outside of who is preparing the form. The CFO prepared and submitted the claims without a secondary review. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: CICOA created an additional position in our Fiscal department to help add capacity and address various segregation of duties concerns. On April 3, 2023, CICOA hired a Senior Director of Financial Reporting to fill this new position. The CFO has done/will continue various training with the Senior Director and other staff to transfer knowledge and responsibilities currently held by the CFO, including future preparation and submission of the FSSA Contract Claim Reimbursement documents. The CFO will serve as either the primary or secondary reviewer of such Claim Reimbursements after preparation by other Fiscal staff. Key item to note: this finding was made as part of the audit for the fiscal year ended June 30, 2022, and the above corrective actions were not made until late in the fiscal year ended June 30, 2023/early fiscal year 2024. Due to this timing, necessary changes did not exist until fiscal year 2024. Responsible Party and Timeline for Completion: to be completed by CFO (with assistance from Senior Director of Financial Reporting and other Fiscal staff), beginning no later than Claims Reimbursements submitted for services provided starting in fiscal year 2024.

2022-005 Reporting, Matching, and Earmarking U.S. Department of Homeland Security Recommendation: We recommend the County implement internal controls to ensure that required reporting, which includes matching and earmarking, is completed timely as required. Explanation of disagreement with audit finding: There are no disagreement with the audit finding. Action planned/taken in response to finding: The County will identify all federal awards that reporting is required. Once programs subject to reporting are identified, the County will then determine what reports are required to be prepared and submitted. The County will also monitor and document the County’s progress for matching and earmarking requirements. Name(s) of the contact person(s) responsible for corrective action: Debi Reynolds Planned completion date for corrective action plan: June 30, 2024

Following the completion of the 2021 Single Audit, we adjusted the Organization's Accounting Policies & Procedure Manual to include detailed information outlined in HUD's electronic Line of Credit Control System (eLOCCS) inclusive of the roles and responsibilities of the system's Users and Approving Official. Specifically, Accounting Department Leadership (i.e., the Chief Financial Officer), designated accounting personnel (i.e., Accountants), and/or agency Executive Leadership (i.e., CEO/Executive Director), must be cognizant of a grant's period of performance.

FINDING 2021/2022-011: Wage Rate Compliance Response: The District will implement internal controls to ensure compliance requirements of all federal funds received. Contractors will be required to submit certified payroll records to demonstrate they are complying with prevailing wages if the project is paid with federal funds.

Audit Finding Reference: 2022-005 Limit Federal Cash on Hand (Significant Deficiency) Planned Corrective Action: The district is aware of this finding and will be taking steps to address this in the coming months. The City needs to decrease the cash balance in the school lunch fund so that it falls within acceptable Federal guidelines. Name of Contact Person and Completion Date Kevin McHugh, City of Lynn School Business Manager December 31, 2024

Management Response / Corrective Action: Rowan-Salisbury School hired a new payroll director in May of 2022 who identified the cause for the above noted discrepancy, noting the team was overbudgeting taxes on staff personnel payments due to employees who opt in for the ?pre-tax contributions.? When an employee enrolls in the ?pre-tax contributions,? the budgeted amount for Social Security/Medicaid is adjusted so that the rate no longer meets the 7.65% calculated amounts for all employees. As a result, the team has gone through each month?s drawdown and determined that $7,793.78 was over budgeted and we are correcting that in our February 2023 drawdown by reducing the drawdown by $7,793.78. We have also adjusted our budget calculation so that we are properly accounting for those employees who opted for ?pre-tax contributions? going forward.

December 19, 2022The City of Staunton respectfully submits the following corrective action plan for the year ended June 30, 2022.Name and address of public accounting firm:Brown Edwards & Company LLP 1909 Financial Drive Harrisonburg VA 22801Audit Period: July 1 , 2021 - June 30, 2022The findings from the June 30, 2022 Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the schedule.FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT2022-001: Emergency Connectivity Funds - Assistance Listing #32.009 Condition:The inventory provided was incomplete , vague, or otherwise lacked some or all of the required data. The inventory also made it difficult to determine if ECF devices were allotted to multiple individuals, or if devices funded by other sources were included and not appropriately removed from the list s.Criteria:Emergency Connectivity Fund (" ECF") Program participants are required to maintain asset and service inventories of the devices and services purchased with ECF Program support. For each connected device or services provided, the inventory must include, but is not limited to: the device type, make/model, serial number, full name of person the equipment was provided to and dates of service the device was loaned out and returned. Additionally, those inventories must identify ECF funded equipment in the event of sale or disposal to remain in compliance with the program requirement s.Cause:Controls or reviews do not appear to be in place to ensure equipment inventory contains all the necessary data, is up to date, and accurate.Effect:Inaccurate and incomplete inventory lists.Recommendation:We recommend that controls be put in place to ensure that the School IT department is following proper grant requirements. Furthermore equipment lists should differentiate between federally funded devices with restrictions on disposals, along with applicable program in formation , from devices funded by other sources. Finally , the equipment lists should be updated, with old equipment no longer in service being removed and current equipment showing the time and date of assignment to students or faculty.Corrective Action:We concur. School IT staff have been reminded of the importance of maintaining accurate equipment records that differentiate between federally funded devices, which may have restrictions on disposals reviewed, and other devices funded by non-federal sources. Staff has reviewed and updated the equipment inventory listings to reflect correct assignment to location, student and/or staff and have implemented procedures to ensure that going forward, the equipment listings are updated in a timely manner.If the Federal Audit Clearinghouse has questions regarding this plan, please call Jessie L. Moyers , Chief Financial Officer for the City of Staunton at 540-332-3820.Sincerely,Jessie L. Moyers, CPAChief financial Officer City of Staunton VA

District subsequently sought and obtained CDE approval for the expenditures identified in finding 2022-003.District has initiated a procedure where any requisitions for purchases utilizing Federal funds are routed through the Director of state and federal programs prior to being approved. The director of state and federal programs, prior to approving the purchase requisition, will obtain approval from the CDE. All contracts utilizing federal funds will include language related to Federal wage rate requirements. The supervisor of Purchasing will be tasked with ensuring the contract language is present in agreements for services utilizing Federal funds.