Corrective Action Plans

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City designate a responsible and qualified grant manager, establish internal controls for reporting, and file required reports in a timely and accurate manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Coronavius State and Local Fiscal Recovery Funds have all been depleted. 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.

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 determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. The auditors also recommended the Organization put a process in place to make sure all applications are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization made several changes at the end of 2023 to ensure we appropriate documentation in patient charts. The following is a summary of the changes: • Hired a patient services manager to manage the front desk and call center in November 2023. Moved sliding fee application process to the front desk from enrollment, previously the applications were handed off for scanning. Now the front desk owns the entire process from getting the application from the patient to scanning it into the chart. We have implemented a monthly audit process to spot check applications for accuracy and ensure complete documentation in the chart. We also began using an app called Luma to help patients complete sliding fee electronically when a patient is comfortable. This eliminates the need to scan documents.

Finding 2023-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Federal Agency Name: Department of Health and Human Services Program Name: Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Federal Assistance Listing: #93.391 Finding Summary: During the course of our engagement, we noted a material program missing from the Schedule that was not identified by management. Responsible Individuals: Kevin Abel, CEO and Brigid Burke, CFO Status: Procedures and controls over tracking and recording of federal programs with the Schedule will be updated in order to provide a complete Schedule. Anticipated Completion Date: 12/31/2024

2023-004 Preparation of and Internal controls over Schedule of Expenditures of Federal Awards Preparation (Material Weakness) Federal Agency: U.S Department of Education Program Name: Education Stabilization Fund Assistance Listing Number: 84.425 Award Period: June 30, 2023 Recommendation: The Board of Education and management should review the financial reporting process. Once this review is complete, the District should then perform a risk assessment to determine the best way to implement appropriate internal controls over financial reporting to ensure that the District prepares the schedule conformity with Uniform Guidance. Action Taken (Unaudited): Management plans to work with a third-party consulting firm to address issues and improve protocols. Contact Name – Dr. Jessica Dain Expected Completion Date - 12/31/2024

Finding 2023-001: Reportable Finding Considered a Material Weakness – Eligibility Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Responsible Officials – The Charity Foundation acknowledges the finding regarding the improper payment of 9,424 benefit checks to ineligible beneficiaries due to insufficient verification of employment and identity documentation. This resulted in $5,654,400 in questioned costs. We understand the seriousness of this issue and have implemented corrective actions to prevent future occurrences. Corrective Actions – Root Cause Analysis: The deficiency arose because the Foundation’s application portal, designed and managed by consultant contractors, failed to accurately verify employment and identity documentation, leading to the approval of ineligible beneficiaries. Revised Eligibility Verification Process: In November 2023, the Charity Foundation implemented updated procedures to enhance the verification of applicant eligibility under the FFWR program: • Initial In-Person Screening: Applicants must now provide proof of employment, such as a paystub or W-2, in person at their place of work (farm, meatpacking facility, or grocery store). This initial screening is intended to ensure that workers are properly verified before accessing the application portal.   • Unique Identifier Creation and Control: The Charity Foundation creates and controls unique identifier codes used for logging into the application portal. These identifiers ensure secure access and prevent duplicate applications. During the initial screening process, the consultants assisting with the sign-up process distribute these unique identifiers to each eligible worker in person at the plants. • Portal Access and Document Submission: After receiving the unique identifier, applicants log into the portal and are required to upload their identification documents. A dedicated team manually reviews each document to verify that the applicant’s identity and employment meet FFWR eligibility requirements and that the information matches the details entered by the applicant. Ongoing Monitoring and Compliance: To ensure the integrity of the process, the Foundation’s internal review team conducts regular compliance checks on the submitted documentation. This ongoing monitoring process ensures that all uploaded documentation meets program standards. Staff Training: The Foundation will continue to train team members responsible for verifying applications. This training covers FFWR program requirements, proper identification and employment records review, and how to flag potential discrepancies. Regular training ensures the team remains informed of program expectations and changes. Consultant Accountability: We have revised our contract with the consultant contractors managing the application portal to establish stricter accountability measures. This includes ongoing performance reviews and quality control checks to ensure the portal supports accurate identification and employment verification. Results: These changes were successfully implemented in November 2023 and are now the standard operating procedure for the Charity Foundation’s FFWR program. Responsible Person: The Director of Finance is responsible for overseeing the implementation of the updated eligibility verification process. The Director also ensures compliance with FFWR requirements through continuous monitoring and periodic internal audits. Completion Timeline: The corrective actions were fully implemented as of November 2023 and continue to be in effect for all FFWR program applicants moving forward.

2023-004 Eligibility Section 8 Project-Based Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 670 of tenants, 20 tenant files were tested and the following deficiencies were noted: • Nine files did not have annual recertifications performed during the year, • Eight files did not have 9886 release of information forms within 15 months of annual recertification, • Six files did not have an annual recertification performed within 12 months, • Six files did not have documentation necessary to verify the reported income, and • Three files did not have a 214 declaration form for all members of the household. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024

2022-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 484 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 4 tenants selected for testing): • One file did not have an annual recertification performed during the year, • One file did not have an annual recertification performed within 12 months, • Two files did not have 9886 release of information forms within 15 month of the annual recertification, • One file did not have a 214 declaration form for all members of the household, and • One file did not have documentation necessary to verify the reported income. Emergency Housing Voucher AL #14.871 (a total of 5 tenants selected for testing): • Four files did not have an annual recertification performed within 12 months, • Three files did not have a 214 declaration form for all members of the household, • Four files did not have 9886 release of information forms within 15 month of the annual recertification, and • Five files did not have rent reasonableness form performed for the annual certification. The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT 2023-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 1,500 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 5 tenants selected for testing): • Five files did not have supporting documents needed to determine eligibility. Emergency Housing Voucher AL #14.871 (a total of 5 tenants selected for testing): • Four files did not have supporting documents needed to determine eligibility, and • One files did not have an annual recertification performed. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

2023-002 Eligibility Moving to Work Demonstration Program AL No. 14.881 Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 18,300 of Section 8 Housing Choice Voucher and 2,300 Low Rent Public Housing tenants the following deficiencies were noted: Section 8 Housing Choice Voucher (a total of 40 tenants selected for testing): • Thirty-five files did not have annual recertifications performed during the year, • Nine files did not have 9886 release of information forms within 15 months of annual recertification, • Four files did not have a annual recertification performed with 12 months of the previous certification, • Three file did not have an inspection performed during the year • Three files did not have documentation necessary to verify the reported income, • Two files did not have a 214 declaration for a member of the household, and • Two files did not have documentation necessary to verify custody of dependents. Low Rent Public Housing (a total of 40 tenants selected for testing): • Fourteen files did not contain flat rent options forms, • Ten files did not have documentation necessary to verify the reported income, • Seven files did not have the annual recertification performed or documented, • Five files did not have a 214 declaration for a member of the household, • Three files did not have support necessary to verify income allowances, • Two files did not have 9886 release of information form within 15 months of the annual recertification, and • One file did not have annual recertifications performed within 12 months of the previous annual certification. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected during the final quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the final quarter of 2024.

2023-001 Financial Reporting – Disclaimer of Opinion Material Weakness in Internal Control Material Noncompliance Condition: During our audit of the Authority’s financial statements, numerous adjustments were needed to properly report the financial statements in accordance with generally accepted accounting principles. Certain accounts had not been properly reconciled and corrective entries were not readily available. Significant audit adjustments were necessary for several audit areas and the audit was significantly delayed due to these adjustments. Given the amount of adjustments needed the auditor did not have enough time to complete the necessary audit procedures and as such have issued a disclaimer of opinion on the financial statements. Auditor’s Recommendations: The Authority should continue to develop and implement internal controls over both internal and external reporting, and the year-end close process to ensure reporting remains accurate and timely, with any unexpected financial data being investigated and corrected before it is reported. The Authority should consider additional staff training on development activities. Action Taken: The Houston Housing Authority agrees with this finding and related recommendations. During this audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In addition, we hired a firm to come in and undertake a review of the finance department. The purpose of this review was to review our existing staffing levels, workloads, experience, etc., for purposes of proposing a reorganization of the finance department to address any deficiencies. We have reviewed the recommendations from this consultant and are in the process of implementing many of the recommended changes. We are in the process of bringing in additional staff to expand the capacity of the Finance department. As we had fallen behind on our audits we anticipated the weaknesses noted in prior audits would continue to be present in future audits including the 2023 audit. We have been working very diligently to address the issues within the finance department that gave rise to this finding. We fully expected this finding or a similar finding to be present for the 2023 audit as many of the departmental improvements and changes were not in place during the 2023 calendar year. We have also been somewhat limited in the time available to implement changes as we have been working on clearing up the prior audit delinquencies since hiring out new outside auditors. This will be the first time in years where we will have a prior year audit available to us prior to the end of the current year. We will be able to have any 2023 audit adjustments posted to the general ledger prior to yearend 2024 so many of the reconciliation issues that have been encountered on the prior audits are not expected to be present when we move into the 2024 audit. The VP Fiscal and Business Operations as well as the Director of Finance are responsible for implementing the necessary process and procedural changes to eliminate the need for this type of finding for the 2024 audit.

Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority’s management company has hired a Deputy Director who completes quality control audits on all tenant files periodically. The Deputy Director holds monthly meetings with all eligibility staff workers to ensure compliance with policies and procedures. Planned Completion Date for CAP Immediately.

Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management has thoroughly reviewed all the terms and conditions of its grant awards with internal management and externally with the Department of Health and Human Services and other regulatory bodies to ensure the proper completion of subaward reports in FSRS, the SF429 and other required reporting. The above noted issue was discovered during the course of the 2022 audit, but after the reporting deadlines for the 2023 year. Upon discovery of the requirement, Management took the above noted steps to become compliant with both 2022 and 2023. The finding repeated in 2023 solely due to the timing of the discover of the issue. Effective to date, all FSRS and applicable SF429 reports have been filed correctly and timely.

Views of Responsible Officials and Action Taken: FCE agrees with the finding and has implemented a corrective action plan that requires the accounting and reporting to be performed by an outside CPA firm with expertise in accrual basis accounting, cost allocation and grant accounting concepts. During FCE’s monthly financial review, we examine each grant/class level in QB, ensuring that expenses are properly charged to the correct grant in the correct period of performance.

Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. The reimbursement reports were to be reviewed by the District Manager prior to submission. Approval of the reimbursement requests and supporting reports by the District Manager were often delayed. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper financial reporting. Lack of timely filing of reimbursement requests could result in overstating accounts receivable balances and critical revenues lost due to cutoff terms of the grant award. Questioned Cost: No Context: Delays in filing reimbursement claims and internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures resulted in lost revenues and delayed recognition of revenue, which required adjustments to correct the financial statements. Repeat of a Prior-Year Finding: Yes, Financial Statement Findings 2022-001 Recommendation: The District should establish a more simplified and effective process for the review and approval of GAAP basis reporting and grant reimbursement requests and grant reporting. As part of this process, supporting general ledger reports and supporting data should be subject to a qualified individual to review and approval on a timely basis. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our year-end processes and acknowledges that there is additional improvement needed. For FY23, WPHW created a year-end check list and started the review process. Unfortunately, due to staff absences and NetSuite issues, we were not able to fully implement these changes. Both situations have provided us with lessons learned for how to correctly implement changes in the future. For FY24, WPWH implemented the following process: 1) Full year-end check list is distributed and review by staff (Accounting Specialists, Accountants, and AR/AP Specialists) prior to year-end for review and training, conducted by the Director of Accounting and Accounting Manager a. Review each step with staff and provide training on the expectation for each step 2) Accounting Specialists and Accountants complete necessary year-end tasks 3) Accounting Manager reviews all completed tasks to ensure accuracy and completeness 4) Director of Accounting conducts a final review and signs off at the end of the year With this clear process in place, we anticipate this issue being fully resolved in FY24.

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new processes that would have fully addressed prior concerns. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks. However, we encountered several issues with the implementation of the new system, which delayed prior year corrected actions. In May 2024, WPHW decide to no longer work with NetSuite, due to the number of issues with the system and the company. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. At the time of the transition back to QuickBooks fully, we also made significant staff role changes. Our accounting department now has a Director of Accounting and two new managers, AR/AP Manager and Accounting Manager. With these new positions, we have developed the following procedures for adjusting journal entries: 1) Accounting Director, Accounting Manager or AR/AP Manager identifying need for a journal entry 2) Accounting Specialist or AR/AP Specialist pulls the supporting documentation for the required entry, creates journal entry template in Excel, and prepares journal entry packet with supporting documentation for entry into QB. 3) Accountant or Accounting Manager reviews packet and determines who can enter journal a. If reviewed by Accountant, entry is entered QuickBooks by Accounting Specialist b. If reviewed by Accounting Manager, entry is entered into QuickBooks by Accountant 4) Once journal entry is entered into QuickBooks, entry is printed from QB system and added to packet. The packet is returned to the preparer to ensure all elements were completed corrected and signed off on 5) Completed packet goes to filing and are scanned into our electronic file system All adjustments must go through three different individuals to ensure separation of duties. This process will be implemented during Q4 of FY24. The Director of Accounting will go back over all the journals completed before this date to review how each were completed and delegate additional review to the Accounting Manager and Accounting Specialist to ensure each journal entry had appropriate review and support. With this process in place, we anticipate this issue being fully resolved in FY25.

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trainings for new staff with an emphasis on accrual accounting for the Office Manager who performs the bookkeeping function.

Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2024

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be taken to prevent ineligible expenses from being submitted in the future: • Exclude all ineligible expenses from any future Provider Relief Fund Portal submissions. • Offset the ineligible costs with lost revenues and unreimbursed expenses attributable to Corona virus. Princeton Community Hospital was a new acquisition into West Virginia University Health System as of January 1, 2023 and had not fully integrated into our processes at the time that this portal submission was completed. Upon further review, Princeton Community Hospital had lost revenues that support a significant portion of the funding received for this reporting period. Those lost revenues, along with eligible expenses, fully support the funding received. Completion Date: 09/27/2024

Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed and approved by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to ensure prior to entering into an agreement with an outside entity using federal funds, the City will perform the suspension and debarment check. Documentation of this review will be retained with the grant documents. In addition, the City will research grant management software options to further enhance grant monitoring. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024

Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant allowable costs and activities determinations and reporting requirements and will implement a process that ensures federal expenditure accounting and reports are prepared and then reviewed and approved by a separate employee prior to submission.

Finding 2023-001 Material Weakness, Internal Control Over Compliance and Compliance, Reporting Personnel Responsible for Corrective Action: Adam Rogers Anticipated Completion Date: Already completed Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant reporting requirements and has implemented a process that ensures federal expenditure accounting and reports are prepared by the Grants Analyst and then reviewed and approved by the Deputy Director of Finance or Director of Finance to provide oversight and detect and correct errors before reports are submitted.

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart D, Property Standards, The non-Federal entity must submit annually an inventory listing of federally-owned property in its custody to the Federal awarding agency as defined within existing governing statues, regulations, or terms and conditions of the award. Procedures for the delegated staff administering these regulatory activities will follow the minimum requirements of maintaining property records. Final review of inventory will have final reviewed by Department’s CFO of approval and will be documented annually. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025