Corrective Action Plans

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation claimed expenses that were reimbursed by other funding sources. These expenses were improperly included in the HHS Special Report which caused the report to be inaccurate. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: The Corporation will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and ensure are properly recorded in the report required to be submitted to the federal agency. The Corporation will also implement a review process to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: March 31, 2024

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation’s final lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program did not agree to the amount claimed in the report submitted to the Department of Health and Human Services for Period 3 and Period 4. Additionally, the Corporation’s total net patient care revenues did not agree to the amount in the report submitted to the Department of Health and Human Services for Period 4. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: Management will implement a control process which includes monitoring over amounts reported relating to lost revenue amounts and the related calculation. Anticipated Completion Date: March 31, 2024

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation did not have an adequate internal control policy in place to ensure review and approval of the lost revenue calculation and report submitted to the Department of Health and Human Services for Period 3 and Period 4. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: Management will implement a control process which includes a secondary review and approval of any future lost revenue calculation and report submitted under the federal program. Anticipated Completion Date: March 31, 2024

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.

Access, Inc. concurs with the finding and has begun implementing corrective action. Access, Inc. has recently employed a CFO with extensive experience with the Department of Labor grants and contracts, to assist with the accounting process which will enhance the organizations’ ability to ensure accounting records are accurate and complete.

We agree that due to the turnover of finance staff and the lack of consistent leadership in the finance department, we realized the need for strong leadership for our finance team. Consequently, the recruitment of an experienced Finance Director is in process, who has extensive experience working with nonprofit organizations, the U.S. government, and the United Nations. This new hire will ensure the finance department has strong leadership with a deep understanding of GAAP standards and the complexities involved in nonprofit accounting. Additionally, existing staff members will receive comprehensive training on GAAP and other relevant financial procedures to ensure they have the necessary knowledge and skills to perform their duties accurately. This training will be ongoing to keep the staff updated on any changes in accounting standards and practices. Furthermore, Isuroon will engage a certified accounting firm to conduct monthly reviews of its books of accounts. This firm will provide regular feedback and guidance, identifying any discrepancies or areas needing improvement and suggesting best practices to ensure compliance with GAAP and the accuracy of financial reporting. By implementing these measures, we aim to establish robust internal controls over the financial closing process, ensuring all necessary adjustments are recorded and reviewed in a timely manner. This comprehensive approach will mitigate the risk of material misstatements, enhance the reliability of financial statements, and demonstrate a commitment to transparency and accountability in financial management.

Condition 2: The Authority did not submit its audited financial statements to the Federal Audit Clearinghouse and to REAC by the required due dates. Corrective Action 2: The Authority has retained an accounting firm to serve as a fee accountant. Our fee accountants will complete the unaudited Financial Data Schedule submission and provide workpapers to the auditors to enable a timely audited submission. Completion Date: September 30, 2023

The Garden’s Uniform Guidance Audit for the year ended December 31, 2022 was delayed as Garden management was unare that that their federal expenditures exceeded the audit requirement threshold for the first time. Going forward, Garden management will ensure the data collection form and reporting package are submitted within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the end of the audit period.

Contact Person Megan Rath 2022-003 Corrective Action Plan The USDA was made aware that the financial statements had errors and were unaudited at the time of the submission of the RD 442-2 and RD 442-3 for 2022. The Association’s audited financial statements are now up to date. Proper checks and balances have been put into place to ensure ongoing complete and accurate financial data for USDA reporting. Completion Date The corrective action plan steps are planned to be sufficiently in place prior to the beginning of the 2023 USDA required reporting.

Annual Financial Reporting Under Generally Accepted Accounting Principles (GAAP) Fiscal Year: 2022 City’s Response: We concur. Views of Responsible Officials and Corrective Action: We have determined we cannot afford to hire additional staff that is required to properly prepare financial statements, disclosures, supplemental information, schedule of expenditures of federal awards and schedule of state financial assistance per generally accepted accounting principles in the United States of America. We feel that it makes more sense to work closely with our auditors to meet that criteria. Name of Responsible Person: Tracy Rau, Clerk/Treasurer Projected Implementation Date: Estimated, July 2024

Segregation of Duties Views of Responsible Officials and Planned Corrective Actions: Management will continue to review processes to determine where improvements can be made. Our 2021 findings were not reported until mid-year 2022. As a part of Inspiration’s corrective action, we contracted with professional CPA firm, Butler CPA out of Kendallville, Indiana in August 2022. This has enhanced our efficiency, accuracy, and segregationof duties. The board of directors plays an active role in oversight of Inspiration Ministries Inc.’s ativities. The monthly board packets include but are not limited to reconciled financial statements such as profit and loss statement and balance sheet.

As part of the December 31, 2022 audit process and due to new funding received by Preventionfocus, it was discovered that management did not accurately track the expenditure of federal awards during the fiscal year. This resulted in management not being aware that it had expended federal awards of greater than $750,000, which would require a single audit, and the Agency was unable to timely submit a Data Collection Form to the Federal Audit Clearinghouse. Recommendation: The auditors recommended that the Executive Director and Director of Administration develop policies and procedures to prepare and reconcile total federal expenditures to their general ledger annually to enable timely submission of the Data Collection Form to the Federal Audit Clearinghouse. Action Taken: Management agrees with this recommendation. The Executive Director and Director of Administration are in the process of developing policies and procedures that will help to ensure timely and accurate tracking of federal expenditures on an annual basis. Victoria Simmons, Director of Administration, will assume responsibility for implementation by September 30, 2024.

Item 2022-001 – Eligibility: Eligibility for Individuals Federal Program – Healthy Start Initiative Assistance Listing Number – 93.926 Material Weakness Condition: The Council did not have internal controls established for an independent review that the participants accepted into the program met the qualifying criteria. Eligibility may be determined by the Council employees or by certain health care facilities. Corrective Action: The Healthy Start Program does monitor clients closely for eligibility according to their residential zip code (the primary criteria for eligibility.) and verified perinatal status. The Fatherhood Program, requires participants have a partner who participated in the Healthy Start program. Beginning October 1, 2022, the Program Coordinator for Healthy Start reviewed the eligibility documentation to verify status but did not sign documentation for this verification. The Healthy Start Program transitioned to another local non-profit October 31, 2023.

Finding 2022-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date : June 30, 2025

Federal Award Findings and Questioned Costs: Finding 2022-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: Stephen Wilson, Finance Director Corrective Action Plan: As the Borough is currently behind on its audit’s we are aware that this will continue to be an issue until we are caught up. Completion Date: June 30, 2025

Hospital Authority of Liberty County (A Component Unit of Liberty County, Georgia) respectfully submits the following corrective action plan for the year ended November 30, 2022. The finding from the November 30, 2022 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness - Noncompliance (2022-001) Recommendation: The Authority should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Planned Corrective Action: The Authority has elected to pay off the outstanding balance of the USDA loan. Derek Rozier Chief Financial Officer

Finding Number: 2022-005 Planned Corrective Action: AMHA and our accounting firm are working diligently to meet deadlines. Completed bank recs and financial documents are finished more timely. Anticipated Completion Date: January 1, 2023 Responsible Contact Person: Sherrie Boudinot

Finding Number: 2022-004 Planned Corrective Action: AMHA has contracted with the Inspection Group and is also working on a contract with HAPCAP to also do inspections to ensure that all inspections are done in time. If the unit fails a second inspection, in most cases the HAP is abated, or a formal extension is granted on occasion. Anticipated Completion Date: January 1, 2023 Responsible Contact Person: Erica Flanders

Reference Number: 2022-001 Name of Contact Person: Tracy Largent Corrective Action: Staff inquired with the State Water Resources Control Board and with our auditors regarding if a single audit would be necessary for the funds received through the Water Arrearages Program. A definitive answer was not available. In the future the District will include all funds that could possibly be considered federal, regardless of confirmation. Proposed Completion Date: 5/12/2023

2022-004 Special Tests and Provisions – Selection from the Waiting List Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance Condition: 13 out of 123 new admissions were tested. Exceptions were noted as follows: • 3 tenant file errors where the HAP contract was not signed by the Authority until after 120 days of the tenant’s move-in date, but was signed by the landlord within 120 days of the tenant’s move-in date (adoption of HUD COVID waiver). • 1 tenant file error where the tenant’s application date, time, and preference did not agree to the date, time, and preference recorded on the waiting list. The tenant should have been housed earlier based on the tenant’s application date, time, and preference. • 1 tenant file had the following errors: o The HAP was not signed by the Authority until after 120 days of the tenant’s move-in date, but was signed by the landlord within 120 days of the tenant’s move-in date (adoption of HUD COVID waiver). o The tenant’s application date and time did not agree to the date, time, on the waiting list. The tenant should have been housed earlier based on their application date, time, and preference. • A separate waiting list was maintained for tenant based mainstream vouchers in the same county or municipality covered by the regular Section 8 waiting list (the mainstream waiting list has currently been exhausted). The Authority’s administrative plan does not allow a separate waiting list for the mainstream vouchers. In addition, the separate tenant based mainstream voucher waiting list was ranked randomly by the Authority’s system through a lottery ranking technique. This is not in compliance with the Authority’s administrative plan, which states that the waiting list should be organized by preference point and then by date and time of application (first come first serve basis). Recommendation: The Authority should correct the deficiencies and ensure staff is aware of acceptable procedures as outlined in the Authority’s Administrative plan. In addition, the Authority should review staffing levels, skill sets and case load. Furthermore, the Authority should utilize an ongoing quality control review process to ensure proper procedures are being followed. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

2022-003 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance Repeat of Finding from March 31, 2021 (Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing, but testing was suspended after 24 files due to the number of errors. Exceptions were noted as follows: • 1 tenant file error where the Authority performed their rent reasonableness procedures on a 2-bedroom unit for a 1-bedroom unit, and the comparable rents did not appear reasonable. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent by $23: o 1 error for miscalculation of the tenant’s social security income o 1 error for miscalculation of the tenant’s medical expense. • 1 tenant file had the following errors: o Two members of the household did not check the box on the 214-affidavit form indicating their eligible immigration status, but based on their birth certificates, they have eligible immigration status. o Miscalculation of the tenant’s utility allowance amount. Correcting the utility allowance amount would not change the HAP rent. • 1 tenant file error where the utility allowance amount was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would not change the HAP rent. • 1 tenant file had the following errors: o The 50058 form reported the wrong number of bedrooms in the unit. o The tenant did not sign the lease agreement. • 1 tenant file error where the tenant’s utility allowance amount was calculated incorrectly. Correcting the utility allowance amount would not change the HAP rent. • 1 tenant file had the following errors & correcting the errors would decrease HAP rent $11: o Miscalculation of the tenant’s social security income o Miscalculation of the tenant’s medical expense. • 1 tenant file had the following errors and correcting the miscalculation of tenant’s income and utility allowance would decrease the HAP by $8.: o Miscalculation of the tenant’s supplemental security benefit o Miscalculation of the tenant’s utility allowance amount. o The tenant’s supplemental security benefit income was coded as social security income when it should have been coded as supplemental income on the 50058 form. o Missing 214-affidavit form for a member in the tenant’s household, but based on their birth certificate, they have eligible immigration status. o Member of the household, over the age of 18, did not sign and date the 9886 form. o The HAP contract was not signed and dated by the Authority. • 1 tenant file error due to a missing signed lead base paint form. • 1 tenant file had the following errors: o The 50058 form incorrectly reported the tenant’s monthly rent. Correcting this error increases the HAP rent by $8. o The lease agreement’s signature page is missing. • 1 tenant file error where the rent reasonableness procedure was performed one month after the tenant’s move-in date. The rent appears reasonable, but should have been performed before the tenant’s move-in date. • 1 tenant file had the following errors: o Missing HAP contract and lease agreement. o Missing rent reasonableness support. • 1 tenant file error for missing rent reasonableness support. • 1 tenant file had the following errors: o The utility allowance amount was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would not change the HAP rent. o The lease agreement’s signature page is missing. • 1 tenant file had the following errors: o Miscalculation of the tenant’s social security income. Correcting the miscalculation would decrease the HAP by $2. o Miscalculation of the tenant’s annual unreimbursed medical expense. Correcting the miscalculation would have no effect on the HAP rent. o The tenant’s name was reported incorrectly on the 50058 form. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-form indicating their immigration status. However, based on the tenant’s birth certificate, the tenant has eligible immigration status. o A member of the household over the age of 18 didn’t sign and date the 9886 form. o General assistance was included as household income when it should have been excluded. Correcting this error would increase the HAP rent by $12. o Missing rent reasonableness support. o The landlord did not sign the lease agreement. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-form indicating their immigration status. However, based on the tenant’s birth certificate, the tenant has eligible immigration status. o Missing support for total annual unreimbursed childcare costs. o Missing support for total annual unreimbursed medical expense. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

2022-005 Special Tests and Provisions – UEL Formula (Form 52722) and Formula Income Public and Indian Housing Program – CFDA 14.850 Material Weakness in Internal Control and Material Noncompliance Condition: Unable to test HUD Form 52722, 52723, and the utility ledger for accuracy and completion. Recommendation: The Authority should retain hard copies or electronic copies of HUD Form 52722, 52723, and the utility ledger for each fiscal year under audit. Action Taken: We concur with the recommendation. Due to the ongoing COVID-19 pandemic and related staff absences and turnover, we were not able to locate hard copies or electronic copies of HUD Form 52722, 52723, or the utility ledger. We will retain hard copies or electronic copies of HUD Form 52722, 52723, and the utility ledger for each fiscal year under audit.

2022-002 Reporting – Inaccurate and Late FDS Submission and Late OMB Data Collection Form Submission Public and Indian Housing Program – CFDA Number 14.850 Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-002 from March 31, 2021 (initially occurred as Finding 2020-002 from March 31, 2020) Condition: The Authority’s original unaudited FDS filing did not include the Authority’s blended component unit. In addition, the unaudited FDS filings were not submitted within the timeframes specified by HUD. The Authority submitted the unaudited FDS filing on May 10, 2023 (the due date was May 30, 2022). The Authority was also required to submit the OMB Data Collection form to the Federal Audit Clearinghouse (“FAC”) by December 31, 2022 at completion of the single audit, but was not filed timely as the audit was completed on September 9, 2024. Recommendation: The Authority should make every effort to file its REAC submissions accurately and timely and submit the OMB Data Collection form timely. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were not able to accurately close the books before the HUD specified unaudited FDS filing deadline and unable to timely file the OMB Data Collection Form. We are very focused on ensuring there is adequate staffing and sufficient processes in place in order to be able to close the books prior to submitting a materially accurate unaudited FDS submission for the following fiscal year as well as timely file the OMB Data Collection Form.

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the East Tallahatchie School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2022:  Finding 2022-001 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will implement controls and procedures to ensure that all expenditures are properly authorized prior to goods being ordered or services being rendered. C. Anticipated completion date of corrective action: Immediately 2022-002 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, proper safeguarding of assets and accurate accounting records. C. Anticipated completion date of corrective action: Immediately 2 2022-003 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, proper safeguarding of assets, and accurate accounting records. C. Anticipated completion date of corrective action: Immediately 2022-004 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, proper safeguarding of assets, and accurate accounting records. C. Anticipated completion date of corrective action: Immediately 2022-005 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, proper safeguarding of assets, and accurate accounting records. C. Anticipated completion date of corrective action: Immediately 3 2022-006 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, proper safeguarding of assets and accurate accounting records. C. Anticipated completion date of corrective action: Immediately 2022-007 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Raymond Russell Title: Superintendent B. Description of corrective action planned: The district will strengthen its internal control systems over reporting to ensure single audit reporting package and data collection form are submitted to the Federal Audit Clearinghouse within established timeframe and financial statements are prepared timely. C. Anticipated completion date of corrective action: Immediately

Finding 2022‐002: Eligibility‐(Material weakness in Compliance, Internal Control, and Service Provision within the APA (Assistance Program) Program) Effect: The Organization provided APA/R&P program funding to ineligible refugees and lawful permanent residents due to inadequate verification and inconsistent documentation practices. Auditor's Recommendation: The Organization should enhance its eligibility verification process to ensure that only enrolled refugees receive funding. Implementing regular training for staff and updating guidelines will help maintain accurate and complete documentation, ensuring compliance and maximizing the effectiveness of the APA/R&P program. Management Response: We agree with the recommendation and have also submitted the following response: Ensuring refugee eligibility as a sub-recipient of HIAS involves a comprehensive and diligent process. Staff are trained in verification and eligibility as required by the funder and follow an enhanced eligibility verification process. Screening is completed at the funder level to ensure refugee eligibility and program placement. Once approved, a referral is sent to the designated providers. Eligibility: The referral number designates the refugee to a program; even though the Funder system lists “None,” the referral is eligible. For the 7 in the sample, each refugee had a designated approved number from HIAS Verification: In the one exception where a refugee was a lawful permanent resident, JFSSV conducted its due diligence in the verification process and identified the client. This was immediately reported to the funder and rectified as required by the funder. Documentation: During the fiscal year 21/22, amidst the wrap-up of COVID-19, intake was conducted via telehealth processes, and verbal approval was accepted. Additionally, not all services required forms to be signed, such as “providing information on accessing legal permanent resident status, family reunification procedures, assisting school-age children.” These services were verbally discussed during the intake process and updated in the refugees' case notes in the funder system. JFSSV has provided Harshwal & Company LLP with detailed explanations on all samples and provided testing requirements with refugee backup during the audit. JFSSV ensures proper documentation and support as required by the grantor's requirements, and JFSSV adheres to all monitoring visits and grant program reviews To address the specific concerns raised regarding internal controls over compliance and eligibility verification, JFSSV will: Enhance the Eligibility Verification Process: JFSSV will continue to review and strengthen its eligibility verification process to ensure that only enrolled refugees receive funding. Regular Staff Training: JFSSV will ensure continuous training to ensure they are well-versed in the updated guidelines and best practices for eligibility verification and documentation required from the Funder. Improve Documentation Practices: JFSSV will continue best practices in validating eligibility determinations and related documentation to be complete, accurate, and current. This includes maintaining thorough records in the case note log within the Funder’s system.