Corrective Action Plans

Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately

Plan of Action: Drafted new procedure that will be implemented 5/15/24 and will develop a tracking system in Microsoft Forms for the Project Director or Authorizing Officer requesting and approval funds by 6/1/24. Date of implementation: 6/1/2024

Plan of Action: The organization updated its F1.14 Federal Grants Management Policy on update 6/1/2023 and was approved by HRSA and reviewed and approved by the organizational board on 9/12/2023. The Annual Policy Bulletin will be reviewed and implemented annually. Date of implementation: 9/12/2023

The Organization will designate a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission.

2022-002 Reporting to the Federal Audit Clearinghouse (Material Weakness) Federal Agency: U.S. Department of Education Program Names: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555 and 10.559 Award Period: June 30, 2022 Recommendation: The Board of Education and management should implement internal control procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline. Action Taken (Unaudited): Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collections form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance. Contact Name – Tim Beying Expected Completion Date - 06/30/2024

2022-001 Preparation of and Internal controls over Schedule of Expenditures of Federal Awards Preparation (Material Weakness) Federal Agency: U.S. Department of Education Program Names: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555 and 10.559 Award Period: June 30, 2022 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 develop proper written policies and procedures for the internal control over compliance to ensure accuracy and completeness in the preparation of the schedule as required by Uniform Guidance during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance. Contact Name – Tim Beying Expected Completion Date - 06/30/2024

Item: 2022-004 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities – Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Centers for Disease Control and Prevention Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: The entity’s system of internal controls did detect, or document the rationale for, instances in which the amounts charged to a federal program did not agree to the underlying supporting documentation maintained by the Organization. Condition: The entity’s system of internal controls did detect, or document the rationale for, instances in which the amounts charged to a federal program did not agree to the underlying supporting documentation maintained by the Organization. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2023 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. Billings are reviewed by supervisors, including a review of the underlying supporting documentation, prior to submission of the billing. Additional training and record retention practices will be added and/or enhanced to ensure there is evidence of supervisory review of the underlying supporting documentation. Such review and record retention processes will include documentation of noted discrepancies and rationale for such discrepancies if not corrected.

Item: 2022-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities – Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Centers for Disease Control and Prevention Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.430 – Compensation – charges to federal programs for salaries and wages should be supported by a system of internal controls which provides reasonable assurance the amounts charged are accurate, allowable and properly allocated. Condition: The entity’s system of internal controls did not retain contemporaneous documentation of supervisory review over payroll allocations charged to the federal programs. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2023 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. Payroll allocations are monitored on a routine basis to ensure they are reasonable and accurate. Additional training and record retention practices will be added and/or enhanced to ensure there is evidence of supervisory review.

Finding 2022-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: William Arnold, Interim City Manager Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will also carefully review reporting requirements and ensure that requirements are adhered to. This includes the following programs: US Department of the Interior, US Department of the Treasury Federal Payment in Lieu of Taxes (PILT) and Coronavirus State and Local Fiscal Recovery Funds/ ARPA Non-profit Recovery Fund. Proposed Completion Date: Fiscal year 2023

December 27, 2022 Valley Community Services Board respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2022 The 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 - FINANCIAL STATEMENT AUDIT If the Federal Audit Clearinghouse has questions regarding this plan, please call Devin Foster, Director of Finance, or Dereck Criner, Director of Human Resources and Interim Chief Financial Officer during the audit period, at (540) 887-3200. 2022-007: Emergency Solutions Grant Program - AL #14.231, Controls over reimbursements and program monitoring (Material Weakness) Condition: The Community Based Services Supervisor is the only person involved with submitting reimbursement requests and monitoring the budget and expenditures for the program. A separate review of reimbursement requests is not performed. The accounting department is not involved with managing the program budgets. Criteria: More than one staff person should be involved for accountability and monitoring of the program. Expenditures used to recognize revenue in accounting should correspond to expenses reimbursed or identified for federal and state award programs. Cause: With turnover in accounting staff during the year, items were not reviewed or monitored for the program. Effect: Errors in reporting or misuse of funding could potentially go undetected due to lack of separation of functions and proper oversight. Recommendation: We recommend implementing internal controls over the reimbursement requests and budget monitoring process by involving another person prior to submitting the request. Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or Assistant Director or accounting. Views of Responsible Officials and Planned Corrective Action: Effective February 2022, all requests for reimbursement under this program are submitted by the fund manager to the program's Assistant Director prior to submission to Accounting. Reimbursement filings are provided to Accounting in a timely manner and a fund reconciliation spreadsheet will be created to share with the fund manager and Assistant Director on a monthly basis. Additionally, Accounting now receives a copy of the submitted reimbursement requires and will be including a review of expenses, requests for reimbursement, and reimbursements received as part of the monthly reconciliation. 2022-008: Emergency Solutions Grant Program-AL# 14.231, Controls over cash management and reimbursement requests (Material Weakness) (Continued) Condition: Requests for reimbursement were not submitted timely, with multiple months submitted 80 days after the expenditure had incurred. Amounts recorded for revenue did not accurately reflect final requested reimbursement. Criteria: Reimbursements should be submitted timely and should be provided and reconciled to financial data in general ledger by accounting team. Differences should be resolved, and reimbursement received should ultimately reflect total program revenue in general ledger. Cause: With turnover in staff during the year, items were not always available timely. In addition, management was not always aware of reporting requirements or aware of activity under program reimbursements. Effect: Errors in reporting could ultimately lead to differences in financial accounting vs program activity. Accurate and timely reporting and requests can improve cash flows and ensure program is able to meet funding needs. Recommendation: Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or another individual in the finance department. These spreadsheets should ultimately identify amounts that were submitted for request for reimbursement and be recorded in the general ledger. Amounts recorded for revenue in the general ledger should agree between the two, with monthly or quarterly reconciliations performed to ensure financial reporting accurately reflects spending and reimbursement activity. Views of Responsible Officials and Planned Corrective Action: VCSB will amend the reconciliations process for CHERP to include a documented review and approval of all expenses, reimbursement requests, and reimbursements received. Additionally, the Accountant and Director of Finance are working with the program fund manager to submit requests for reimbursement in a more timely manner. Sincerely yours, Derek Criner Director of Human Resources

December 27, 2022 Valley Community Services Board respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2022 The 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 - FINANCIAL STATEMENT AUDIT If the Federal Audit Clearinghouse has questions regarding this plan, please call Devin Foster, Director of Finance, or Dereck Criner, Director of Human Resources and Interim Chief Financial Officer during the audit period, at (540) 887-3200. 2022-007: Emergency Solutions Grant Program - AL #14.231, Controls over reimbursements and program monitoring (Material Weakness) Condition: The Community Based Services Supervisor is the only person involved with submitting reimbursement requests and monitoring the budget and expenditures for the program. A separate review of reimbursement requests is not performed. The accounting department is not involved with managing the program budgets. Criteria: More than one staff person should be involved for accountability and monitoring of the program. Expenditures used to recognize revenue in accounting should correspond to expenses reimbursed or identified for federal and state award programs. Cause: With turnover in accounting staff during the year, items were not reviewed or monitored for the program. Effect: Errors in reporting or misuse of funding could potentially go undetected due to lack of separation of functions and proper oversight. Recommendation: We recommend implementing internal controls over the reimbursement requests and budget monitoring process by involving another person prior to submitting the request. Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or Assistant Director or accounting. Views of Responsible Officials and Planned Corrective Action: Effective February 2022, all requests for reimbursement under this program are submitted by the fund manager to the program's Assistant Director prior to submission to Accounting. Reimbursement filings are provided to Accounting in a timely manner and a fund reconciliation spreadsheet will be created to share with the fund manager and Assistant Director on a monthly basis. Additionally, Accounting now receives a copy of the submitted reimbursement requires and will be including a review of expenses, requests for reimbursement, and reimbursements received as part of the monthly reconciliation. 2022-008: Emergency Solutions Grant Program-AL# 14.231, Controls over cash management and reimbursement requests (Material Weakness) (Continued) Condition: Requests for reimbursement were not submitted timely, with multiple months submitted 80 days after the expenditure had incurred. Amounts recorded for revenue did not accurately reflect final requested reimbursement. Criteria: Reimbursements should be submitted timely and should be provided and reconciled to financial data in general ledger by accounting team. Differences should be resolved, and reimbursement received should ultimately reflect total program revenue in general ledger. Cause: With turnover in staff during the year, items were not always available timely. In addition, management was not always aware of reporting requirements or aware of activity under program reimbursements. Effect: Errors in reporting could ultimately lead to differences in financial accounting vs program activity. Accurate and timely reporting and requests can improve cash flows and ensure program is able to meet funding needs. Recommendation: Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or another individual in the finance department. These spreadsheets should ultimately identify amounts that were submitted for request for reimbursement and be recorded in the general ledger. Amounts recorded for revenue in the general ledger should agree between the two, with monthly or quarterly reconciliations performed to ensure financial reporting accurately reflects spending and reimbursement activity. Views of Responsible Officials and Planned Corrective Action: VCSB will amend the reconciliations process for CHERP to include a documented review and approval of all expenses, reimbursement requests, and reimbursements received. Additionally, the Accountant and Director of Finance are working with the program fund manager to submit requests for reimbursement in a more timely manner. Sincerely yours, Derek Criner Director of Human Resources

Finding Number: 2022-007 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: Guidance and timelines for reporting on the CSLFRF award have been changing constantly. Staff will take better care to follow future guidance. Additionally, all funds have been expended. Anticipated Completion Date: Completed

2022-002 Inadequate Supporting Documentation Material Weakness The Chairman of the Tongue River Valley Joint Power Board will make two copies of all invoices. One set of invoices will be retained by the Chairman and the other will be retained by the treasurer to improve the necessary documentation. This process began June 2022 and is ongoing.

Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2022, the Hospital should have USDA debt reserves at least equal to $320,669. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Compliance Requirement: Allowable Costs and Activities Finding Summary: The Hospital opted for a budget to actual comparison for the calculation of lost revenue as an alternate reasonable methodology, however the actual amounts used did not consider adjustments during the fiscal year. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Period 4 reporting was completed prior to the financial statement audit for fiscal year 2022. Management will evaluate the process for the calculation of lost revenues to incorporate any financial statement adjustments.

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Compliance Requirement: Reporting Finding Summary: The Hospital opted for a budget to actual comparison for the calculation of lost revenue as an alternate reasonable methodology, however the actual amounts used did not consider adjustments during the fiscal year. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Period 4 reporting was completed prior to the financial statement audit for fiscal year 2022. Management will evaluate the process for reporting to consider any financial statement adjustments.

Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2022 Compliance Requirement: Special Tests and Provisions – Reasonable Rental Rates Grant Award Number: CA0955L9T032007, CA0955L9T032108, CA0143L9T032013, CA0143L9T032114, CA1303L9T032006, CA1303L9T032107 Finding Summary: As a result of our procedures performed, we noted for 56 out of 60 rental payment transactions tested, the Organization did not have policies and procedures in place to ensure the reasonableness of contract rents being paid for individual housing units in relation to rents being charged for comparable units. This should have included an analysis of rents in the immediate area of the participants housing. However, we noted the rental payments made using grant funds did not exceed the HUD-determined fair market rents and ranged from 1% to 39% below the 2022 HUD-determined fair market rents. Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Develop policies and procedures for staff working on grants to ensure that all contract rents being paid for individual housing units are reasonable in relation to rents being charged for comparable units. Additionally, the policies and procedures will ensure that grant funds being used to pay rent will not exceed HUD-determined fair market rents. • Train grant staff on new policies and procedures. Name of Responsible Person: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024

Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all the documents are in place before processing the determination of eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A checklist will be created that staff will use to check off all relevant data that has come in. This list will be reviewed by the Intake team before files are sent to Public Housing. Name(s) of the contact person(s) responsible for corrective action: Myvy Ngo Planned completion date for corrective action plan: Immediately

Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management to assign a person that verifies all relevant documents are gathered and added to the tenant file before processing new move ins. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A checklist will be created that staff will use to check off all relevant data that has come in. This list will be reviewed by the Intake team before files are sent to Public Housing and public housing will review again before moving a prospective tenant into housing. Name(s) of the contact person(s) responsible for corrective action: Myvy Ngo Planned completion date for corrective action plan: Immediately

Please be informed, due to the late filing of the single audit, the corrective action plan will be completed with the 2023 single audit.

Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were appropriately tracked to meet award requirements. In addition, it was identified that all expenses did not have adequate documentation supporting the review and approval of the amounts meeting the matching requirements. Additionally, select payroll allocations did not have supporting documentation for the amounts allocated to the program. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to appropriately track and monitor matching requirements in each period for all awards. In addition, we will implement approval processes to ensure proper qualification for the match requirements and allocations. Anticipated Completion Date: December 31, 2023

U.S. Department of Education Education Innovation and Research CFDA #84.411C Finding Summary: A complete system of internal controls requires all expenditures to be properly approved and supported by appropriate documentation. In addition, all expenditures charged to the federal programs are required to be allowable costs under the program and allocated in accordance with CFA’s cost allocation plan. Responsible Individuals: Lona Teague, Jessi Black, All Staff Corrective Action Plan: Staff will ensure that all expenditures are supported by appropriate documentation and allowable under the program it is allocated to. The finance department will ensure all expenditures are properly approved before payment. Anticipated Completion Date: 06/30/2024

The Village board of trustees will continue to provide additional oversight by making the budget committee a permanent standing committee that will meet quarterly to go over finances presented to them by the clerk and treasurer. Additionally, the budget committee will continue to go over line items of the budget comparison looking for incorrect entries.

The Village board of trustees will continue to provide additional oversight by making the budget committee a permanent standing committee that will meet quarterly to go over finances presented to them by the clerk and treasurer. Additionally, the budget committee will continue to go over line items of the budget comparison looking for incorrect entries.

Audit Finding Reference: 2022-001 Improve Time and Effort Documentation Planned Corrective Action: We understand the importance and requirement regarding this finding. Semi-Annual certification of all staff funded fully out of grants will be completed. Monthly Time and Effort certifications will be completed for all staff funded out of multiple accounts, grant or local. Stipend and Payment for additional work forms will be completed for all staff supporting grant funded activities outside of contractual time. These forms will be re­ viewed and maintained by Grant administrators. The district will use forms created and recommended for use by Massachusetts Department of Elementary and Secondary Education. Sample forms are attached. Name of Contact Person and Completion Date: Laureen Cipolla, Accountability and Student Achievement, laureen.cipolla@leominsterschools.org 978-537-7700 x l345 Anticipated date of completion - 6/30/23