Corrective Action Plans

Name of Auditee: City of Niagara Falls, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2022 CAP Prepared by: Daniel Morello, City Controller Phone: (716) 286-4346 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2022-002 Management's Response The City is in agreement with this audit finding. Due in part to delays in finalizing both the 2021-2022 annual action plan and the 2022-2023 annual action plan, the City was delayed in being able to utilize those funds until approval was provided by HUD. The City continues to direct funds to projects that have the ability to be completed in a timely manner in order to be consistent with the CDBG regulation related to timeliness. The City is aware of the timeliness requirements and will continue to select projects that better allow the City to operate in accordance with these regulations. Estimated Completion Date - Next HUD verification date of May 1, 2024

Finding 2022-001 Contact Person responsible for corrective action: ? Alex Cheung ? Director of Finance and Accounting ? Lynna Magnuson ? Director of Supported Housing Anticipated completion date: 6/30/23 Corrective Action Plan: 1. All rents that were able to be recalculated for June 2022, were recalculated and have been provided 2. The SO Rent Worksheet will be updated with the correct rent calculations reflecting for June 2022 and submitted as evidence of corrective action 3. Going forward, rents will be calculated initially upon program entry and at least annually, in addition to any time income changes for a client, in accordance with HUD guidelines 4. Rent calculations and supporting documentation will be uploaded to a Shared file with Caminar?s Finance Department to allow for audit, cross-referencing, reporting, and security of information 5. Records will be audited and quality assured internally at least quarterly 6. An annual rent calculation checklist will ensure that all documents are gathered within the 120 days prior to the annual certification and rent calculation. a. The annual checklist should be prepared by the staff and approved by the Program Director on an annual basis. b. The same annual checklist will be reviewed by Accounting Department.

2022-011) Program Income Management?s response and corrective action is as follows: The OCD utilizes a loan service agency to manage, administer and oversee the funds for the loan program. Requests for loan forgiveness are submitted to the OCD monthly for staff approval. All loans are reviewed for forgiveness in compliance with the Code of Federal Regulations and are approved by the OCD and the Office of the Mayor-President before being executed by the Parish Attorney?s Office to provide multiple layers of review. Case files are maintained at the OCD. Documentation of monthly reconciling has been provided along with an accounting ledger on the change in the loan balance in 2022 as caused by escrow support and loan forgiveness activities for low to moderate income residents, but we acknowledge that this process could be improved. The OCD is working to develop additional internal controls and will evaluate the current loan service agency?s effectiveness at managing, reconciling, and providing reports on the portfolio. Expected Implementation Date: October 2023 Contact person: Marlee Pittman, Interim Director, Office of Community Development

2022-010) Program Income Management?s response and corrective action is as follows: The Office of Community Development (OCD) provides funding to affordable housing developers using Federal funds. Since 2021, the OCD has worked alongside dozens of developers, the State, and private investors to add over 800 units of affordable housing to our housing market. These affordable housing funds are often provided to nonprofits and local developers by means of a forgivable loan. This loan is intended to generate no income, but instead allows the parish to place a lien on the property to enforce the long-term affordability requirements required by the Federal government. The outsourced loan servicing agency provides administrative support for the HOME mortgage program and interest generating activities; however, the affordable housing support is not a part of that scope. Instead, the City-Parish Parish Attorney?s Office works alongside the Office of Community Development and the Clerk of Courts to record the forgivable loans as liens on the property. The lien ensures that developers are unable to sell the home for market rate activities or otherwise dispense of the property or manage the property in a way that is incompliant with the Code of Federal Regulations. Expected Implementation Date: December 2024 Contact person: Marlee Pittman, Interim Director, Office of Community Development

2022-009) Program Income Management?s response and corrective action is as follows: The OCD utilizes a loan service agency to manage, administer and oversee the funds for the loan program. Requests for loan forgiveness are submitted to the OCD by the loan service agency monthly for staff approval. All loans are reviewed for forgiveness in compliance with the Code of Federal Regulations and are approved by the OCD and the Office of the Mayor-President before being executed by the Parish Attorney?s Office to provide multiple layers of review. Case files are maintained at the OCD. Documentation of monthly reconciling has been provided along with an accounting ledger, but we acknowledge that this process could be improved. The OCD is working to develop additional internal controls and will evaluate the current loan service agency?s effectiveness at managing the portfolio. Expected Implementation Date: October 2023 Contact person: Marlee Pittman, Interim Director, Office of Community Development

We have been and are budgeting to spend more money in 2023 than we have collected or will collect in revenues. We are anticipating a deficit in 2023 for the Child Nutrition Program. This will cause our Net Cash Resources to decrease.

Finding 2022-001 PROGRAM INCOME ? CFD #93.224 (Significant Deficiency in Internal Control over Compliance) Response: Corrective Action Plan The Operation Department will conduct a verification of the sliding fee scale. In their internal monthly Sliding Fee Discount audit process, the Site Manager is to review and verify each patient application, to the current Federal Poverty Level, to ensure patient is receiving the correct discount. Attached is a copy of policy and procedure for this corrective action plan.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Andrew Nicodemus Contact Phone Number: 765-362-2342 Views of the Responsible Official: We agree with the finding. Description of Corrective Action Plan: Crawfordsville Community School Corporation plans to review all internal control procedures, including the control procedures over Program Income for the Child Nutrition Cluster. After this review, we will implement a system to ensure that compliance with the federal program income requirements is met. Anticipated Completion Date: We expect this Corrective Action to be implement by the end of April 2023 to allow for a full review of all internal control processes and procedures.

Financial Statements On identification of the issue, management began reporting program income within 30 days as appropriate. All program income has been receipted appropriately. Management will continue to enter the required program income within 30 days. Management has a process for tracking program income and reflecting it properly in their accounts. This process was in place and functioning for all of 2022. Corrective Action Plan Pages Finding Number: 2022-001 Federal Assistance Listing Number: 14.239 HOME Investment Partnerships Program Year Ended: December 31, 2022 Responsible Individual: Mark Opalka Fiscal Consultant Management?s Response and Corrective Action Plan: The Agency agrees with the finding and recommendation. For part of 2022, the Agency did not report all program income timely in IDIS. On identification of the issue, management began reporting program income within 30 days as appropriate. All program income has been receipted appropriately. Management will continue to enter the required program income within 30 days. Management has a process for tracking program income and reflecting it properly in their accounts. This process was in place and functioning for all of 2022. The above procedures have already been implemented.

Corrective Action Plan and Status of Prior Year Findings Management?s Corrective Action Plan: Individual(s) Responsible for Corrective Action Plan Tysha Dixon Director, Financial Reporting (215) 496-8168 Anticipated Completion Date Completed March 2023 Management?s Corrective Action Plan Management will continue to rely on its existing controls in place; however, noting that Management will closely monitor loans and loan disbursements where the funding source has changed closely to ensure that disbursements are in accordance with funding terms and approval limits. Management will continue to rely on its existing controls that are in place, including the ongoing communication with the City for any changes in transactions that require their approval. In the circumstances where management is pending a contract amendment from the City for loans requiring additional funding, management will determine if there are unrestricted funding sources to support the change in the approved amount of the loan until the amended contract is finalized. Questioned Program: CFDA #14.218 Community Development Block Grants (CDBG)

WSIN concurs on finding 2022-002. To prevent further incidences, WSIN plans to revise its written accounting procedures to strengthen internal control policies on reporting program income. Greater emphasis will be taken to ensure the general ledger is updated in a timely manner, so program income is reported on the federal financial quarterly reports based off the WSIN general ledger rather than a secondary tracking spreadsheet. WSIN management will ensure financial reporting has been through a secondary review prior to submission to US DOJ/OJP/BJA.

Condition: As of the March 31, 2022, reporting date, the Town reported obligations of $5,044,950 while actual obligations were only $1,134,400. Corrective Action Planned: With the reporting due on 4/30/23 the method of reporting on the obligated funds will be utilized when submitting the report. Anticipated Completion Date: 4/30/23 Contact: Kristine Russell, Town Accountant

2022-004 Assistance to Tribally Controlled Community Colleges and Universities ? Assistance Listing No. 15.027 Recommendation: We recommend that the College implement a process for tracking program income and returning the funds in accordance with the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has taken corrective action by seeking guidance and preferred treatment of advance draws. The College has implemented a process to track interest earned on advance draws and plans to utilize such earnings in accordance with the guidance obtained from the granting agency. Name of the contact person responsible for corrective action: Shona Campbell, Business Office Director Planned completion date for corrective action plan: June 30, 2023

Item 2022-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement: Reporting Criteria: The U.S. Department of Treasury SLFRF Compliance and Reporting Guidance requires the County prepare quarterly submissions of the Project and Expenditure Report. The 2022 Compliance Supplement identifies multiple Key Line Items in the report, including cumulative expenditures and current period expenditures. Internal control should be established and maintained to provide reasonable assurance that these requirements are complied with by submitting the reports accurately. Condition: For the fiscal year under audit, the Project and Expenditure Report reported cumulative expenditures as program income, and the total obligation was reported as cumulative expenditures before the amounts had actually been spent. Cause: The County followed a process for reviewing the reports and understanding program requirements; however, the new and emerging nature of the program and related guidance limited the internal knowledge necessary to identify the errors. Effect: Required reports submitted to the Federal Agency contained inaccuracies to identified key elements. Recommendation: We recommend that the County expand its review process for key reports to consider if new or emerging funding merits additional staff training or the engagement of outside assistance. PERSON RESPONSIBLE FOR CORRECTION ACTION: Becky Haynes, County Auditor CORRECTIVE ACTION PLANNED: We agree with the finding and have initiated discussions to provide training and implement procedures to ensure compliance. ANTICIPATED COMPLETION DATE: September 30, 2023

2022-003 Child Nutrition Cluster Recommendation: School Corporation management should establish a system of internal controls to ensure compliance with the grant agreement and program income requirements. Documentation should be retained to support the existence and accuracy of all program income earned. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation with review existing control processes surrounding program income and strengthen procedures to ensure documentation to support program income is adequate and reviewed. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

Finding 2022-003 Federal Transit Cluster - SEFA Management?s or Department?s Response: Management agrees. Views of Responsible Officials and Corrective Action: SCRRA will document the process to review the SEFA from prior year. Compare the SEFA to the final Single Audit Report to ensure the ending balances tie back to the Single Audit Report, before starting the current year?s SEFA. Name of Responsible Person: Thelma Bloes Implementation Date: June 30, 2023

Twin Oaks will implement a policy so that only the cash needed will be drawn down to cover expenses to ensure that excess cash is not drawn down. This will be reviewed on an annual basis or as needed.

Finding 2022-001 Condition: As of the March 31, 2022 reporting date, the Town expended $137,500 related to first responder bonuses. However, no obligations or expenditures were reported in the Project and Expenditure report. Corrective Action Planned: It is anticipated the ARPA portal will be open in April. The reporting will be updated in the portal by April 30, 2023. Anticipated Completion Date: April 30, 2023 Contact: Victoria Rose, Town Accountant

Finding 2022-005 Child Nutrition Program Income and Expense Report The Food Service Income and Expense Report for the year ended 6/30/22 was revised March 29, 2023 by the food service bookkeeper and reviewed by Crossmark Business Services before it was entered. The error in the federal reimbursement was corrected as well. To prevent these errors from happening in the future, Crossmark has created an excel file to make it easier for the food service bookkeeper to complete this report. Any submissions or revisions will be reviewed by Crossmark Business Services before they are entered in the CNP website.

Finding: Certain timecards within the Child Nutrition Cluster - Assistance Listing #10.555, #10.553 and COVID-19 #10.559, were not properly approved prior to payment of the payroll expenditure. Response: Application used to accumulate time and attendance records does not contain embedded administrative programming and controls to ensure all time and attendance information is approved by the employee and supervisor prior to payroll preparation. Management is working with the software provider to develop and embed the appropriate administrative controls and procedures to provide automated processing. In the immediate term, management will, with the assistance of the software provider, develop and utilize a hard copy report of all time and attendance records for each pay period by employee, school and/or department. Prior to payroll preparation, all entries on the report will be reconciled and manual employee and supervisor approvals will be documented. Principals and Department Heads will receive training in proper procedures for timecard approval. Anticipated Completion Date: August 2023

2022-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corporation has conducted several staff trainings and has revised its review procedures for checking compliance to improve monitoring of the process by the Corporation. Completion Date: Estimated December 2023 Contact Person: Rajuan Sherman Chief Financial Officer 2731 M.L. King, Jr. Blvd Tuscaloosa, AL 35403 (205) 614-6070 rsherman@whatleyhealth.org

FINDING 2022-001 Condition: The Organization had allocated expenditures, which supported an activity that generated program income, to a federal award that was not a major program. This program income was not deducted from total allowable costs or added to the award. The auditor discovered the expenditures during a scan of the expenditures allocated to federal awards and requested that the Organization analyze its charges to federal awards to determine if there were additional amounts. The total of such expenditures discovered was $3,655. Recommendation: The Organization should reevaluate its procedures and controls regarding the allocation of expenditures, which supported an activity that generated program income, to a federal award to ensure proper compliance. Planned Corrective Actions: The Organization agrees with the finding and plans to carry out the recommendation noted above by October 31, 2023.

2022-002 Community Development Block Grants/State?s Program and Non-Entitlement Grants in Hawaii We recommend that the City develop and maintain policies and procedures regarding loan monitoring and ensure that all documentation of loan monitoring be maintained on an annual basis. Management?s Response: Finance was unaware of the need to have current utility bills included with the files. Responsible Individual: It is the Finance Director?s, Emily Aldrich, responsibility to ensure that all loan files are complete and accurate. Corrective Action Plan: An annual checklist has been added to each loan file to ensure that all proper documentation is included. Anticipated Completion Date: March 31, 2023 ? all files will be updated with the necessary checklist and appropriate documentation.

Staff will strive to submit the reports by the required deadline and will work with their third-party consultant to assist as necessary. Staff has been in contact with its HUD representatives about the program income issue as well as the difficulty in posting PR 29 reports. Responsible Person: Rosemary Perch Expected Implementation Date: 07/01/2023

Finding 2022-001 Name of Contact Person ? Tammy Krei, Director of Housing & Neighborhood Development Corrective Action Effective immediately, the Housing & Neighborhood Development (HND) Department will, on much timelier basis, forward monthly IDIS program income balancing reports received for all grants to the Finance Department for balancing/reconciliation with the WCDA General Ledger.