Corrective Action Plans

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.

Name of Contact Person: Alyssa McDermott Corrective Action Plan: The City of Woonsocket has experienced significant turnover over the past years. With the division of housing and community development fully staffed, a thorough review of project files has occurred. Properties that were funded through CDBG or HOME Entitlement funds are fully documented. Properties that are not owned by the City of Woonsocket or received funding from CDBG or HOME entitlement funds are not documented in this office. Properties owned by the Redevelopment Agency of Woonsocket, Woonsocket Housing Authority, or properties that HUD have foreclosed on are not documented by this office. Proposed Completion Date: 06/30/2023

Findings and Recommendations: Finding Type: Material Noncompliance with Laws and Regulations. Condition: The Academy?s NSFSA?s fund balance exceeded the allowable three months? average expenditures at June 30, 2022. The Academy had approximately 4.61 months of expenditures as fund balance at June 30, 2022. Recommendation: The Academy should submit a spend down plan and obtain Michigan Department of Education?s prior approval to improve the food quality or take other action to improve the program in accordance with 7 CFR 210.19(a)(2). Corrective Action Plan: The Academy is aware of the finding and has implemented procedures in order to prevent further noncompliance in the future. The Academy is working towards completion of the spend down plan currently in place which was previously approved by Michigan Department of Education. Responsible Department: Business department and Food Service department. Responsible Person: Frank Patterson (Business Manager) in conjunction with the Food Service Director and the Superintendent. Planned Completion Date (TBD or Date): Spend-down plan currently implemented and expected completion prior to June 30, 2023.

Reporting views of responsible officials and planned corrective actions Management will put in place procedures to ensure verification of tenant assets is done during recertification.

Reporting views of responsible officials and planned corrective actions Management will put controls and procedures in place that ensure all tenant files are maintained in accordance with the HUD Handbook.

Finding No. 2021-002 Internal Control Over Preparation ofthe Schedule of Federal Expenditures - ? The Organizations lack internal accounting control prevented management from identifying information necessary to prepare the Schedule of Expenditure of Federal Awards in a complete and accurate statement. ACTION PLAN: Management communicated with DYS staff asking for clarification, as they were not stated in the contract. These expenditures were identified once the clarification was received. The guidance received from DYS was used to prepare the TANF fund expenditures for FY 22. A MOU was issued by DYS for FY22 combining vee expenditures and Juvenile Justice for T ANF fund use. We did not have deferred income. Also, for FY 22, identification of state and federal funding was identified in the chart of accounts and classes. I exhausted all outside resources to confirm if proper identification was being made. Further efforts will be made to ensure federal expenditures are properly identified for the fiscal based financial reporting period and related federal schedules.

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER FINANCIAL REPORTING: Finding 2022-002 - Schedule of Expenditures of Federal - Awards CFDA Title and Number: 93.600 - Head Start and Early Head Start - Federal Agency: Department of Health and Human Services - Internal Control over Financial Reporting and Compliance: Auditee Responsibilities - Organization's Response 2022 and Corrective Action Plan: The Organization concurs with the recommendation and had already released updated financial policies and procedures as of September 2022. Further revisions will be made in 2023 and include specific instructions for particular grants including federal and state. Additional training is needed for all levels of the fiscal team as well as for program managers to better understand the fiscal requirements of each grant. It is acknowledged that the fiscal team must be expanded and restructured and we have already started the process of recruiting a new CFO. The new CFO will be expected to consistently maintain a comprehensive matrix including all grant requirements. During this time we are seeking a consultant to help us establish better processes, controls and systems and assist until a permanent CFO is established. Other consultants may be obtained for supportive services as needed/recommended in the future. All applicable staff (fiscal and management) will be trained regarding procedures to review grant expenditures for compliance with terms of the grant, and to maintain sufficient records that reconcile to amounts reported as grant expenditures. Further, a new accounting system, Blackbaud, with enhanced cost recording, reporting and budgeting capabilities, has been approved by our Board of Directors to be implemented at the start of the next fiscal year. This implementation includes extensive training for fiscal and program staff. The fiscal committee and the Board will receive monthly updates on the progress being made in these areas. (Current responsible party: Renee Hungerford, Executive Director/CEO) Auditor's Response to Organization's Response 2022 and Corrective Plan: We have noted the Organization's response which appears sufficient and appropriate in the circumstances, and we further note the certain referenced steps already taken in discussion with management.

Action: During the 2022 reporting year, we created and filled a Sliding Fee Discount Coordinator position for the primary purpose of ensuring completeness and processing accuracy of Sliding Fee Discount Program applications. This staff person meets with a majority of patient applicants to discuss the Program features and process steps as well as to assist in collection of supporting documentation and completion of the application itself. In addition, this staff member provides both scheduled and ad hoc training to other staff on the Program and audits those applications and practice management inputs completed by others. The performance and results of this employee has been excellent; however, the position was not filled with role responsibility until after the reported finding which occurred in 2022. There were no reported findings on selected samples processed in the second half of 2022 and subsequent to when the position took over responsibility for the Sliding fee Discount Program and we are confident the risk of future findings has been minimized. Anticipated Date of Completion: Completed Responsible Party: Steve Bevans, CFO and Ryan Willoughby, Sliding Fee Discount Coordinator

March 2, 2023 Shenandoah Area Agency on Aging respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, Virginia 22801 Audit period: September 30, 2022 The findings from the September 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 2022-004: Authorized Signer for Bank Accounts Condition: Four bank confirmations signed by the executive director were sent to financial institutions holding SAAA assets as part of our audit were denied due to being signed by an unauthorized individual. Criteria: As part of management's responsibility to safeguard assets, the authorized signer for bank accounts should be documented. Cause: Management was unaware the listing of authorized check signers had not been updated by the bank as requested. Effect: It is critical for an entity to be able to access its cash deposits held by financial institutions. When a listing of authorized signers is not updated, the entity opens itself to opportunities for loss. Terminated employees may still have access to organizational assets or the organization may be prohibited from accessing their accounts at financial institutions if there is no perceived authority to access the funds. FINDINGS-FINANCIAL STATEMENT AUDIT (Continued) 2022-004: Authorized Signer for Bank Accounts (Continued) Recommendation: Management or governance should determine who has access to bank accounts and ensure only the appropriate parties maintain ongoing access for the safekeeping of the organization's assets. Planned Corrective Action: This finding was caused by the bank not updating its signature cards as requested by the Agency. This finding was immediately corrected once identified by the auditors. 2022-005: Material Audit Adjustments Condition: During the audit, we detected one material misstatement in the trial balance presented to us to begin our audit that was considered a material audit correction. Criteria: Generally accepted auditing standards dictates that detection of errors in an audit is a strong indicator of a significant deficiency or material weakness. Accordingly, we are required to communicate this finding as such. Cause: Financial information was missing or inaccurate. Effect: Assets and liabilities were overstated. Recommendation: We recommend that management implement a process to ensure accuracy of balance sheet and statement of activity accounts. Planned Corrective Action: Management agrees with the finding. During the last quarter of the fiscal year, the finance department experienced a vacancy. As a result, we were short-handed. There was one account that was not reconciled in a timely manner. After the year end, the position has since been filled. All significant balance sheets will be reconciled in a timely manner as in previous years. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT 2022-001: Cost Sharing Fees, ALN 93.045 Special Programs for the Aging - Title III, Part Cl - Nutrition services and Special Programs for the Aging-Title III, Part C2 - Nutrition services, Program income Condition: Individuals receiving Title III-C funded services for home delivered meals were charged cost sharing fees. Criteria: Agencies providing services funded under the Title III-C programs may not charge cost sharing fees for the Title 111-C services under Title III-C per 42 U.S. Code? 3030 c-2(a)(2). Cause: No controls or processes were in place to prevent cost sharing fees being charged to individuals receiving services provided under Title III-C programs. Effect: The cost sharing fees for Title III-C services are not allowed under federal guidelines and therefore these fees are considered a questioned cost. Questioned Cost Amount: $4,400 Perspective Information: Noted two fees were charged for Title 111-C services out of a sample of twenty-five cost sharing fees. Recommendation: Cost sharing fees are not allowed to be charged for Title III-C services provided to individuals. Only voluntary contributions may be made for these services. Management should implement procedures to ensure these fees do not continue to be charged. Planned Corrective Action: Management agrees with the finding. As noted in finding 2022-005, the vacant position, which has now been filled, was responsible for compliance review. Additional procedural reviews and corrected report formatting have been implemented to prohibit cost-sharing fees from being charged to the program. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT (Continued) 2022-002: Unallowable Costs, ALN 93.053 Nutrition Services Incentive Program, Allowable Costs Condition: Administrative expenditures were improperly classified as expenditures funded by the Nutrition Services Incentive Program (NSIP). Criteria: NSIP funds may only be used to purchase domestic foods as outlined under Title 7 U.S. Code of Federal Regulations Part 250.68, Nutrition Services Incentive Program. Grant funding received through NSIP may not be used to pay for administration or other services. Cause: Unallowable costs were improperly classified to the financial records supporting NSIP expenditures and allowable costs were improperly allocated to other projects. Effect: Financial records supporting costs expensed under the NSIP award do not reflect the nature of the expenditures requested for reimbursement. Expenditures were misclassified within the financial records to improper programs and thus are considered a questioned cost. Questioned Cost Amount: $98,327 Perspective Information: Noted in one out of a sample of twenty-five expenditures charged to the Aging Cluster. Two of the items in the sample were expenditures charged to NSIP. We reviewed the list of the remaining expenditures charged to NSIP and confirmed the sample was representative of the entire population. Recommendation: It is critical for the underlying financial records to support an organization's claims for costs reimbursements under federal award programs with adequate documentation. Staff must allocate costs appropriately for allowable costs under each federal program and ensure expenditures charged to the federal programs are for appropriate purposes and are properly classified in the records to avoid noncompliance with federal regulations and program requirements. Planned Corrective Action: Management partially agrees with the finding. We agree that certain amounts were misapplied to the NSIP account. However, the funds did purchase food as required by the grant. We believe this to be a reporting error and not a misuse of grant funds. With the vacant position recently filled, we have added additional review procedures to prevent any reoccurrence of misapplication. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT (Continued) 2022-003: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging- Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part Cl - Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting Condition: The 13th Aging Monthly Report required by the pass through agency, Virginia Department of Aging and Rehabilitative Services (VDARS) was not submitted timely and contained inaccurate revenue and expenditure data. Criteria: VDARS requires the annual I3th Month Aging Monthly Report to be submitted by November 15t?h The report must contain complete and accurate information as a restating of the monthly reporting for the fiscal year. Cause: The 131 Aging Monthly Report was not reconciled to underlying financial records, resulting in unexplained differences between the report and trial balance provided as part of the audit. Additionally, the report was not submitted by November 15, 2022. Effect: The submission of the 13th AMR was not performed timely and included data that did not agree to underlying financial records. This should have been caught during the course of a review process before submission. Therefore, it is considered a significant deficiency of internal controls over compliance. Recommendation: Ensure reporting is submitted timely by the deadline stated by VDARS. Implement a review process for each monthly submission, including documentation of the review. Reconcile the federal, state and local totals reported in the Aging Monthly Report to the underlying financial records as stated in the financial system to ensure accuracy before submission to VDARS. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The AMR report was not filed in a timely manner. As noted in finding 2022-0005, the vacated position during the last quarter of the year was responsible for submittals. We note that the report has since been filed. With the position being filled, we believe the 13th AMR will be filed in a timely and accurate manner as in previous years. If the Federal Audit Clearinghouse has questions regarding this plan, please call Cindy Donaldson, Director of Finance at 540-635-7141. Sincerely yours,