Corrective Action Plans

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,

Finding No. 2022-003 Corrective Action Plan 1. Name of the contact person responsible for corrective action Brooks Champion- Controller 2. Corrective action planned ROH will implement controls and processes to ensure program income is reviewed by those familiar with both the program and specifically the program income allocation methodology prior to submission and that evidence of review is maintained. 3. Completion date April 15, 2023 4. If the client does not agree with the audit findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding No. 2022-003 5. The reference numbers the auditors assigned to the audit findings in the schedule of findings and questioned costs Finding No. 2022-003

Finding No.: 2022-_ 004__ Condition: The District prepared analysis of the profitability of the food service program was not clerically accurate by a material amount. Plan: The profitability analysis will be reviewed by someone independent of the preparer to ensure that all food service receipts and disbursements are included in the profitability analysis. Anticipated Date of Completion: 06/30/2023 Name of Contact Person: Adam Clapp Management Response: Management will implement the corrective action plan for the year ended June 30, 2023.

Contact Person ? Kenneth Azure, Executive Director Corrective Action Plan ? Management will review its policies and procedures for grant reporting. Completion Date ? 12/31/2022

2022-001 Community Development Block Grants/State?s Program and Non-Entitlement Grants in Hawaii We recommend that the City only report actual program income expended during the fiscal year instead of amounts authorized to be expended. Management?s Response: We concur with the finding. The City currently has a large grant from CDBG related to the upgrade of the Memorial Park Pool Facility. The City inadvertently reported a use of program income towards the project (which is required). However, it was determined that the grant funds were first used as the project was still ongoing. Responsible Individual: Andy Heath, Finance Director Corrective Action Plan: The City will work to assure the proper amounts of grant and program income are reported to the auditors. Anticipated Completion Date: FY 2022-23

2022-02: Significant Deficiency ? Program income compliance and controls Federal Agency: Department of Health and Human Services Program: Certified Community Behavioral Health Clinic Demonstration Grant Assistance Listing Number: 93.829 Management agrees that during the year ended December 31, 2022, Flushing did not have a formal control in place to identify, monitor and report program income collected from providing mental health counseling services to patients under the grant. Management has contacted The Department of Health and Human Services to inform them of this finding. Medisys Health Network, which includes Jamaica Hospital and Flushing, is the recipient of various federal grants, including another grant with program income requirements which was identified as a result of management?s review of the awards and for which controls have been designed and implemented to ensure compliance with the requirement. We believe our oversight of this compliance requirement was an isolated situation because the NoA only included one brief sentence regarding program income. Flushing will implement the following process to formalize controls related to the program income compliance requirement for the grant. 1) Management will review monthly charge/income reports for each clinician hired under the grant to keep track of the program income related to the grant. Management has started reviewing the program revenue and will set up quarterly reviews with the program director. 2) Management will keep track of all program income related to the grant and compare the income to the current expenses, and retain documentation supporting how the program income was used to further eligible project objectives prior to requesting reimbursement from the agency under the grant. 3) These controls and procedures will be implemented by the end of the 3rd quarter of 2023. Management responsible for corrective action plan: Gina Aharonoff, Program Director (gaharono@jhmc.org) Manzar Sassani, Vice President of Finance (msassani@jhmc.org)

The income verification process has been reviewed the Director of Food Service. She understands that the verification must be an official document of earnings (i.e. paystub).

2022-016 Finding: Program Income - ALN 14.239 ? Home Investment Partnerships Program / Department of Housing and Urban Development / Award Number: M22-MC080204 / Award Year: 2022 Status: Corrective action in progress Corrective Action: The City agrees with the finding as this was a simple oversight for the finance team due to the extreme staff shortages we?ve encountered over the last year. HOST has a process of reviewing and approving program income in Workday and associated grantor entries. We are filling vacancies to support the general ledger transactions and currently onboarding a new staff accountant to support this effort. Del Norte Loan # 34-36-01 had cash flow in 2021, and a subsequent payment due in 2022. An interest payment of $48,500 was completed credited correctly. The interest was booked in the General Ledger (GL) under HOME/GR2437 instead of NSP2/GR98, causing the NR to be inaccurately overstated in HOME/GR2437 and understated NSP2/GR98. This has been remediated going forward by practicing a process of reconciling each fund with each revenue category. Person(s) Responsible for Implementing: HOST ? Ami Webb Implementation Date: August 2023

ACED will make all necessary adjustments in its next Cash on Hand submission which occur in October 2023. Going forward the Cash on Hand report will be reviewed by Senior Staff for accuracy and completeness.

B. Corrective Action Plan: Any corrections that have not already been made will be made in a timely manner. ACED typically waits to receipt certain Program Income in order to be in compliance with CDBG program regulations. ACED will develop a schedule for receipting Program Income that will result in all Program Income being receipted in a timely manner.

Home Investment Partnership Program 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: Responsible Individual: Corrective Action Plan: Anticipated Completion Date:

Community Development Block Grants/State?s Program and Non-Entitlement Grants in Hawaii We recommend that the City develop procedures to ensure that the CDBG Annual Performance Report is filed by the required due date. Management?s Response: Responsible Individual: Corrective Action Plan: Anticipated Completion Date:

Finding 2022-002 Condition: As of the March 31, 2022, reporting date, the Town underreported federal expenditures by $211,064. Corrective Action Plan: The Emergency Management Director will confirm with the Finance Director the ARPA expenditures being submitted to Treasury on the annual Project and Expenditure Report, and reconcile with expenses listed in all applicable MUNIS accounts. Anticipated Completion Date: 4/30/2023 Contact Information: Chief Michael Cassidy, Emergency Management Director cassidym@holliston.k12.ma.us Chris Heymanns, Finance Director ? Treasurer/Collector heymannsc@holliston.k12.ma.us

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Service Fund Balance Management Assessment - We concur with the audit assessment regarding this matter. Planned Corrective Action - The District is aware of the USDA fund balance requirements. The District operated under the Seamless Summer Option during fiscal year 2021-22 which allowed all of our students to eat both breakfast and lunch for free. The District received a large amount of federal funding which in turn resulted in more fund balance than allowed by USDA at 6/30/2022 ($5,466). The Food Service Director and Business Manager are in the process of creating a spenddown plan to be submitted to MDE which will move fund balance within an allowable range. Responsible Party - Business Manager Date of Planned Corrective Action - June 2023

Finding No. 2022-001 Criteria Per Uniform Guidance, the required reports for federal awards should include all activity for the reporting period, are supported by applicable accounting or performance records, and are fairly presented in accordance with governing requirements. Additionally, per HUD guidance, the Quarterly Cash on Hand report must be submitted to the respective field office within 30 days after the end of the reporting period. Condition For the seven Community Development Block Grants/Entitlement Grant reports sampled, disbursement and program income data reported on the report submissions did not directly tie to the general ledger. For four of seven reports sampled, the Quarterly Cash on Hand Reports were submitted after the federal report due dates. Corrective Action The Township will implement review procedures to ensure the IDIS system grant program reports are completed timely and are reconciled to the Township general ledger schedules monthly. Responsible Party Township Chief Financial Officer Anticipated Completion Date Corrective action procedures are already in place and operating.

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Condition: As of the June 30, 2022 reporting date, the City’s Project and Expenditure Reports overstated expenditures by $274,713 and overstated obligations by $14,045,059. Corrective Action Planned: ARPA Director reviews all expenditures for the quarter with City Auditor to reconcile cumulative expenditures and obligations for entry into portal. Anticipated Completion Date: October 31, 2023 Contact: Bridget Almon, Director of Financial Services Kara Humm, ARPA Director Sedryk Sousa, City Auditor

The Organization and the grantor will work to ensure that final financial reports will be accurate and tie to the underlying financial records in all respects at the end of the year. The grantor noted that they are not concerned about the accuracy of interim reports since the incorrectly reported information does not affect the funds reimbursement amount.Recommendation: We recommend that the Organization implements a review process to tie the monthly, quarterly, and annual financial reports to the underlying financial records as the reports are prepared. Planned Action: The Organization and the grantor will work to ensure that final financial reports will be accurate and tie to the underlying financial records in all respects at the end of the year. The Recommendation: We recommend that the Organization implements a review process to tie the monthly, quarterly, and annual financial reports to the underlying financial records as the reports are prepared. Planned Action: The Organization and the grantor will work to ensure that final financial reports will be accurate and tie to the underlying financial records in all respects at the end of the year. The grantor noted that they are not concerned about the accuracy of interim reports since the incorrectly reported information does not affect the funds reimbursement amount.