Corrective Action Plans

2023-003 Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Sam Kimball Title:  Corporate Controller Phone Number: 202-296-9165 Estimated Completion Date – October 2024 Corrective Action: Management acknowledges the finding and notes that the costs identified related to a project that ended in March 2023. On October 1, 2023, the Foundation implemented a new ERP system that includes better controls around the period of performance, preventing transactions from being entered after the award end date and/or close out date, reducing the risk of recording transactions to projects outside of the stated period of performance. Therefore, management does not anticipate similar issues around period of performance going forward, as the risks are additionally addressed with the new system design.

2023-002 Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact: Sam Kimball Title:  Corporate Controller Phone Number: 202-296-9165 Estimated Completion Date – May 2024 Corrective Action: Management acknowledges the finding and notes that there are policies and procedures in place at the Foundation designed to mitigate this risk, as evidenced by the auditors noting no issues in the overwhelming majority of samples selected. In this specific instance, the Foundation overpaid the final invoiced amount and was issued a refund for the difference from the vendor during 2024.

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County review its procedures relative to allocating costs to Federal programs, and ensure only cost within the grant period are included. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements regarding period of performance. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

Low-Income Home Energy Assistance Program (LIHEAP) – Assistance Listing No. 93.568 Recommendation: We recommend the County design controls to ensure the accounting records reconcile to the reimbursement request and documentation be retained. Reconciliations should be reviewed and approved by an individual other than the preparer at the time of the request and this documentation should be retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure proper compliance with all program requirements. Community Resources staff have been trained on keeping proper detailed records of all cash draws. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Director of Community Resources. Planned completion date for corrective action plan: July 1, 2024

Section 8 Housing Choice Vouchers Program -Finding 2023-002 Finding – Of a sample size of 25 units that previously failed inspection, one unit did not pass reinspection within 30 days. Housing assistance payments were not abated nor was the tenant evicted resulting in questioned cost of $3,412. This is considered a significant deficiency in internal controls over compliance for special tests and provisions type of compliance related to Housing Quality Standards (HQS) inspections. The Agency has not properly performed HQS inspections in compliance with program requirements. Recommendation – The Agency design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Corrective Action – The Agency will increase oversight in the Section 8 Housing Choice voucher Program with respect to following up on units that previously failed inspections in accordance with HQS to ensure that established internal control policies are being followed on a timely basis. Implementation Date – August 1, 2024

Finding – Of a sample size of 21 tenant files, income was miscalculated on one file resulting in questioned costs of $304. This is considered a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Agency has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Recommendation – The Agency design and implement internal control procedures that will reasonably assure compliance with Uniform Guidance and the compliance supplement. Corrective Action - The Agency will increase oversight in the Section 8 Housing Choice voucher Program with respect to calculated income to ensure that established internal control policies are being followed on a timely basis. Implementation Date -August 1, 2024

Recommendation: We recommend that all purchases and payments are reviewed and approved, with part of that procedure being to review that the expenditures are allowable for the grant in which they are being recorded to. This review and approval should be documented so it is clear who reviewed it and when. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The School intends to ensure that all federal expenditures are reviewed and approved prior to purchase and prior to coding them to the federal program going forward. Name of the contact person responsible for corrective action: Verlon Laird Planned completion date for corrective action plan: 6/30/2024

Corrective Actions Planned or Taken We have instituted a new process to perform rent reasonableness review of all rental units as required and records retained. Completed June 30, 2024. Responsible individual: Valerie Tawrel (Phone number – 331.280.2245)

FINDING 2023-002: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Management will implement internal controls to ensure timely monthly contributions to the replacement reserve and will address the shortfall by making up the missed deposits in the subsequent period alongside the normal required contributions. Action Taken: The Organization will make the necessary required deposits to bring the balance of the reserve for replacement in alignment with requirements of Section 811 Capital Advance Program Regulatory Agreement.

Views of responsible officials and planned corrective action: Management agrees with the finding and will implement the aforementioned recommendations. Ketha Kimbrough, Executive Director, will be responsible to implement this corrective action by December 31, 2024.

CORRECTIVE ACTION PLAN Name and Number of the Project: Alamo Area Mutual Housing Association Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2023 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING 2023-003: Section 223(a)(7) HUD Insured Loan, Assistance Listing 14.135 - AAMHA Western Hills, LLC HUD Project No. 115-115888, AAMHA KPTP, LLC HUD Project No 115-35652 and Section 223(f) HUD Insured Loan, Assistance Listing 14.155 - AAMHA Calcasieu, LLC HUD Project No 115-11280Section 223(a)(7) HUD Insured Loan, Assistance Listing 14.135. Entity expenses and receipts were recorded on the incorrect project’s books. CORRECTIVE ACTION COMPLETED: a. AAMHA Western Hills, LLC - On April 24, 2024, $3,199 was received from an affiliate. b. AAMHA KPTP, LLC - During 2023, $16,321 was received from affiliates. On May 10, 2023, the Project received $8,027. c. AAMHA Calcasieu, LLC – On April 16, 2024, the Project received $5,869 from an affiliate. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Any questions regarding the above corrective action plan should be directed to Christine Drennon, Executive Director.

Finding: According to the Uniform Guidance, 2 CFR 200.303(a), non-Federal entities receiving Federal awards must establish and maintain effective internal controls over these awards. These controls must provide reasonable assurance that the entity manages the Federal award in compliance with applicable Federal statutes, regulations, and the terms and conditions of the award. The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, May 2023, requires the Alabama Department of Labor to operate a Worker Profiling and Reemployment Services (WPRS) or Reemployment Services and Eligibility Assessments (RESEA) program. The Alabama Department of Labor operates a RESEA program. Under the RESEA program, Alabama Department of Labor staff must be promptly and appropriately notified of any eligibility issues identified during any review of a claimant’s information. Claimants are also required to attend appointments for reemployment to maintain their eligibility status. The Alabama Department of Labor has controls in place to provide notification of claimants who failed to report to scheduled RESEA appointments, however those controls were not operating as designed. While reviewing 25 claimant’s information, we noted that 8 claimants failed to report to their scheduled appointments for reemployment. These failures to appear are reported to staff at the Alabama Department of Labor and should prompt a stop of benefit payments; however, the Alabama Department of Labor did not stop payment on these 8 claimants which resulted in overpayments totaling $8,884.00. There was also one instance where Alabama Department of Labor could not provide documentation to support staff was appropriately notified of the eligibility status for a claimant. The Alabama Department of Labor’s policies and procedures did not operate as designed to prevent payments to ineligible claimants. Because the Alabama Department of Labor’s internal controls were not operating as designed, this caused benefits to be paid to ineligible claimants. Recommendation: The Alabama Department of Labor should ensure internal controls are operating as designed to help ensure payments are not made to ineligible claimants. Response/Views: ADOL does not agree with this finding as explained in the Request for Views CAP letter. Corrective Action Planned: Issues reported were beyond ADOL control due to another system shared by multiple state agencies being brought down due to cyberattack. The shared system is not the system of record for UI benefit payments. UI claim records were manually reviewed by UI staff and noted accordingly upon review. Additional measures and procedures have already been implemented in case of future occurrences. Anticipated Completion Date: Already corrected. System processes implemented in October 2023 Contact Person(s): Thomas Daniel, ADOL Unemployment Compensation Division Director

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2023, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Public Health (ADPH) passed through a portion of the Immunization Cooperative Agreement federal award to subrecipients. During our audit, the ADPH’s Office of Program Integrity (OPI) notified us that based on its investigation a subrecipient was not submitting adequate supporting documentation for reimbursement requests. A total of thirteen subrecipients requested and received reimbursement of program expenses during the fiscal year. Based upon procedures performed, we noted that of the 13 subrecipients who received federal award reimbursements, six did not provide adequate detailed documentation to support their requests for reimbursement. In addition, forty-eight of the sixty-three invoices submitted for reimbursement by the subrecipients did not have adequate documentation resulting in questioned costs of $8,478,032.39 and one of the invoices included an improper payment of $2,600.00 for a total question cost of $8,480,632.39. The ADPH did not have adequate policies and procedures in place to ensure that all requests for reimbursement were supported by adequate detailed documentation to ensure all coast are allowed under the federal award. This is a material weakness in internal controls. Recommendation: The Alabama Department of Public Health should take action to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and to ensure costs are allowable under the federal award. Response/Views: We agree with the Examiners' finding; adequate documentation did not exist at the time of the audit to substantiate payments that resulted in questioned costs and improper payments. However, we do not concur with the total amount of the questioned costs cited in the report. ADPH's Office of Program Integrity initiated its own ongoing investigation. As this process continues, we are requesting additional documentation from the subrecipients, which will affect the questioned costs of this program. Corrective Action Planned: As noted, ADPH's Office of Program Integrity (OPI) has initiated its own internal on-going investigation. As part of that investigation, the Federal Grantor was notified of the situation and OPI is requesting supporting documentation from the sub grantees. ADPH is strengthening the internal control system for grants management. ADPH has and will continue to develop internal grant training for all employees who handle any phase of grant activities or have managerial responsibility for a grant. ADPH is working to make this training mandatory. In addition, the Centers for Disease Control has grant training available which will be utilized. The Bureau of Financial Services is establishing a Grants Management Office and has distributed grant tools such as a standard Risk Assessment Form for grant program use. Corrective action within the Immunization Division will include hiring additional staff to support the grant review and monitoring process. Immunization will implement the following procedures: • Grant guidance will be reviewed semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation for source documents will be reviewed against grant guidance as received by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied. • Grant monitoring staff will ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • Invoices or vague requests requiring additional documentation will be held until the necessary information is provided. • Ensure all program grant staff have access to and attend all available Finance and Grant training courses. • Engage assigned Grant Accountant quarterly or as needed. • Conduct a Risk Assessment on all new subrecipients within 30 days of a signed grant agreement which will be forwarded to OPI for review. • Immunization staff will conduct a Risk Assessment on all current subrecipients within 60 days which will be forwarded to OPI for review. • Immunization staff, along with Finance and OPI, will develop a subrecipient monitoring plan based on the Risk Assessment of each subrecipient. The monitoring plan will be completed within 30 days of the receipt of the completed Risk Assessment. • Copies of all completed monitoring activities, as outlined in the monitoring plan, will be forwarded to OPI. Anticipated Completion Date: April 1, 2025 Contact Person(s): Immunization: Denise Strickland, Immunization Division Director; Daniels, Immunization Operations Manager; Harrison Wallace, Director, Bureau of Communicable Disease; Bureau of Financial Services: Shaundra B. Morris, Chief Accountant; Office of Program Integrity: Debra S. Thrash, Director

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2023, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Transportation (the “Department”) passed through a portion of the Formula Grants for Rural Areas and Tribal Transit Program federal award to subrecipients. One of the subrecipients requested and received reimbursement of program expenses. Subsequent to the payments of the invoices, the Department received information alleging that falsified or altered documents related to expenditures submitted by a subrecipient. Upon receipt of these allegations, the Department initiated a review of the supporting documents which had been submitted by the subrecipient. The review consisted of obtaining documents from vendors and comparing those documents to the ones submitted by the subrecipient. The results of this comparison indicated that the amounts owed and the description of goods and services provided columns had been changed. Nine of ten supporting documents for meeting expenses submitted for reimbursement by the subrecipient during the audit period were altered and were not true and accurate. These altered supporting documents totaled $94,123.56. The Alabama Department of Transportation reimbursed the subrecipient based on the altered documents and, therefore, improperly expended Formula Grants for Rural Areas and Tribal Transit Program federal award funds. Recommendation: The Alabama Department of Transportation should take actions to ensure that all reimbursements of expenses are adequately documented, based on true and accurate supporting documentation, and to ensure costs are allowable under the federal award. Response/Views: We agree that there appears to have been falsified supporting documentation submitted by a subrecipient. Corrective Action Planned: Once we were made aware of the allegation, we began a thorough review of the subrecipient’s invoices. Based on the information discovered during our review, we notified the Federal Transit Administration, Alabama Attorney General’s Office, Alabama Ethics Commission, and the Alabama Department of Examiners of Public Accounts. The Office of Inspector General for the U.S. Department of Transportation is currently investigating the case. The subrecipient involved in this matter is no longer associated with our Transit Program. The duties that they performed were either moved to another subrecipient or in-house. We have modified our invoice review process, and the changes have been applied to all subrecipients for the Transit Program. Anticipated Completion Date: We have taken the steps outlined above as of August 28, 2024. Contact Person(s): Jeff Hornsby, Chief Financial Officer

Finding 2023-001: Reportable Finding Considered a Material Weakness – Eligibility Assistance Listing Number: 10.181 Agency: U.S. Department of Agriculture Program: Pandemic Relief Activities: Farm and Food Worker Relief Program (FFWR) Award Number: AM22FFWDC0002-02 Grant Years: 2023 Views of Responsible Officials – The Charity Foundation acknowledges the finding regarding the improper payment of 9,424 benefit checks to ineligible beneficiaries due to insufficient verification of employment and identity documentation. This resulted in $5,654,400 in questioned costs. We understand the seriousness of this issue and have implemented corrective actions to prevent future occurrences. Corrective Actions – Root Cause Analysis: The deficiency arose because the Foundation’s application portal, designed and managed by consultant contractors, failed to accurately verify employment and identity documentation, leading to the approval of ineligible beneficiaries. Revised Eligibility Verification Process: In November 2023, the Charity Foundation implemented updated procedures to enhance the verification of applicant eligibility under the FFWR program: • Initial In-Person Screening: Applicants must now provide proof of employment, such as a paystub or W-2, in person at their place of work (farm, meatpacking facility, or grocery store). This initial screening is intended to ensure that workers are properly verified before accessing the application portal.   • Unique Identifier Creation and Control: The Charity Foundation creates and controls unique identifier codes used for logging into the application portal. These identifiers ensure secure access and prevent duplicate applications. During the initial screening process, the consultants assisting with the sign-up process distribute these unique identifiers to each eligible worker in person at the plants. • Portal Access and Document Submission: After receiving the unique identifier, applicants log into the portal and are required to upload their identification documents. A dedicated team manually reviews each document to verify that the applicant’s identity and employment meet FFWR eligibility requirements and that the information matches the details entered by the applicant. Ongoing Monitoring and Compliance: To ensure the integrity of the process, the Foundation’s internal review team conducts regular compliance checks on the submitted documentation. This ongoing monitoring process ensures that all uploaded documentation meets program standards. Staff Training: The Foundation will continue to train team members responsible for verifying applications. This training covers FFWR program requirements, proper identification and employment records review, and how to flag potential discrepancies. Regular training ensures the team remains informed of program expectations and changes. Consultant Accountability: We have revised our contract with the consultant contractors managing the application portal to establish stricter accountability measures. This includes ongoing performance reviews and quality control checks to ensure the portal supports accurate identification and employment verification. Results: These changes were successfully implemented in November 2023 and are now the standard operating procedure for the Charity Foundation’s FFWR program. Responsible Person: The Director of Finance is responsible for overseeing the implementation of the updated eligibility verification process. The Director also ensures compliance with FFWR requirements through continuous monitoring and periodic internal audits. Completion Timeline: The corrective actions were fully implemented as of November 2023 and continue to be in effect for all FFWR program applicants moving forward.

Corrective Action Plan: In standing financial aid meetings, we will review Federal Loan limits and what our process/procedures are if a student is close to limits to insure, we don’t over award. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: 2024

THE COUNCIL WILL ENSURE THAT ALL FUTURE PROCUREMENTS CORRECTLY USE AND RETAIN A PROCUREMENT SHEET WHICH DOCUMENTS THE ITEMS PURCHASED, THE BIDS RECEIVED/REQUESTED, AS WELL AS AN ANALYSIS OF THE REASONS FOR THE WINNING BID. THE WINNING CONTRACTOR/VENDOR WILL BE SEARCHED ON THE SAM WEBSITE TO DETERMINE THAT THEY ARE NOT SUSPENDED/DEBARRED.

Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into place a monthly audit for ensuring compliance to the sliding fee discount policy. Responsible persons: Nichole Henderson, Quality Improvement Quality Assurance Director and Demetria Johnson, Billing Manager will be in charge of implementing the corrective action. Expected Implementation Date: Started August 1, 2024.

REFERENCE # 2023-002 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY Program WIOA CLUSTER: WIOA ADULT PROGRAM (Assistance Listing Number 17.258) WIOA YOUTH ACTIVITIES – (Assistance Listing Number 17.259) WIOA DISLOCATED WORKER FORMULA GRANTS – (Assistance Listing Number 17.278) Identification Number(s) VARIOUS AND AA-36336-21-55-A-36 Finding The Suffolk County Department of Labor (the “Department”) receives WIOA Adult; Youth and Dislocated Worker Formula Grants from New York State Department of Labor (the “Agency”). The Department reports to the Agency on an accrual basis, as required by the Agency. The County’s Schedule of Expenditures of Federal Awards (the “SEFA”) is presented on the accrual basis of accounting. The Department provides all supporting documents to the Agency for reimbursement. We noted that the Department included expenditures in the amount of $373,855, which were incurred and dated in the prior year. The Department recorded the expenditures and revenue in the 2023 financial statements. These expenditures were also added to the SEFA in calendar year ended December 31, 2023. Questioned Costs Cannot be determined. Recommendation We recommend the Department report expenditures on the SEFA on the accrual basis of accounting, which is the basis the County utilizes for other federal programs. Corrective Action Plan Throughout the year, the Department will regularly reconcile vouchers to ensure that expenditures and associated revenue are reported in the correct year on the SEFA. Two staff members in the department (one as the primary, the other as the alternate) will be assigned the responsibility of tracking the SEFA reconciliation process. When preparing the annual SEFA, the department will reconcile expenditure reports with the expenditures reported on the annual SEFA. During year-end processing, the Department, when entering vouchers into the financial system, will ensure items to be accrued will contain the letter “A” as a prefix to the voucher number. The Department will also check to ensure all items that should be accrued, are in fact accrued prior to year-end closing. In addition, the Department will confirm the date entered in the financial system, reflects the proper year in which the expenditure and associated revenue should be recorded. Action Date This process will commence on September 16, 2024. Final Implementation Date Implementation of this plan will be completed by 2/28/25. We recognize that since this is a continuous improvement process, we will review the success of our implemented procedures on an annual basis. Name And Phone No. Of Person Responsible For Implementation Paul Goerke (primary) 631.853.6606 Yvonne Spreckels (alternate) 631.853.6628

We will implement procedures to ensure that our policies and procedures requiring the maintenance of documentation to support expenditures claimed under federal awards be followed consistently for all claimed expenditures in October 2024.

We will implement procedures to maintain accurate timecards or time studies for employees who have payroll claimed under the federal programs beginning in October 2024. This is a repeat finding from last year’s audit. We did not receive the corrective action plan for this audit until February of 2024 to know to implement changes. In pulling these items, the same findings would be noted due to not knowing those changes needed to be made during 2023.

Management agrees with the finding. Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will provide a new updated Federal Awards and Accounting Manual to all management of Federal Awards.

Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2024

The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.

The County will ensure that procedures are in place to ensure support is maintained on file for eligibility determinations.