Corrective Action Plans

Response/Views: We agree with the finding as it is stated. Corrective Action Planned: We shall comply accordingly for future federal fund projects requiring Davis-Bacon reporting. Anticipated Completion Date: NIA. The project has already taken place Contact Person(s): Cassandra Allen 334.864.9343

Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement     Contact: Chris Holmes   Title: Controller  Phone Number: 202-235-1938  Estimated Completion Date – done  Corrective Action  The results of the 2023 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on the allowability of trailing costs and the unallowability of newly incurred costs. During 2023, PSI resumed delivering in person training to its global finance and program staff and will continue to offer training during 2024.

Finding No: 2023-001 Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.498 Program: COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Compliance Requirement: Activities allowed or unallowed/allowable costs Award Year: January 1, 2020 through December 31, 2022 (a) Criteria or Requirement 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. (b) Condition Found The System did not have adequate controls related to determining allowability of expenditures for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Grant. Our testing identified one charge within the population that had been charged incorrectly to the federal program. This charge was for government contract labor totaling $126,313 that was determined to be an unallowable expenditure that should have been removed prior to submission to the federal agency. In addition, during our testwork over expenses, we selected for testing a sample of 40 expenses charged to the program. One of our samples related to COVID lab tests was identified with a cost that should have been zero as the tests were voided and the vendor invoice reflected a zero balance; however, a standard test was inappropriately charged to the federal program in excess of the vendor invoice. Further, one sample was identified as having the incorrect price applied to the cost due to the drug being purchased from a different vendor, which had a lower price. This resulted in a higher price being charged to the federal program.The resulting impact of the above two items was $508 inappropriately charged to the federal program. In addition, the System was unable to provide evidence of management review and approval for three of the 40 expenses sampled. These three disbursements were for allowable costs under the terms and conditions of the program. (c) Cause The System’s review process in place over the recording of these costs did not operate effectively to prevent unallowable charges and inaccurate amounts from being submitted for reimbursement by the federal agency. The System was unable to provide evidence of certain management reviews and approvals due to system limitations that only maintain electronic approvals (via email) for 365 days. (d) Effect Federal funds were expended for unallowable purposes or for inaccurate amounts and evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (e) Questioned Cost Expenditures related to contract labor and other costs of $126,821. (f) Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding (h) Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs. (i) View of Responsible Officials The Monthly Cost Capture detail for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (ALN No. 93.498) reporting was developed to appropriately track expenditures that qualified under the grant. A wide variety of costs from across the company were charged to a COVID cost department. These costs originated in a variety of ways. While the overall amounts were tracked and reviewed, a comprehensive 100% review was not conducted. As a result, the government labor expenditure and the cost for a COVID lab specimen that spilled in transit were inappropriately included. Additionally, a higher cost per unit was used to allocate for a specific drug used by COVID inpatients. Furthermore, there were three Morris and Dickson invoices that were submitted to AP electronically approving payment via email, but the emails automatically delete after 365 days. (j) Corrective Action Plan The expenditures for the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (ALN No. 93.498) were reported through the PRF Reporting Portal using quarterly financial data. The portal restricted the entry of expenses up to the awarded amount plus interest earned. Consequently, we have sufficient expenses to cover any ineligible expenditures identified in this audit. As the program has concluded, no further actions are required for COVID drug and COVID lab test findings, as these were already accounted for in system reports that are now obsolete due to surpassing the Period of Availability dates. A new process will be implemented for manager sign-off on Morris and Dickson invoices submitted to AP electronically to ensure proper approval evidence is captured and documented correctly. Anticipated Completion Date: 6/30/2024 Name of Contact Person for Corrective Action: Sharon Nobles, Chief Financial Officer

Response/Views: We disagree with this finding. We followed all initial guidance received from ALSDE regarding this grant opportunity. The grant was presented as a no cost opportunity for the county. We only received revised guidance and instructions from ALSDE after the initial phase had been completed, which caused significant confusion and financial implications for the county. Our only recourse was to trust the sole source letter which we received from the vendor. Corrective Action Planned: The Superintendent is currently organizing professional development sessions related to compliance with procurement procedures for federal programs. These sessions will be required for all applicable staff to include district administrators, departmental directors and coordinators, and other staff as appropriate. A review of related Board policies and procedures will be included in this training and in all subsequent related professional development sessions in an effort to ensure the continuation of knowledge and compliance. Anticipated Completion Date: Organized professional development sessions are to be schedule as soon as appropriate speakers have been secured. It is the intent of the Board to possibly begin training as the new school year begins. Contact Person(s): Dodd Hawthorne, Superintendent

• Finding 2023-002 – In June 2024, Management provided re-education to grant personnel preparing and reviewing calculations to ensure an adequate understanding of the key calculation elements are identified and validated for the grant year. o Responsible Party: Peggy Wisher

Corrective Action Plan The University will establish processes and policies to pull attendance reports after census date of each term/semester for any students who receive Title IV aid and are identified as non-attendance. We will use this information to recalculate Federal Pell Grant and Federal Direct Student Loan awards based on enrollment or change in enrollment status. At the end of each term/semester, the University will review F/FA grades for any student who receives Title IV aid and will adjust their aid accordingly to comply with Title 34 of the Code of Federal Regulations, Part 690.80. In addition, we are currently reviewing F/FA grades for the 2023-2024 academic year. Anticipated Completion Date: June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid

Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the “Davis-Bacon Act”). The Board did not have controls in place to ensure the Davis-Bacon Act wage rate requirements were included in construction contracts. Therefore, the construction project contract awarded during the fiscal year did not include prevailing wage rate clauses nor did the contractors submit weekly certified payrolls to the Board. Response: Management will implement controls to ensure future contracts funded with COVID-19 Education Stabilization Funds (ESF) in excess of $2,000 specify applicability of wage rate requirements.

Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New CFO is preparing a Subsidy Calculation procedure so new staff will be aware of what is eligible and non-eligible transactions for preparing forms. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling and/or Carlton Brown

Eligibility – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: CLA recommends management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: : Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 10 files on a monthly basis. Agency working with Human Resources contractor to fill open staff positions Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

In 2024 the manual component of the calculations has been eliminated and all calculations of billing units are now completed using an Excel spreadsheet.

In 2024, all contracts / grants have been updated to current year budgeted fringe and payroll tax rates. These will be updated annually with any changes going forward.

Sanford Corrective Action Plan December 31, 2023 Finding 2023-001 – Suspension and Debarment/Procurement Information on the federal program: Federal Agency: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.155 Award Year: 2021 Planned corrective actions: As it relates to the reliance on the third-party vendor that conducts suspension and debarment -party vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) Report and therefore did not provide this level of report to Sanford. To provide context on scale of vendors subject to suspension and debarment, Sanford paid a total of 23,754 vendors in 2023. There were three vendors identified through the vendor setup and monitoring process to be suspended or debarred. None of those vendors were associated with the programs funded with federal funds. Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendor is effectively mitigated through existing preventive and detective internal controls. In August 2023, Sanford began documenting a periodic validation of the suspension and debarment search results performed by the third-party vendor for vendor searches that yield no suspension and debarment match. In addition, Sanford enhanced its procedural documentation regarding retention of evidence related to reconciliation of vendor list when discrepancies are identified and the suspension and debarment results generated through the vendor setup process. Responsible official: Tracy Sattler, Director of Compliance and Melanie Paape, Vice President of Supply Chain Operations As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of procurement under the program $2,298,733 in expenditures exceeded the micro purchase threshold and $307,249 were found to have inadequate documents for sole source. Sanford will provide education to applicable departments related to the compliance requirements subject to procurement. Sanford will document the procurement process from the initial approval to potential sale/disposition items. Responsible official: Kristi Crawford, Director of Office of Grants Anticipated completion date: June 30, 2024

Management is currently working on creating policies and procedures for applications submitted by family members of employees and to require all clients to complete a disclosure that states if they are a family member of an employee. The Executive Director notified the Legislative Auditor and Fourth District Attorney of the matter on June 10, 2024. The board of directors has placed the LIHEAP manager on administrative leave.

2023-001 ALN #14.850 – Public and Indian Housing Program – Activities Allowed, Unallowed Management agrees with the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Chanosha Lawton, Executive Director Projected Completion Date: June 30, 2024

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Washington respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2023 through December 31, 2023 The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2023-001: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should make the appropriate transfers out of the insurance escrow account to remedy the overfunding and perform regular analysis to ensure that funding is adequate but not excessive. Action Taken: New procedures have been implemented to ensure appropriate amounts are reserved in escrow. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO

The District will disaggregate the budget to actual review process to correspond to the level provided in the approved budget. Expenditures in excess of program budgets will be excluded from program costs. Stuart Parks, Superintendent 815-436-7000

The district will review control procedures over disbursements to ensure all payments are properly supported by proper documentation. Vendor invoices will be matched with purchase orders and shipping documents to identify vendor double billings and prevent duplicate payments. The District recovered $46,700 overpaid for the classroom furniture and is in discussions with the subrecipients to recover the remaining $5,663 overpaid for laptops. Stuart Parks, Superintendent 815-436-7000

The Corporation is working to make the required deposits as cash flow permits.

The Corporation is working to make the required deposits as cash flow permits.

Time and Effort sheets will be completed and maintained in personnel files and federal program records.

Had it not been for the transition between superintendents, I do not believe we would have had this finding. Since being in this position, I have contacted DESE (Jayne Green) numerous times for prior approval for things, including those that she stated didn't require the prior approval. Based on the recommendation by the audit or, I contacted Mrs. Green who had me submit a prior approval letter to Mr. Eric James, also in DESE. I submitted that request on Tuesday, June 18, 2024 and received an approval email back from DESE and Mr. James on Wednesday, June 19, 2024, which is attached.

FINDING 2023-003: Unauthorized receipt of COVID-19 Supplemental Payments (CSP) Name of contact person – Megan Netland, Vice President of Asset Management Corrective action – The applications for reimbursement for program periods 1 through 3 were made in error. The Corporation has contacted HUD and is awaiting a response. Proposed completion date – Management has contacted HUD and is awaiting a response.

Part of the payroll reconciliatiion will be revised to include review of employees charged to grants to ensure they are assigned to the grant and tracking their time properly including salaire snad stipends.

Planned Corrective Action: Management of the Health Board have placed appropriate measures to oversee the internal control process of the month and year-end close. The accounting staff will prepare the transactions and the controller will approve it accordingly and the Director of FP&A will rectify them whenever FFR reports are completed. We have implemented strong internal control by separating the preparation of the month and year end reporting to be done by staff accountant and approved by Controller or Director of FPA. In addition, the CFO is reviewing month-end reconciliations on a quarterly basis. Name of Responsible Party: Zecharias Mesgane, CMA, Director of FP&A Anticipated Completion Date: September 30, 2024.

Finding 2023-002 Material weakness in internal controls over compliance and instances of noncompliance related to allowable costs. Repeat Finding Yes. 2022-04 Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: We agree that all awards should be charged the actual allocation percentages of time and effort. It is our assessment that staffing turnover did contribute to challenges with the set-up and deployment of Paylocity in Fall of 2022. We are committed to improving our time and effort system. Currently, we are in the process of migrating accounting and payroll functions to new systems. Additionally, we have dedicated a fiscal staff member’s time to review all payroll expenditures and adjust as needed prior to our next draw. Anticipated completion date: April 30, 2024.