Corrective Action Plans

RE: Butte Native Wellness Center’s Management Response to fiscal year ending September 30, 2022 independent audit findings. Dear Board Members: The following is the Butte Native Wellness Center’s management response to the audit comments and findings regarding the independent audit conducted by WIPFLI and Company for the fiscal year ending September 30, 2022. The Summary of Auditor’s Results is attached. Within these results, the auditor’s report issued an unmodified opinion on whether the financial statements were prepared in accordance with GAAP as was the auditor's report issue on compliance for major programs. A material weakness was identified internal control over major programs, which is reviewed below. Audit Finding and Questioned Cost Related to Federal Awards: 2022-01 Internal Controls over Compliance and Compliance over Allowable Costs/Allowable Activities-Expenditures. This finding is related to Urban Indian Health Services federal grant passed through the U.S. Department of Health and Human Services, AL 93.193, with award year 2022. Criteria or Specific Requirement: Internal controls over allowable cost and allowable activities should be properly designed to provide assurance of meeting compliance requirements and should operate effectively. Supporting documentation for allocated expenditures should be maintained to demonstrate compliance with allowable costs and allowable activities. Condition: Costs were allocated between multiple projects throughout the year based on effort of employees. We were able to review some of the basis for the allocations, however, not all the documentation was available for review. Cause: Due to staff turnover, all the allocation documentation could not be located. Effect: Unallowed costs and activities could be incurred without proper documentation available for review and approval by the Company. Questioned Costs: $29,310. Context: We selected forty-five items in our sample, of those we were not provided all of the supporting documentation for sixteen items related to costs allocations. As allowed under auditing standards, we did not quantify sampling risk, resulting in our sample being not statistically valid, but acceptable under auditing standards. Repeat: No Auditor's Recommendations: While we were not able to review all allocation documentation for the year under audit, we did review subsequent allocation documentation that appeared reasonable. Therefore, management should continue to maintain the allocation documentation for subsequent years. Management Response: Butte Native Wellness Center acknowledges the finding and recognizes the need for strengthened internal controls to ensure compliance with allowable costs and allowable activities. The allocation of costs between multiple projects was based on employee effort, however, due to key staff turnover and transitions and gaps in record retention and oversight, some supporting documentation could not be located for review. Specifically, the Business and Finance Manager was employed from January 3, 2022 – April 11, 2022. The Executive Director resigned effective July 15, 2022. The last day she physically worked in the office was June 16, 2022. The Operations Manager, who was hired on May 25, 2022, assumed the oversight of office functions along with supervision of staff until a new Executive Director was hired on September 12, 2022. This Executive Director’s employment terminated on November 4, 2022. A new Executive Director was hired on December 12, 2022 and remains in the position. An outside accounting firm provided accounting and bookkeeping services until February 2022 when Butte Native Wellness Center entered into a contract with an individual to provide accounting services. That contract was not renewed when it expired in February 2023. In 2023, contracts were secured with two accounting professionals to provide key finance and accounting operations and the contracts are still in place. These contracts have allowed for proper segregation of duties, strengthened internal control structure, and enhanced accounting and financial policies, including the creation of the proper documentation and support for the agency. Corrective Action Plan: 1. Strengthening Documentation Procedures: • Management has implemented enhanced procedures to ensure all cost allocation documentation is properly maintained. • A centralized filing system, both physical and digital, has been established to ensure accessibility and retention of documentation, mitigating the risk of information loss during staff transitions 2. Training and Accountability: • All relevant personnel, including finance and program staff, will receive training on proper documentation and record-keeping practices to ensure compliance. • A designated employee will be responsible for overseeing cost allocation documentation, ensuring continuity regardless of staff changes. 3. Regular Internal Review: • Management will conduct periodic internal reviews of cost allocations to verify that all required documentation is complete and accurate. • Any missing documentation will be identified and addressed before submission for external audits. 4. Leadership Stability and Oversight: • With the Executive Director and contract accountants now acclimated to the organization and a more stable leadership structure in place, management has reinforced internal controls and oversight to prevent similar issues in the future. • Additional cross-training initiatives are being implemented to ensure institutional knowledge is retained despite staff turnover. 5. Future Compliance Commitment: • While some documentation for the year under audit was unavailable, management has reviewed subsequent allocation documentation, which was found to be reasonable. • Moving forward, all allocation documentation will be retained in accordance with compliance requirements. Management is committed to ensuring compliance with internal control standards and appreciates the auditor’s recommendations. With leadership transitions stabilizing, including a fully engaged Executive Director and improved oversight, we are confident in our ability to maintain proper documentation and strengthen financial controls. If you should have further questions or have comments, please call me at (406) 782-0461 or email trandall@buttenwc.org. Regards, Tina Randall Executive Director

Management agrees with the auditors’ findings and has implemented policies and procedures to improve recording accuracy of grant funds, including ensuring that all finance staff are properly trained. A guide will be created for current and future staff.

Fraud was identified by board members of the Dover Interfaith Mission for Housing (DIMH) in November 2023 with respect to the Emergency Housing and Health programs, and an internal investigation ensued. Prior to this finding, a committee of the board reviewed the Executive Director’s (ED) financial reporting and were confident in her documentation, which was also approved by the City of Dover manager of the Emergency Housing and Health programs. Briefly, the ED had invented invoices from motels and landlords along with applications from individuals and families who did not exist. In both programs, DIMH provided funds to cover motel stays and landlord payments and was reimbursed by the City of Dover. In practice, the ED simply took DIMH funds, deposited them into a personal account, and provided invented documents to the City that resulted in reimbursement to DIMH. This clever ruse had eluded both board and city personnel monitoring the expenditures and reimbursements. Once there was suspicion of fraud, board members not involved in prior program oversight actively reviewed files with the City’s program manager to ascertain its extent. A meeting was held between the board chair and the city’s program manager to review all files in order to determine the approximate extent of the fraud, which was clearly limited to these two grant programs. In early January 2023, DIMH board members arranged to meet with the Dover Police Department to provide an overview of the fraud. This led to police contact with local FBI and HUD inspector general offices along with the US attorney for Delaware, with the same board members providing all files and in-person descriptions of the scam. These agencies continued to work on uncovering the details of the case and are expected to meet with the former ED on February 28, 2025. In early 2024, the DIMH board engaged a new external accounting firm and created a new control environment with significant internal controls and separation of duties developed in collaboration with the contracted CPA firm.

Fraud was identified by board members of the Dover Interfaith Mission for Housing (DIMH) in November 2023 with respect to the Emergency Housing and Health programs, and an internal investigation ensued. Prior to this finding, a committee of the board reviewed the Executive Director’s (ED) financial reporting and were confident in her documentation, which was also approved by the City of Dover manager of the Emergency Housing and Health programs. Briefly, the ED had invented invoices from motels and landlords along with applications from individuals and families who did not exist. In both programs, DIMH provided funds to cover motel stays and landlord payments and was reimbursed by the City of Dover. In practice, the ED simply took DIMH funds, deposited them into a personal account, and provided invented documents to the City that resulted in reimbursement to DIMH. This clever ruse had eluded both board and city personnel monitoring the expenditures and reimbursements. Once there was suspicion of fraud, board members not involved in prior program oversight actively reviewed files with the City’s program manager to ascertain its extent. A meeting was held between the board chair and the city’s program manager to review all files in order to determine the approximate extent of the fraud, which was clearly limited to these two grant programs. In early January 2023, DIMH board members arranged to meet with the Dover Police Department to provide an overview of the fraud. This led to police contact with local FBI and HUD inspector general offices along with the US attorney for Delaware, with the same board members providing all files and in-person descriptions of the scam. These agencies continued to work on uncovering the details of the case and are expected to meet with the former ED on February 28, 2025. In early 2024, the DIMH board engaged a new external accounting firm and created a new control environment with significant internal controls and separation of duties developed in collaboration with the contracted CPA firm.

Auditee Response: The auditee agrees with the finding. This was a perfect storm of events that created this scenario including COVID requiring the discontinuation of our Point of Sale (POS) System, tally sheets by classroom being used in place of that system, a change in head cooks during the year, and a failure to communicate properly between the Director of Food Service and the new Head Cook. Action Taken: The district has and will reinstitute the use of its POS system so that a child purchasing lunch types in their number and it is credited to that child's account. This system can then be used to track meal purchases throughout the day, week, or month. Since the HeadStart classroom are not MWSD students, they do not have numbers within the system. The Director of Food Services will use this system to report meal purchases and reimbursement rather than rely on head cooks and their tally sheets. Despite this, training should be conducted annually with all head cooks as to the qualifications of a reimbursable meal within the school district, so as to provide a fail safe in the event the POS system goes down for a period of time. Timelines/Contract: Most of this has taken place already in that we have returned to using a POS system. This system has the ability to track data and run reports, so it makes it error free when available. However, people ultimately must have the knowledge too so that they understand the parameters of a reimbursable meal should the system go down. Therefore, annual trainings will be instituted regarding such operations effective immediately. The Director of Food Service will be directed to use one in-service day annually for the purpose of teaching all staff members about reimbursable meals and how the HeadStart Programs fit into that. This should be completed no later than fall of 2025. The contact person would be Joe Stroup, Superintendent.

Audit Finding 2022-003: Material Weakness in Internal Control over Major Programs. It is understood that there was no support for various expenditures submitted for reimbursement. Expenditures submitted for reimbursement were missing support due to duplication within the 2022 CSBG grant in the amount of $86,955. The 2022 CSBG was extended to July 29, 2023 and expenditures were submitted to support the $86,955 prior to that date. There was also missing support for the COVID 19 CARES Act grant in the amount of $40,000. UPI is working with the DCA to remediate the issue. As noted in finding 2022- 001, the bookkeeper does not have the technical ability to track the application of expenditures to grants and reconcile the FSR’s to the general ledger. To improve controls and avoid recurrence, the organization has hired an outside consultant to serve as controller. In addition, UPI has updated their record retention policy. Beginning in October 2024, the consultant will adjust and reconcile the accrual basis general ledger monthly and review the application of expenditures among grants.

The Company/Auditee will (and Has) repaid the management fees

The Company/Auditee will (and Has) repaid the management fees

The Company/Auditee will (and Has) repaid the management fees

Finding 2022-001 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal awards, ensuring adherence to 2 CFR Part 200. The Outsourced Grant Manager will implement systems to accurately allocate salaries, wages, and other expenditures. Key actions include:  Payroll Expenditures: Establish procedures to approve payroll allocations based on actual time and effort reporting, requiring supervisor approval and periodic reviews for compliance.  Non-Payroll Expenditures: Develop approval processes for non-payroll expenses, ensuring detailed documentation and implementing checks to verify overhead allocations.  Documentation and Review: Implement a comprehensive filing system for approvals and supporting documents, with regular training for staff.  Ongoing Compliance Monitoring: Conduct periodic internal audits to ensure adherence to internal controls and federal regulations, addressing issues promptly. These measures will strengthen CDF’s internal controls, ensure compliance, and maintain the integrity of federal award management. Anticipated Completion Date: December 31, 2025.

Allowable Costs, Period of Performance, and Cash Management Recommendation: Recommended Recovery Connections of Central Florida, Inc. maintain documentation of disbursement approval and supporting documentation of costs included within requests for payment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We will implement a more structured process for documenting the approval of disbursements. This includes ensuring that all disbursements are formally approved by the appropriate authority within the organization. We will also maintain a written record of the approval, including the name of the individual who authorized the disbursement and the date of approval. Name(s) of the contact person(s) responsible for corrective action: George Margoles Judy Jackson Planned completion date for corrective action plan: March 31, 2025

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: July 1, 2021 through June 30, 2022 CAP Prepared by: Name: Ershela Sims, PhD Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that organizations must minimize the time elapsing between disbursement of federal funds by grantor, and expenditure of funds for allowable activities. The Organization disbursed and held excess funds from grantor in the amount of $27,300 for an extended period of time before subsequently correcting the issue. b. Action Taken or Planned on the Finding The Organization noted this instance on their own prior to June 30, 2022 audit, and reduced the amount requested for reimbursement from grantor in a subsequent month, resulting in a net $0 of funds disbursed vs funds expended for the overall grant period, which runs through August 2023. WEPAN management has established increased control processes, including additional checks of reimbursement calculations, before submission to grantor for reimbursement (draw).

2022 - 006 Procurement (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2008-007, 2015-004, 2016-003, 2017 – 005, 2018-004, 2019-005,2020-005 and 2021-004) Significant Deficiency CFDA 20.205 Highway Planning and Construction Condition: During our testing of the Highway Planning and Construction Program (ALN 20.205), we reviewed three transactions selected to assess compliance with procurement standards. However, the Governmental Department was unable to provide procurement documentation for any of these transactions, including evidence of procurement planning, bid evaluations, or contract award decisions. Furthermore, no documentation was available to confirm that the Governmental Department had conducted searches for suspended or debarred vendors, as required under federal regulations. This lack of documentation prevented us from verifying compliance with federal procurement and vendor eligibility requirements for these transactions. Corrective Action Plan: Procurement and Directors will be trained on procurement policies and procedures and followed to minimize any unauthorized or unallowable purchases.

2022 – 009: Activities Allowed and Unallowed, Allowable Costs, Period of Availability (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008 and 2021-007) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 15.030 Indian Law Enforcement ALN 93.575 Child Care and Development Block Grant ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, we selected 120 transactions for testing from each major program. The following number of transactions were not provided for our review during the audit: ALN 93.441 – Indian Self Determination – 47 transactions ALN 20.205 – Highway Planning and Construction - 11 transactions ALN 15.030 – Indian Law Enforcement – 8 transactions ALN 93.575 – Child Care and Development Block Grant – 22 transactions ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds – 9 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year.

All non‐payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.

Expense documentation will be maintained to support expenses in the future.

FA 2022-004 Strengthen Controls over Financial Reporting Compliance Requirement: Reporting Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A200010 (Year: 2021) SO10A210010-21A (Year: 2022) Questioned Costs: $37,644 Description: The School District did not file accurate completion reports for the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawdowns are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will include detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Terrance H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2022-002 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: $58,415 Description: A review of expenditures charged to the Elementary and Secondary Emergency Relief Fund program revealed that the School District's internal control procedures were not operating to ensure that expenditures were appropriately documented to support allowability. Corrective Action Plans: District office will review payroll process and develop a procedure to ensure proper documentation is kept in an orderly manner. Estimated Completion Date: December 31, 2024 Contact Person: Terrance H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A200010 (Year: 2021) SO10A210010-21A (Year: 2022) Questioned Costs: $23,398 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawbacks are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will included detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Terrance H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

Finding No: 2022-003 Questioned Cost Due to Subsequent Events Response: Agree Planned Corrective Action: The Company, having complied with the disbursement at the time incurred, agreed that a ‘Question Cost’ aroused by the subsequent credit issued and applied to the account by NYS UIB. Management is to report the amount of $324,825.67 to HRSA as Questioned Cost, and request HRSA approval for an election to apply this amount against unreimbursed lost revenue, in the reporting period. Guided by FQA HRSA report of February 16,2024 bullet option 2, page 16, on Question Cost per 45 CFR §75.2. “For providers that were not required to report in subsequent reporting period and chose to replace its unallowable expenses with its unreimbursed lost revenues in the reporting period in question” In the corrective action plan, the provider would indicate that the unallowable expense was “replaced “by unreimbursed lost revenues” Anticipated Completion Date: January 31, 2025.

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement policy to include the relevant sections from the Code of Federal Regulations and will provide education to the areas involved in procurement and use of federal funds on these requirements. Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

ALN 21.023 – Lack of Internal Controls and Noncompliance with Subrecipient Monitoring – Emergency Rental Assistance Program (Repeat Finding 2021-013) Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting practices. Cleveland County is working toward improvements for Fiscal Year 2025 and has reconciled billing to align with the contract scope of work. However, we recognize the need for documented internal controls and are committed to addressing all recommendations to ensure compliance and transparency in future programs. The County appreciates the constructive feedback and will continue to refine its processes to better serve its citizens.

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any unobligated funds or, if applicable, seek authorization to retain the funds for use in other similar programs. This process will ensure proper financial management and compliance.

FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) Questioned Costs: $189,893 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: Management has implemented internal controls procedures to ensure transactions are properly processed and reported. Additional procedures have been established to review transaction to make they align with the approved budget. Estimated Completion Date: June 30, 2024 Contact Person: Georgette Evans Telephone: 478-374-3783 Email: gevans@dodge.k12.ga.us

Finding 2022-009 Lack of Internal Control over Compliance Eligibility Type of Finding: Material weakness in internal control over compliance and material noncompliance Name of Contact: Jana Rae Koenig, Executive Director Corrective Action Plan: The Native Village of Point Hope will adhere to the grant agreement and Administrative Management System Manual Chapter III: Financial Management and Chapter VI: Records Management to ensure that all proper documentation is recorded and kept on-file and that authorized personnel are selected to receive program services. Proposed Completion Date: Before the end of the next audit cycle.