Corrective Action Plans

2022-003 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance Repeat of Finding from March 31, 2021 (Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing, but testing was suspended after 24 files due to the number of errors. Exceptions were noted as follows: • 1 tenant file error where the Authority performed their rent reasonableness procedures on a 2-bedroom unit for a 1-bedroom unit, and the comparable rents did not appear reasonable. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent by $23: o 1 error for miscalculation of the tenant’s social security income o 1 error for miscalculation of the tenant’s medical expense. • 1 tenant file had the following errors: o Two members of the household did not check the box on the 214-affidavit form indicating their eligible immigration status, but based on their birth certificates, they have eligible immigration status. o Miscalculation of the tenant’s utility allowance amount. Correcting the utility allowance amount would not change the HAP rent. • 1 tenant file error where the utility allowance amount was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would not change the HAP rent. • 1 tenant file had the following errors: o The 50058 form reported the wrong number of bedrooms in the unit. o The tenant did not sign the lease agreement. • 1 tenant file error where the tenant’s utility allowance amount was calculated incorrectly. Correcting the utility allowance amount would not change the HAP rent. • 1 tenant file had the following errors & correcting the errors would decrease HAP rent $11: o Miscalculation of the tenant’s social security income o Miscalculation of the tenant’s medical expense. • 1 tenant file had the following errors and correcting the miscalculation of tenant’s income and utility allowance would decrease the HAP by $8.: o Miscalculation of the tenant’s supplemental security benefit o Miscalculation of the tenant’s utility allowance amount. o The tenant’s supplemental security benefit income was coded as social security income when it should have been coded as supplemental income on the 50058 form. o Missing 214-affidavit form for a member in the tenant’s household, but based on their birth certificate, they have eligible immigration status. o Member of the household, over the age of 18, did not sign and date the 9886 form. o The HAP contract was not signed and dated by the Authority. • 1 tenant file error due to a missing signed lead base paint form. • 1 tenant file had the following errors: o The 50058 form incorrectly reported the tenant’s monthly rent. Correcting this error increases the HAP rent by $8. o The lease agreement’s signature page is missing. • 1 tenant file error where the rent reasonableness procedure was performed one month after the tenant’s move-in date. The rent appears reasonable, but should have been performed before the tenant’s move-in date. • 1 tenant file had the following errors: o Missing HAP contract and lease agreement. o Missing rent reasonableness support. • 1 tenant file error for missing rent reasonableness support. • 1 tenant file had the following errors: o The utility allowance amount was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would not change the HAP rent. o The lease agreement’s signature page is missing. • 1 tenant file had the following errors: o Miscalculation of the tenant’s social security income. Correcting the miscalculation would decrease the HAP by $2. o Miscalculation of the tenant’s annual unreimbursed medical expense. Correcting the miscalculation would have no effect on the HAP rent. o The tenant’s name was reported incorrectly on the 50058 form. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-form indicating their immigration status. However, based on the tenant’s birth certificate, the tenant has eligible immigration status. o A member of the household over the age of 18 didn’t sign and date the 9886 form. o General assistance was included as household income when it should have been excluded. Correcting this error would increase the HAP rent by $12. o Missing rent reasonableness support. o The landlord did not sign the lease agreement. • 1 tenant file had the following errors: o A member of the household did not check the checkbox on the 214-form indicating their immigration status. However, based on the tenant’s birth certificate, the tenant has eligible immigration status. o Missing support for total annual unreimbursed childcare costs. o Missing support for total annual unreimbursed medical expense. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

Federal Award Findings Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: David Andrew, Tribal Administrator Corrective Action Plan: The Native Village will work with an accounting firm to ensure that the SF-SAC is remitted to the federal clearinghouse within the 9-month deadline. Proposed Completion Date: December 31, 2023

Finding 2022-003: Internal Controls and Compliance over Reporting (Significant Deficiency) Conditions: The Organization did not submit the quarterly reports within the specified time frame in accordance with the HIAS agreements. Additionally, the Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ending June 30, 2022. The Organization was not in compliance with the reporting requirements, federal regulations, and guidelines. Effect: The Organization was not in compliance with the reporting requirements, federal regulations, and guidelines, and it could be exposed to a reduction or elimination of funds by the federal awarding agencies. Auditor's Recommendation: JFSSV recommends that the Organization evaluate its policies and procedures regarding report submission to ensure the timely submission of all compliance reports. In addition, the Organization should maintain documentation to support the appropriate and timely submission of the single audit (SF-SAC form). Management Response: We agree with the recommendation and have also submitted the following response: According to the HIAS agreement, the following reporting deadlines are specified for HIAS to their funder PRM: Programmatic and Financial Reporting Deadlines: · HIAS must submit performance and financial reports to PRM thirty (30) days after the end of each reporting period and in accordance with the schedule outlined by PRM. · HIAS must also submit a final program and financial report ninety (90) calendar days after the period of performance end date. To ensure timely submission of the foregoing reports to PRM, the Agency “HIAS” shall submit performance and financial reports to HIAS as follows: Programmatic Reports: The Agency will file monthly R&P Period reports through the IRIS database, as well as other programmatic reports as requested by HIAS. Financial Reports: The Agency agrees to submit financial reports monthly on or before the 15th day of the following month after the books have closed. Financial reports must be submitted using the Arrivals and Expenditure Workbook provided by HIAS. HIAS agrees to make payments on these financial reports on or before the 25th day of the month for invoices submitted on or before the 15th day of the month. To ensure HIAS stays in compliance, JFSSV makes every effort to submit accurate reports on time. Funder HIAS agreed in an email sent to the auditors that invoice submission after the 15th is acceptable. As a result, the organization has never been denied reimbursement funding. Some of the delays with invoice submission were due to the following reasons: · When the 15th falls on a weekend (or Friday) or a company and Jewish holidays. · Additional effort to compile client and expense information due to volume and complexity. · The templates required for reporting and reimbursement have not yet been established. · Budget revisions. Furthermore, consultation reports are not considered "submitted" until they receive approval from HIAS. This process ensures no corrections, and the report is finalized and meets the requirements of HIAS reporting. It can take a few days to review and clarify any questions HIAS may have. JFSSV has presented Harshwal & Company LLP with funder approval on late filings and documentation of reporting submission. To address the specific concerns raised regarding internal controls over compliance and reporting, JFSSV will: Evaluate and Update Policies and Procedures: JFSSV will review HIAS-approved Policies and procedures and ensure documentation on any late invoices due to the items listed above. Enhance Communication and Coordination: JFSSV will continue to communicate and coordinate with HIAS to ensure the timely approval of consultation reports and to clarify any issues promptly. Maintain Comprehensive Documentation: JFSSV will maintain comprehensive documentation to support the submission of the single audit (SF-SAC form) and other compliance reports. JFSSV agrees with the delay in completing the FY22 audit. The unforeseen necessity for an additional auditor, which came to light during the initial audit process, significantly impacted JFSSV's timeline. Although this presented an unexpected challenge, JFSSV swiftly engaged a new auditing firm to restart the audit. Additionally, to ensure efficiency and accuracy moving forward, JFSSV made the decision to transfer our outsourcing accounting department. Furthermore, JFSSV is taking proactive measures to streamline its processes for future audits, with the aim of achieving faster turnarounds and compliance with reporting requirements, federal regulations, and guidelines. JFSSV is committed to maintaining and improving its financial and operational controls. We will monitor corrective actions and adjust our procedures as necessary to prevent similar issues in the future.

Finding 2022-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correctly reflect the employee’s assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. These conversations occurred with the team in July 2024.

The Director of Finance and Accounting Manager will work with the Grants and Contract Accountant to coordinate grant kickoff meetings with Program Directors and Managers to ensure they have procedures in place to meet the requirements for the agreement. These meetings will be held in August and September.

Correction action planned: When HRSA opens the portal again the numbers will be updated to estimates using the gross revenues by payor and the yearly contractual adjustments amounts. If the portal does not open again the facility will calculate net patient revenues, using estimates, in a separate file to be sent to HRSA upon request. Anticipated completion date: upon request. Contact person responsible for correction action: Tesa Anewishki, CEO.

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. The new system performs an automated allowance calculation; however, a manual distribution of the allowance is required to record the adjustment in the proper period. Unbilled receivables are not adjusted by the system; therefore, a manual journal entry is required to record the allowance. The District was not familiar with the system design and the distribution was not recorded in each month. A manual journal entry must be performed at the end of each month to distribute the allowance in the proper period. The District’s monthly closing procedures have been modified to record the allowance at the end of each month. Anticipated completion date: February 17, 2023 Contact person responsible for corrective action: Kim Manus, Chief Financial Officer

Management again will communicate and provide training to the Program and Finance Departments on the organization’s Procurement Policy and the requirements of uniform guidance. Furthermore, management will re-evaluate internal controls over compliance to ensure proper review and approval of all procurements, including whether appropriate documentation justifying the bypass of a sealed bid process and the conclusion on allowable vendor selections.

Finding 2022-004 Finding Summary: In our testing of reporting, we did not have a documented control in place to review reports prior to submission for reporting directly to Department of Treasury. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will adopt controls to have a review process added before the required reports for federal programs are submitted to federal or state agencies. Anticipated Completion Date: December 31, 2024

Finding 2022-003 – Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education and the Massachusetts Department of Early Education and Care Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Program Criteria: Where employees work solely or partially on a single Federal program or cost objective, their salaries or wages must be supported by periodic certification that the employee worked on these programs for the period covered by the programs. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the school department was not able to provide evidence that required certifications of time and effort for those employees whose time was spent either completely or partially spent on these programs were performed as required by Uniform Guidance. Questioned Costs: Unknown Context: During our test of payroll transactions of the SPED PL 94-142 grants it was noted that the time and effort certifications were not completed for the employees tested. Effect: The School Department was not in compliance with the time and effort certification requirements. Cause: Staffing turnover in the financial department lead to weakened standard procedures/protocols by inexperienced (temporary) staffing. Identification as a Repeat Finding: N/A Recommendation: We recommend the School Department follow procedures to ensure that semi-annual certifications and/or monthly certifications are prepared and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Management Response: Management agrees with the auditors’ findings and will put in procedures and policies to correct the action going forward. Responsible for Corrective Plan: Patrick McIntyre, School Business Manager Estimated Completion Date: Fiscal Year 2024 Action Taken: As required, the School Department ensures that semi-annual certifications and/or monthly certifications are prepared and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Certifications are filed in grant folders and employee personnel files.

Finding 2022-001 – Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education and the Massachusetts Department of Early Education and Care Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Criteria: Grantees must provide reasonable assurance that federal awards are expended only for allowable activities and that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles. Management of the Town is also responsible for establishing and maintaining effective internal control over compliance with federal requirements that have a direct and material effect on a federal program. A deficiency in internal control over compliance exists when the design or operation of a control over compliance does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, noncompliance with a type of compliance requirement of a federal program on a timely basis. Condition and Context: Control deficiencies related to disbursements were noted as a result of the testing of internal controls over payroll. Specifically, a sample of payroll disbursements charged to the programs were tested in order to determine if adequate internal controls were in place. As a result of the testing of payroll disbursements charged to the programs, all of the employees tested were found to not have adequately approved employee payroll rate agreements. Cause: Weaknesses in the design and operation of controls. Effect or Potential Effect: Due to the weaknesses in internal controls noted above, there is a risk of inappropriate salaries and wages being paid. Identification as a Repeat Finding: Yes, finding number 2021-001 Questioned Costs: Questioned costs are reported equal to $256,796.58, calculated as payroll charged to the programs. Recommendation: The Town should improve internal controls over Activities Allowed/Allowable Costs by ensuring employee’s payroll rate agreements are approved by an appropriate level of management and in a timely manner. Managements Response: Though we believe that Finding 2022-001occured due to staff turnover at the time of the rate agreement approval, the Town and the Schools will assure federal awards are expended only for allowable activities. Consistent with State and Federal requirements and as in Acushnet’s updated Federal Grant Procedures Manual (February 2023), the Town will maintain source documentation (invoices, time sheets, payroll stubs, etc.) – including approved payroll rate agreements – that support federal expenditures. Responsible for Corrective Plan: Patrick McIntyre, School Business Manager Estimated Completion Date: Fiscal Year 2023 Action Taken: All employee’s payroll rate agreements are approved by an appropriate level of management and in a timely manner.

Findings Related to Major Federal Award Program Finding 2022-002 Reporting (Compliance; Internal Control Over Compliance) Condition as Noted in Auditor’s Finding: The Commission did not complete and submit their audit to the Federal Audit Clearinghouse by the due date of September 30, 2023. Responsible Individuals: Board of Commissioners and Management Correction Action Plan: The Commission will implement procedures to begin audit preparation work earlier in the calendar year to ensure reports are filed within the nine-month reporting deadline set forth by Uniform Guidance. Anticipated Complete Date: September 30, 2024 Very truly yours, MOBRIDGE HOUSING AND REDEVELOPMENT COMMISSION Rich Galbraith Executive Director

Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance.

2022-005 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of the Treasury and U.S. Department of Health and Human Services Federal Program Name: Various Assistance Listing Numbers: 21.023, 21.027, 93.268, 93.323, 93.575, 93.596, 93.778 Federal Award Identification Number and Year: Various Pass-Through Agency: Various Pass-Through Number(s): Various Award Period: 1/1/2022 – 12/31/22 Type of Finding: Other Matters and Significant Deficiency in Internal Control Over Compliance Condition and Context: The County’s single audit and reporting package was delayed for the year ended December 31, 2022, beyond the due date. Recommendation: The County should evaluate its procedures around timely submission of the single audit. Views of Responsible Officials: There is no disagreement with the audit finding. Corrective Action: The reason for the finding recurrence is in part a result of the timing of when the finding was issued. For example, the 2021 Single Audit was issued in December 2023. At this point, the 2022 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and or are ongoing. The County is implementing best practices in grant administration to ensure the timely submission of the Single Audit. A Deputy Controller, Grant Accounting was hired in February 2023. This position provides oversight, training, communications and regular review of grant receivables and expenditures, along with their inclusion in the General Ledger. Additionally, continued use of Infor’s grant management system and Project codes are increasing efficiency in accurately completing the SEFA and providing documentation as requested for programs being audited. The County began implementing a grant accounting system as part of our implementation of Infor in mid-2021 and are continuing to work with departments to refine their use of the system. The County has prioritized completion of the 2022 Single Audit and has allocated staff time from the Controller’s department and other departments to complete the audit. Throughout the process, the Grant Accountant and Controller staff have facilitated communication and information between grant-funded departments and CLA. These changes in part contribute to the completion of the 2022 Single Audit in less than half the time required to complete the 2021 Single Audit. Depending on external auditor availability and other Financial Audits being conducted, the 2023 SEFA will be complete and ready for review by November 2024, with a goal of completion of the 2023 Single Audit by early 2024. We anticipate a timely submission of the 2024 Single Audit by the due date of September 30, 2025. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

The Organization has taken steps to ensure that the calculation of indirect costs is executed properly and reviewed for compliance in accordance with the contract agreement. Management brought the error in the contracted indirect rate to the funders attention initially, but unfortunately a misstep back to the original contract terms was made before close-out. The development and application of indirect rates will be conducted by the Sr. Director of Finance with oversight by the Chief Financial & Operating Officer and is in place as of the date of this corrective action plan.

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

Management agrees with and will implement the recommendation that processes be in place to review and confirm the completeness and accuracy of intake forms within the regulations while also considering the needs and choices of the program participants. These file completeness processes will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

U.S. Department of Health and Human Services Ozarks Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 – December 31, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 – 003 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Action taken in response to finding: The Hospital will ensure that the required timing of reporting is met in future reporting periods. Name of the contact person responsible for corrective action: Bryan Coffey, Director of Finance. Planned completion date for corrective action plan: July 31, 2024 If the Department of Health and Human Services has questions regarding this plan, please call Bryan Coffey, Director of Finance at (417) 256 - 9111 ext 6003.

U.S. Department of Agriculture Iron County Hospital District dba: Iron County Medical Center (“Medical Center”) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 – June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 – 2023 Community Facilities Loans and Grants Recommendation: We recommend the Hospital design controls to ensure that reporting is completing in accordance with latest USDA guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Medical Center will ensure that controls are put into place to ensure timely reporting in accordance with the USDA guidelines. Name of the contact person responsible for corrective action: Steve Weiss, Interim CFO Planned completion date for corrective action plan: July 1, 2022

Finding 2022-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Criteria: Grantees must provide reasonable assurance that federal awards are expended only for allowable activities and that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles. Management of the Town is also responsible for establishing and maintaining effective internal control over compliance with federal requirements that have a direct and material effect on a federal program. A deficiency in internal control over compliance exists when the design or operation of a control over compliance does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, noncompliance with a type of compliance requirement of a federal program on a timely basis. Condition and Context: Control deficiencies related to disbursements were noted as a result of the testing of internal controls over payroll. Specifically, a sample of payroll disbursements charged to the Accelerated Literacy Learning Grant were tested in order to determine if adequate internal controls were in place. As a result of the testing of payroll disbursements charged to the programs, employees tested were found to not have adequately approved and or documented employee payroll rate agreements. Cause: The School Department failed to produce copies of documented appointment letters to support pay rates of pay and/or wages paid. Effect or Potential Effect: Due to the weaknesses in internal controls noted above, there is a risk of inappropriate rate of pay and/or wages being paid. Identification as a Repeat Finding: N/A Questioned Costs: Questioned costs could not be determined. Recommendation: The Town should improve internal controls over Activities Allowed/Allowable Costs by ensuring employee’s payroll rate agreements are approved by an appropriate level of management and in a timely manner. Responsible for Corrective Plan: Director of Finance, Schools Estimated Completion Date: March 2024 Action Taken: School management will ensure that documented appointment letters from management will support payments.

Finding 2022-003 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Condition: During our test of controls over compliance it was noted that payroll for Nurses was posted to the Education Stabilization ESSER II major program grant, however an English Language Learning Teacher was charged to the Education Stabilization ESSER II major program grant, however not included as part of the original or amended grant application. Criteria: Costs charged to the Education Stabilization ESSER II major program should meet the requirements as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Context: During our review of payroll transactions posted to the Education Stabilization ESSER II major program it was noted that an English Language Learning Teacher was charged to the Education Stabilization ESSER II major program grant and was not included as part of the original or amended grant application. Effect: Town of Bellingham was not in compliance with the allowable costs/ cost principals requirement as set forth by the Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Questioned Costs: Could not be determined. Cause: Amendments to the grant were not posted at the time of change. Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of Bellingham follow procedures to ensure that expenditures charged to the grants are allowable costs as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles) Responsible for Corrective Plan: Director of Finance, Schools Estimated Completion Date: March 2024 Action Taken: Management will ensure that all amendments are processed at the time of the occurrence.

2022-010 Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend management review the record-keeping practices to ensure that personnel documentation related to employee pay rates can be easily accessed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: In 2024 the Authority converted to the Kronos Pro payroll system, and is utilizing the software to its fullest capacity. This conversion will ensure that personnel documentation related to employee pay rates can be easily accessed and is audit-ready. The OFM shall include quality monitoring in its updated policies and procedures. The OAC shall oversee the quality monitoring process quarterly. Name of the contact person responsible for corrective action: Heather Mueller Planned completion date for corrective action plan: 9/30/2024.

FINDING 2022-006 Information on the federal program: Subject: Title III-E – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Title III-E Family Caregiver, COVID-19 – Title III-E Family Caregiver Assistance Listing Number: 93.052 Compliance Requirement: Cash Management Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Context: We noted that for two claims in a sample of two, there was no formal review/approval of the FSSA Contract Claim Reimbursement form outside of who is preparing the form. The CFO prepared and submitted the claims without a secondary review. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: CICOA created an additional position in our Fiscal department to help add capacity and address various segregation of duties concerns. On April 3, 2023, CICOA hired a Senior Director of Financial Reporting to fill this new position. The CFO has done/will continue various training with the Senior Director and other staff to transfer knowledge and responsibilities currently held by the CFO, including future preparation and submission of the FSSA Contract Claim Reimbursement documents. The CFO will serve as either the primary or secondary reviewer of such Claim Reimbursements after preparation by other Fiscal staff. Key item to note: this finding was made as part of the audit for the fiscal year ended June 30, 2022, and the hiring of the Senior Director was not made until late in the fiscal year ended June 30, 2023. Due to this timing, necessary changes did not exist until fiscal year 2024. Responsible Party and Timeline for Completion: To be completed by CFO (with assistance from Senior Director of Financial Reporting and other Fiscal staff), beginning no later than Claims Reimbursements submitted for services provided starting in fiscal year 2024.

FINDING 2022-005 Information on the federal program: Subject: SSBG – Internal Controls Federal Agency: Department of Health and Human Services Federal Program: Social Services Block Grant Assistance Listing Number: 93.667 Compliance Requirement: Cash Management Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Context: We noted that for three claims in a sample of three, there was no formal review/approval of the FSSA Contract Claim Reimbursement form outside of who is preparing the form. The CFO prepared and submitted the claims without a secondary review. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: CICOA created an additional position in our Fiscal department to help add capacity and address various segregation of duties concerns. On April 3, 2023, CICOA hired a Senior Director of Financial Reporting to fill this new position. The CFO has done/will continue various training with the Senior Director and other staff to transfer knowledge and responsibilities currently held by the CFO, including future preparation and submission of the FSSA Contract Claim Reimbursement documents. The CFO will serve as either the primary or secondary reviewer of such Claim Reimbursements after preparation by other Fiscal staff. Key item to note: this finding was made as part of the audit for the fiscal year ended June 30, 2022, and the hiring of the Senior Director was not made until late in the fiscal year ended June 30, 2023/early fiscal year 2024. Due to this timing, necessary changes did not exist until fiscal year 2024. Responsible Party and Timeline for Completion: To be completed by CFO (with assistance from Senior Director of Financial Reporting and other Fiscal staff), beginning no later than Claims Reimbursements submitted for services provided starting in fiscal year 2024.