Corrective Action Plans

The Board Chairman concurs with the findings. The School District was dealing with a shortage of auditors in Montana and the audit started late. Documentation issue was due to the key employee turnover prior to August 2022.

Responsible Official’s Response and Corrective Action Plan In 2022, the Federal Award manager at Associated Black Charities departed mid-year, leading to considerable confusion among the existing management. As we transitioned into 2023, the entire management team underwent changes, resulting in the loss of crucial knowledge about the existing filing system from previous years. With the introduction of new leadership, we are now poised to implement fresh policies and procedures to address our succession planning needs. These updated protocols will outline the process for filing essential information and its specific location, ultimately expediting the audit process. Planned Implementation Date of Corrective Action December 2023 Person Responsible for Corrective Action Travis Curtis, Director of Finance

Responsible Official’s Response and Corrective Action Plan In 2022 and into 2023, there was a significant restructuring of our management team, which resulted in challenges when trying to locate files from the prior administration. In response, management is in the process of formulating new policies and procedures (in addition to the Financial Policies and Procedures implemented in May 2023) specifically designed to address succession planning. The objective is to ensure that critical company knowledge is not concentrated in the hands of a single individual but is instead securely stored on a centralized drive. This approach will facilitate a smoother transition when onboarding new management personnel. Planned Implementation Date of Corrective Action December 2023 Person Responsible for Corrective Action

October 30, 2023 The Town of Vinton respectfully submits the following corrective action plan for the year ending June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, VA 24018 Audit period: June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs (the “Schedule”) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS – FINANCIAL STATEMENT AUDIT 2022-001: Audit Adjustments (Material Weakness) Condition: During the audit, we noted that several year-end audit adjustments were required to ensure that the financials were prepared in accordance with accounting principles generally accepted in the United States of America. The adjustments were related to debt, accounts receivable, and capital assets. Criteria: Audit adjustments were required to correct balances in order for the financial statements to be presented in accordance with accounting principles generally accepted in the United States of America. Cause: With regard to governmental activity long-term debt, it appears that the roll forward was not reviewed before year-end entries were made, resulting in additional adjustments to long-term debt balances. With regard to business-type activities' long-term debt, principal payments were recorded as an expense rather than a reduction to long-term debt, resulting in additional adjustments to these accounts. With regard to governmental activities and business-type activities' accrued interest, amortization schedules were not reviewed before entries were made, resulting in additional adjustments to these accounts. With regard to governmental activities and business-type activities capital assets, roll forwards, and depreciation schedules were not reviewed before entries were made, resulting in additional adjustments. With regard to governmental activities receivables and deferred revenue were not correctly captured and recorded at year end. Effect: There is an increased risk of financial statement misstatement. FINDINGS – FINANCIAL STATEMENT AUDIT (CONTINUED) 2022-001: Audit Adjustments (Material Weakness) (Continued) Recommendation: We recommend establishing procedures in which qualified supervisors are reviewing year-end work papers that feed into the final general ledger and focus on the accuracy of year-end balances. Planned Corrective Action: Management has noted the opportunities for improvement in the review process and segregated duties, as it pertains to audit preparation. Completion of working papers will be completed by Financial and Senior Financial Administrators, then reviewed for correctness by the Finance Director and Treasurer. In addition, the team will work to link the documents to reduce the adjustments of the final documents. 2022-002: Segregation of Duties (Material Weakness) Condition: A fundamental concept of internal controls is the separation of duties. No one employee should have access to both physical assets and the related accounting records, or to all phases of a transaction. A proper segregation of duties has not been established in functions related to accounts payable, accounts receivable, cash disbursements, and information technology. Criteria: • Mail should be opened by an employee not responsible for accounting, such as the Town Clerk. Cash receipts could be recorded and the deposit prepared by this person. The cash receipts journal, supplemented by remittance advice, could be forwarded to the accounting staff for postings to the general ledger and detailed customer accounts. • Customer complaints, returned checks, disputed items, and other such matters should be investigated by someone who is independent of preparing daily cash receipts and deposits. • Checks and remittance advice should be placed into envelopes and mailed by someone with no other accounting responsibilities. • Water and sewer billing should be independent of the accounts receivable function. Cause: The size of the Town’s accounting staff prohibits complete adherence to segregation of duties. Effect: Internal controls are designed to safeguard assets and detect losses from employee dishonesty or error. Recommendation: Steps should be taken to eliminate the performance of conflicting duties where possible or to implement effective compensating controls. FINDINGS – FINANCIAL STATEMENT AUDIT (CONTINUED) 2022-002: Segregation of Duties (Material Weakness) (Continued) Planned Corrective Action: Management noted this finding. The Finance Director has segregated duties, to the extent practical, to minimize instances where the same person has complete control of a transaction or conflicting duties. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2022-003: Coronavirus State and Local Fiscal Recovery Fund – AL# 21.027, Late Filling of Data Collection Form Condition: The Town did not file the data collection form for the year ended June 30, 2022, timely. Criteria: For June 30, 2022 year-end audits, under the requirements in the Uniform Guidance and the Office of Management and Budget (OMB), all entities are required to submit the annual data collection form with the Federal Audit Clearinghouse the earlier of either 30 days after the issuance of the entity’s annual audit or twelve months after the entity’s fiscal year end (June 30th for the Town of Vinton plus a three-month extension). Cause: Management did not complete and certify their portion of the form before the deadline. Form cannot be completed before audit is issued. Effect: The entity’s form was submitted to the Federal Audit Clearinghouse late, delaying the completion of all annual audit requirements for the Town. Recommendation: Management should take steps to ensure that the form is filed timely Planned Corrective Action: Management takes note of this finding. The Finance Director is working with the department to ensure reports are completed and the audit is completed in a timely manner.   FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) 2022-004: Schedule of Expenditures and Federal Awards (Significant Deficiency) Condition: The Schedule of Expenditures and Federal Awards (SEFA) was prepared without supervisor review resulting in several auditor corrections. Criteria: Segregation of duties and review procedures should be applied to federal award workpapers. Cause: Town has not established written internal control policies with regard to federal awards. Effect: Risk that the Town’s information in the SEFA is not accurate, complete, or appropriately presented in accordance with Uniform Guidance. Recommendation: Management should develop and implement written internal control policies. Planned Corrective Action: Management has noted the opportunities for improvement in the review process and segregated duties, as it pertains to audit preparation. Completion of working papers will be completed by Financial and Senior Financial Administrators, then reviewed for correctness by the Finance Director and Treasurer. If the Federal Audit Clearinghouse has questions regarding this plan, please call Andrew Keen, Finance Director (540) 983-0608 ext. 7012. Sincerely yours, Name: Andrew Keen Title: Finance Director

Finding 2022-002 Recommendation: The Organization’s management should ensure all expenses submitted are reimbursable. Corrective Action: The Organization will ensure someone familiar with allowable costs are preparing the payment reimbursement requests. Person Responsible for Corrective Action: President/CEO Anticipated Completion Date for Corrective Action: The corrective action will be immediately implemented in response to the auditor’s recommendation. If there are questions regarding this corrective action plan, please call Scott Johnson, President/CEO, at (404) 210-1776.

2022-001: Audit Report Submission to the Federal Government Corrective Action Plan: The Board has hired a contract accountant to assist the Accounting Manager in the timely financial close to report and audit preparation to ensure timely completion of their financial and compliance audits. Anticipated Completion: December 31, 2023 Responsible Party: Tamie Wick, Accounting Manager. Amy Terrell, Airport Director.

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 correct grant reporting. Department supervising staff will monitor grant reporting documentation. All manual adjusting entries will be requested through the County Auditor’s office to ensure proper supporting documentation is provided. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Community Resources Director. Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: October 2, 2023

Action taken in response to finding: All required reporting of the Coronavirus State & Local Fiscal Recovery Fund will be sent to the County Administrator for review and approval in a timely manner of the reports being submitted to the Federal reviewing agency. Documentation of review and approval will be kept along with other supporting documentation for the program. Name(s) of the contact person(s) responsible for corrective action: Eric Black, Chief Deputy Auditor Planned completion date for corrective action plan: November 1, 2023

Management's Action Plan: Kevin Holland, Vice-President-Stone County and Operations will oversee the supervisory review and approval of timesheets for the next few pay cycles to ensure management is reviewing 100% of the records. He will also work to ensure none of them are being missed through special circumstances as has happended in the past in order to achieve and sustain 100% compliance. Name of Person Responsible for the Plan: Kevin Holland, Vice-President Stone County & Operations. Anticipated Completion Date of the Plan: 3 payroll cycles spanning six weeks. Approximately mid-December 2023 for completion.

Management agrees with the finding and will review the outstanding checks older than three years and take appropriate action, may it be void the old outstanding check, reissue the check or file voluntary correction forms with the State of NJ.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.559 2022-004 Internal Control Over Compliance with Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster federal program. The District did not have sufficient controls in place within its child nutrition cluster federal program to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Kerstin Quigley, Business Manager. Planned Completion Date – December 31, 2023. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – The District’s Business Manager and the Superintendent will ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.

The Company agrees that compliance tracking is pertinent. The Company’s previous Controller tracked all compliance requirements with close cooperation between various departments in the organization. The third-party consultants did not continue tracking certain compliance data which led to the finding. The company has modified their process accordingly to ensure tracking of all compliance requirements.

Information on Federal Program(s) - Department of Health and Human Services, Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan Rural Distribution, Schedule of Expenditures of Federal Awards Reporting Periods 2 and 3, Agency Fiscal Year-Ended June 30, 2022. Management’s Corrective Action Plan In response to the deficiency identified, the Agency will modify its existing internal control protocols in the following ways: • Develop emergency internal control protocols to be implemented during emergency situations whereby all items recoded by accounting staff are reviewed and signed off by the Controller or Director of Finance to ensure appropriate treatment. Train all accounting staff on this expectation. • Ensure adherence of record retention policies and procedures which are consistent with regulatory requirements. • Modify its petty cash protocols to include the review and adequate documentation of all receipts to verify allowability prior to reimbursement. Train all petty cash reviewers on this expectation. Individual Responsible for Corrective Action Plan Auston Johnson Controller 215-386-3838 Anticipated Completion Date: October 31, 2023

2022-001 Gross Patient Revenues Included in Lost Revenue Calculation Corrective action planned: Ensure independent audit of financial statements is performed and finalized prior to Provider Relief Fund or other relevant filing deadlines to ensure completeness of revenue calculation. Anticipated completion date: 12/31/2023 Contact person responsible for corrective action: Anthonie Zimmermann, CFO

Ensure that the Organization's tenant compliance policies are strictly adhered to, complying with FHA Guidance and that proper procurement documentation maintained.

Finding 2022-02: Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Corrective Action Plan: Lack of leadership and structure within the Finance department along with the ripple effects from a previous waiver submission requirement under COVID for delayed audit submissions lead to missed deadlines for the delivery of the financial statements to REAC. To remedy this finding, RRHA’s new CFO has implemented an earlier internal deadline for Unaudited FDS submissions. RRHA’s Unaudited FDS is due November 30th. However, the new internal deadline date will be scheduled before Thanksgiving each year. We will also work with our auditors to establish an audit schedule that will allow us to submit the Audited FDS prior to the June 30th deadline. Name of Responsible Person: Precious Washington, Senior Vice President/Chief Financial Officer Expected Completion Date: September 30, 2024

2022-005 Control Documentation Recommendation: We recommend that the District review its procedures and controls over time and effort documentation for wages charged to Federal programs to ensure all documentation accurately reflets the work performed and that the time and effort documentation agrees with how the employee’s wages are allocated to the grant in the finance system Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will make necessary modifications to its time and effort documentation and control process to ensure all wages charged to Federal programs accurately reflect the work performed. Name(s) of the contact person(s) responsible for corrective action: Tariro Chapinduka, Director of Business Services Planned completion date for corrective action plan: December 31, 2023

Controls, such as a calendar tracker, should be implemented to monitor timely completion and submission of required reports. In addition, there should be a documented review of the report data before submission. The Organization will fully utilize the spreadsheet /database that is in place with key federal contract requirements and deadlines. This document will be reviewed monthly by the program and finance team to ensure reports and submitted on a timely basis. Additional tools will be utilized to facilitate roles and responsibilities and reporting requirements.

2022-01 Technical Name of contact person: Annie Murrell, Director of Social Services Corrective Action: Forced Eligibility Supervisors will ensure that staff are utilizing dictation templates that was implemented in January 2022. This template addresses Admin letters when needed and training was completed with staff. Supervisors have implemented reviewing the task that caseworkers are receiving. Completing these reviews will allow supervisors to monitor timeliness regarding medical forced/recertifications. Supervisors for all Medicaid programs will complete a review of all transfer cases prior to accepting the transfer to identify possible errors in the case. If needed supervisors will reach out to the transferring county. This change will be effective October 2023. Income - Total Countable Income CMA implemented recertification checklist in September 2022 that will assist workers in completing steps during the recertification process and second partying their work as well. Proposed Completion Date: October 31, 2023

Condition: During testing of tenant files, there were 5 instances where inspection documentation or HQS documentation was missing. Corrective Action: Management has established the proposed controls included in the Recommendations outlined in the Federal Awards Findings and Questioned Costs document: Management created a review tool checklist of all required forms for the frontline staff to use as reference, for the Housing Coordinator to review assistance requests and client charts; and for leadership to conduct randomized internal audits; updated the training curriculum for Housing Department staff; new frontline staff has been hired, and trained to include clarification of compliance elements, the rationale and their importance, and which forms satisfy each one. WNCAP recognizes that the deficiency appears to persist, but this is due to the corrective actions being implemented in the first quarter of 2023, which is when the final audit report for FY 2020-21 was completed, and which time period is not covered by this audit. After implementation, internal review of client records confirms that they addressed this deficiency, as evidenced by the complete, compliant files. This will be reflected in the next Single Audit for FY 2022-23, and going forward.

Condition: During the testing of tenant files, certain documentation deficiencies noted as summarized below: 14 – Missing Release of Information documentation. 9 – Missing documentation of client and/or landlord participation agreements. 4 – Missing documentation of current income or verification of 0 income. 3 – Missing documentation of housing plan or assessment. Corrective Action: Management has established the proposed controls included in the previous audit, which match the Recommendations outlined in the Federal Awards Findings and Questioned Costs document: created a review tool checklist of all required forms for management to review assistance requests and client charts; updated the training curriculum for Housing Department staff, new frontline staff has been hired and trained to include clarification of compliance elements, the rationale and their importance, and which forms satisfy each one. Management also decided to overhaul all department forms and has begun a review process. WNCAP recognizes that the deficiency appears to persist, but this is due to the corrective actions being implemented in the first quarter of 2023, which is when the final audit report for FY 2020-21 was completed, and which time period is not covered by this audit. After implementation, internal review of client records confirms that they addressed this deficiency, as evidenced by the complete, compliant files. This will be reflected in the next Single Audit for FY 2022-23, and going forward.

Condition: The WNCAP Single Audit was not submitted to the Federal Audit Clearinghouse within the prescribed period. Corrective Action: The key position of Director of Finance was filled in October 2022, and will remain appropriately staffed going forward. The main cause for this delay was the delay of the previous Single Audit, since it extended into this fiscal year’s timeline. The Director of Finance was able to complete the SEFSA for this audit in a timely manner, and the audit progressed at a reasonable pace. Management will continue to refine internal processes for efficiency; and WNCAP is on track to submit the next Single Audit (FY 2022-23) by the standard deadline of March 31, 2024. In addition, management created a risk assessment policy and procedure to be initiated any time there is turnover in key personnel who play a role in the finance-related activities of the organization. The process includes the following steps: naming an assessor/monitor to lead the effort, who must be the staff member at the highest level of financial responsibility; creation of a monitoring plan that identifies risks, their potential impacts, the actionable steps to mitigate said impacts, and assigns actionable steps to specific staff. The assessor/monitor decides the duration of the monitoring period, and is tasked with routinely meeting with responsible staff to ensure mitigation activities are implemented, and update the monitoring plan as needed. One of the potential impacts named in the policy is “past-due submission of the Single Audit into the FAC”.

During weekly meetings, the importance of timely reporting will be discussed with employees responsible for completion and submittal of reports to ensure that all requirements to the Government, including financial audits, are identified, and submitted in a timely manner. Reporting deadlines specified in the cooperative agreement for monthly financial reports are under discussion with the Federal Government. This is estimated to be completed by December 31, 2023.

Sliding Scale Assessment Planned Corrective Action: (Patients accounts were tested for eligibility for the sliding scale and found that the patient was not eligible for the discount. We are training staff to follow guidelines during their assessment. Sliding fee discounts will be approved by Sanara Leake. Person Responsible for Corrective Action Plan: (Sanara Leake, Revenue Cycle Manager) Anticipated Date of Completion: 10/30/2023

Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. HAPCAP now has multiple staff that have been involved in the process of building audit reports. This will allow for timely audit completion for all future audits. We will also work with our audit firm to begin the work of the audit earlier in the calendar year for the 2023 audit. Contact Person Responsible for Corrective Action: Kelly Hatas, Executive Director Anticipated Completion Date: 10/24/2023 Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. Finding 2022-001: Late Filing of Audit Report Management’s Response The key fiscal point of contact for HAPCAP was on medical leave for a significant portion of time during the work of the audit. This led to delays in the compilation of required reports. Additionally, near the submission deadline, there was a discrepancy in the financials that was ultimately resolved, but took time to research and also contributed to the late submission. All items within the audit were accurate. HAPCAP now has multiple staff that have been involved in the process of building audit reports. This will allow for timely audit completion for all future audits. We will also work with our audit firm to begin the work of the audit earlier in the calendar year for the 2023 audit. Contact Person Responsible for Corrective Action: Kelly Hatas, Executive Director Anticipated Completion Date: 10/24/2023