Corrective Action Plans

U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes Auditee’s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD’s fiscal team enters the drawdown request into the Federal Payment Management System (PMX). An invoice is then created within Workday. When the City’s Department of Treasury receives the funds, the funds should be matched to the invoice and cash posted to the general ledger. One of the challenges with the City’s migration into Workday was billing and invoice matching for grant sponsors. This resulted in no posting of cash received from drawdown request to the general ledger. The Department of Finance has recently developed a process to resolve this issue. BCHD’s fiscal team will work with DOF to develop a reconciliation process for cash draws received after the City’s fiscal year end. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes Auditee’s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD’s fiscal team enters the drawdown request into the Federal Payment Management System (PMX). An invoice is then created within Workday. When the City’s Department of Treasury receives the funds, the funds should be matched to the invoice and cash posted to the general ledger. One of the challenges with the City’s migration into Workday was billing and invoice matching for grant sponsors. This resulted in no posting of cash received from drawdown request to the general ledger. The Department of Finance has recently developed a process to resolve this issue. BCHD’s fiscal team will work with DOF to develop a reconciliation process for cash draws received after the City’s fiscal year end. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.767 Children’s Health Insurance Program (CHIP) Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: No Auditee’s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD’s fiscal team enters the drawdown request into the Federal Payment Management System (PMX). An invoice is then created within Workday. When the City’s Department of Treasury receives the funds, the funds should be matched to the invoice and cash posted to the general ledger. One of the challenges with the City’s migration into Workday was billing and invoice matching for grant sponsors. This resulted in no posting of cash received from drawdown request to the general ledger. The Department of Finance has recently developed a process to resolve this issue. BCHD’s fiscal team will work with DOF to develop a reconciliation process for cash draws received after the City’s fiscal year end. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.044, 93.045, 93.053 Aging Cluster Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on Federal Financial Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2023-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted, had approved and has implemented the new Internal Controls Policy that addresses this deficiency. This policy will includes sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: This was completed February 20, 2024.

Condition: As a precondition to receive federal awards, prospective recipients must have effective internal controls over the federal award. As described in 2 CFR, Part 200.303, nonfederal entities must have certain written policies and procedures surrounding the management of their federal awards. Such policies should include procedures for collecting payments of federal funds per 2 CRF 200.305, cash management (i.e., minimizing the time between draws and actual disbursing of federal awards) per 2 CFR 200.302(b)(6), allowable cost per 2 CFR 200.403, and conflict of interest per 2 CFR 200.318. Per 2 CFR 200.319(d), the non-Federal entity must have written procedures for procurement transactions. Recommendation: The Authority should adopt written policies and procedures over cash management and allowable costs required under the Uniform Guidance. Planned Corrective Action: The Authority implemented these policies during the FY 2024 (BA054 Cash Management Policy and BA059 Authorization of Purchases). Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

Name of Responsible Individual: Brenda Willis, Senior Executive Director of Financial Grants & Contracts Corrective Action: The internal control procedures for federal expenditures will be reviewed and updated to ensure that they comply with federal regulations such as the Uniform Guidance (2 CFR 200) and the Federal Acquisition Regulation (“FAR”). The roles and responsibilities of staff involved in managing and reviewing federal expenditures will be explicitly defined. All personnel handling federal funds will be trained on policies, compliance requirements, and how to detect red flags in grant activity. The approval workflow for federal expenditures will be assessed and updated by adding Sponsored Programs Office to the approval path to assist in preventing fraud and ensure compliance with regulations. The internal controls will be updated by December 2024 and training will commence in early 2025 Anticipated Completion Date: December 31, 2024

FINDING 2023-007 Finding Subject: COVID-19 – Education Stabilization Fund – Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance for the reporting requirement. Not all EESER reports submitted by the School Corporation during the audit period were not supported by the School Corporation's records. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Description of Corrective Action Plan: We are implementing a proper system of internal controls and developing policies and procedures to ensure all reports are submitted accurately. Moving forward we will ensure all ledgers are attached to the reports that have been submitted. Anticipated Completion Date: The anticipated date of correction for this finding is January 1, 2025.

FINDING 2023-004 Finding Subject: Twenty-First Century Community Learning Centers – Cash Management, Program Income and Reporting. Summary of Finding: The School Corporation had not established an effective system of internal controls related to the grant agreement and the Cash Management, Program Income and Reporting compliance requirements. Cash Management The school submitted reimbursement requests without taking into considering the program income or reducing the request by the program income earned due to the lack of adequate program income. Program Income Controls had not been designed or implemented adequately to ensure that the proper fees were assessed and that the cash collections remitted were accurate. Additionally, the school-maintained program income in a separate fund and comingled with other non-grant funded program revenues. The unit did not deduct program income from allowable costs prior to claiming reimbursement. Reporting The total requested reimbursements for the audit period were understated by $32,605 when compared to the ledger. Of the two End of Year reports selected for testing neither properly included program income that was received during the year due to inadequate tracking of program income. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are implementing a system of internal controls to strengthen our policies and procedures and ensure the proper tracking of Program Income is reported and submitted accurately for Twenty First Century Learning center grant funds. Description of Corrective Action Plan: We have reached out to our liaison at the Department of Education to determine if program income should be reported monthly or annually. Management will be working with the Safe Harbor Director to implement a system to ensure separation of the Twenty first Century grants and other funds that are under the Safe Harbor program. Anticipated Completion Date: The anticipated date of correction for this is January 1, 2025.

Finding 2023SA-003 Insufficient Grant Monitoring Comments on the Finding and Each Recommendation: The County agrees with the finding. Action(s) Taken or Planned on the Finding: The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to grant reports that are filed. Name of Contact Person: Judi Pollock, County Clerk Projected Completion Date: Unknown

RLHT will add procedures to the current financial policies document that contain oversight over the receipt and use of federal award funds.

By the end of 2023, the organization adjusted processes surrounding cash management. Since December of 2023, the organization has requested funds after the end of the month based on the actual expenditures of that month to minimize the time elapsing between the transfer of funds from the grant program and disbursement by the organization. However, the audit firm is recommending that the process be in the form of written policies and procedures. We have complied and are following written policies, however the policies were not created before the end of 2023. The change in processing occured immediately upon notification, effective December 6, 2023.

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN August 27, 2024 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings from the year ended December 31, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - Financial Statement Audit and Federal Award Program Audit Finding 2023-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Projects (Section 223(f)/207) Recommendation: We recommend that the Project funds are only used for expenses of the Project. Additionally, we recommend the related entity reimburse the operating cash of the Project $15,985 for the payroll fees paid. Action Taken: Management acknowledges the Project funds were used for expenses of another entity. Management will ensure the related entity reimburses the operating cash of the Project $15,985 for the payroll fees paid and ensure that the Project funds are only used for expenses of the Project. Finding 2023-002: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2023-002 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting ial procedures, system of internal controls and policies. FINDING - Federal Award Program Audit Finding 2023-003: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend that management review its policies and procedures in place to ensure that the residual receipts deposit is made per regulatory guidelines. Action Taken: We agree with Finding 2023-003 described in the accompanying schedule of findings and questioned costs. Management will deposit $4,285 into the Project's residual receipts account. Management will review its policies and procedures in place to ensure that the residual receipts deposit is made per regulatory guidelines. If HUD has questions regarding this corrective action plan, please call 828-758-2617. Sincerely yours, Chassidy Triplett Project Administrator Koinonia, Inc.

FINDING 2023-006 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include proper segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were complied, prepared and submitted by one employee without documentation to support an oversight or review process in place to prevent, or detect and correct, errors. In addition, because the unit was unable to provide supporting documentation for the information contained in the six reports submitted during the audit period, three of these reports contained errors. Contact Person Responsible for Corrective Action: Kelly McPike Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: An effective internal control will be developed to ensure supporting documentation is used and retained for all required reports submitted on behalf of the Education Stabilization Program Funds. The reports will be compiled, prepared, and submitted by more than one employee to support any possible oversight or errors. Anticipated Completion Date: April 2024

2023-003 Name of Contact Person: Matthew Roy Corrective Action: Greenheart is in the process of establishing a timecard system for all staff who work on grants and have their time allocated to a grant. In the meantime, in early 2024, the Grants Director worked directly with payroll and department leaders to review and update the list of personnel who are working on the grant. This was a documented process. Proposed Completion Date: Management considers this finding resolved as of August 2024.

2023-001 Name of Contact Person: Matthew Roy Corrective Action: After the September 2023 staffing changes, the Finance Director and the Accounting Manager reviewed the FFR reports prior to filing. The Finance Director provided verbal approval to file. For all reports going forward, Greenheart will document approval of filing via email exchanges from the Accounting Manager to the Director of Finance. Proposed Completion Date: Management considers this finding resolved as of August 2024.

SafeQuest Solano will implement stronger internal controls and procedures to ensure timely submission of the DCF. This will include designating a responsible party for tracking and submitting the DCF, creating a timeline and checklist for required submissions, and conducting periodic reviews to ensure compliance with deadlines. Additionally, SafeQuest Solano will provide training to relevant staff on the importance of meeting federal compliance requirements. SafeQuest Solano has already implemented a new database system.

The County has written Policy and Procedures to be reviewed by the commission in November 2024 for approval. Responsible Official - Andrea Montoya, Deputy County Manager and Robert Placencio, Finance Director Timeline and Estimated Completion Date - November 2024.

The City has implemented the recommendation first contained in 2022-007. There is a process in place where supervisor review and approval of timesheets is completed and documented. That process continues and will be in place for the entirety of the fiscal year ending June 30, 2024. Responsible Person: Kevin Saycocie Expected Implementation Date: 07/01/2024

Reporting was corrected through the ODOD

1. A critical aspect of Cleveland UMADAOP’s updating of financial policies and procedures will be training on the proper and timely completion of federal forms 2. Weekly meetings will be held with Program Directors with a standard agenda item of upcoming due dates within the subsequent four weeks. 3. During these meetings, Directors will be required to provide status updates and draft submissions when applicable. 4. Once a quarter, a federal compliance requirement will be selected to have a deep dive review. 5. An HQ Administrative Assistant will be hired to monitor compliance as well as adherence to deadlines and will prepare a monthly report for the Executive Director’s review.

Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.