Corrective Action Plans

Assistance listing number and program name: 84.010 Title I Grants to Local Educational Agencies Agency: Arizona Department of Education (ADE) Name of contact person and title: Tim McCain, ADE Chief Financial Officer Chris Brown, ADE Business Officer of Education Programs Anticipated completion date: January 2025 Agency’s response: Concur • ADE is working on standardizing fiscal efficiency by adopting uniform guidelines that monitor obligations and expenditures. These guidelines outline available resources and determine allocation amounts within federal awards and earmark expiration dates within programs. • ADE is also working on standardizing how funds may be reallocated to ensure that no funds are at risk of reverting to USED. Specifically, school improvement funds are now also tracked as part of Title I allocation and reallocation process. This will ensure funds are earmarked and obligated in a timely fashion (i.e., in the period of performance). This item is planned to be completed by January 2025.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Nicole Von Prisk, ADE Deputy Associate Superintendent of Grants Management Matt McClary, ADE Compliance Officer Anticipated completion date: April 2025 Agency’s response: Concur • Tech team supervisor will have someone from that team put eyes on the initial generated report to compare results to prior year, looking at total number of LEAs, then greenlighting the initial report for the Tech Director and the Fiscal Director to review. • Once the Fiscal and Tech Directors receive the report, they will be responsible for sampling the data that populated into the report, by looking at overall numbers who Pass, Pass with Exception, or Fail and doing a comparison for analysis to prior year summary results. They will conduct a random sampling, comparing totals to latest AFR totals, to ensure amounts populated correctly. Once random sampling has been completed, it will be sent to Deputy Associate Superintendent for final checks. • Deputy Associate Superintendent will give final approval to move to public display of data, after confirmation of completeness and accuracy of data populated.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Chris Brown, Business Officer of Education Programs Anticipated completion date: February 2025 Agency’s response: Concur • The Arizona Department of Education (ADE) has already begun to document and execute practices addressing the recommendations issued by the auditor's office. • ADE has already drafted a comprehensive policies and procedures document outlining eligibility, duties, and responsibilities with individuals who oversee and double-check the work. This document was created and refined by reviewing other states’ procedures, federal technical assistance groups, communications with the Title federal program office at the United States Department of Education, and internal procedures in other units. • The Title I unit has been restructured to have an operations team with multiple staff members overseeing data quality and internal controls for allocations. This updated structure ensures that multiple individuals are involved in the allocation process. Staffing for this should be completed by February 2025. • The updated processes include entity management to determine when charter LEAs open and operate each year. Now, other systems validate this information instead of copying the information from the prior year. As such, this item has already been completed. • Finally, the department will follow up with the United States Department of Education (USED) regarding recalculating the fiscal year 2023 and the six ineligible LEAs for Title II funds to determine feasible processes and resolutions to each audit recommendation.

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Jim Whallon, DES Deputy CFO Anticipated completion date: June 30, 2026 Agency’s response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Perform required monitoring of its subrecipients and their compliance with the award terms and program requirements. The Department will revise its agency-wide policies and procedures related to single audit requirements for pass-through entities to include guidance regarding how to establish effective subrecipient monitoring procedures. The Department will also offer additional subrecipient monitoring guidance for programs administered by divisions with existing subrecipient monitoring findings. 2. Properly classify and report subrecipient expenditures on the State’s SEFA. The Department will revise its procedures related to single audit requirements to include steps detailing the instructions for classifying and reporting subrecipient expenditures on the State’s SEFA. The updated procedures will include actions needed to be taken to ensure each pass-through relationship is appropriately determined and that every subrecipient relationship is communicated to the staff responsible for compiling the State’s SEFA. 3. Develop, implement, and train all divisions on entity-wide written subrecipient-monitoring policies and procedures requiring all divisions to: a. Assess the risk of each subrecipient’s noncompliance and carry out monitoring activities based on those risk assessments such as reviewing financial and performance reports, providing training or technical assistance on program-related matters, and performing on-site reviews, selective audits, and/or other monitoring procedures. b. Verify subrecipients receive timely single audits, if required; follow up on and ensure that corrective action is taken on any audit findings that could potentially affect the program; and issue management decisions for any audit findings pertaining to the federal award. c. Maintain documentation of monitoring procedures demonstrating they were performed, including the monitoring procedures’ results and any Department actions taken, if appropriate. In addition to the revisions in policy and procedures outlined in Recommendation #1 above, the Department will train staff responsible for administering compliance requirements for pass-through entities. This training will include instructions to formulate a risk assessment, review controls related to compliance requirements, review timely single audit submittal, follow up on audit findings, issue management decisions for findings, and maintain adequate documentation of monitoring procedures. The training will be provided to all staff responsible for administering programs with pass-through entities. 4. Allocate sufficient resources, such as staffing, to comply with the award terms and program requirements, and designate individuals within each division to perform necessary subrecipient-monitoring procedures. The Department will conduct analyses to determine resources needed, including staffing, to ensure compliance with applicable requirements. For example, the Department will assess the efficiency of its subrecipient-monitoring procedures, estimate future workloads, determine staffing needed to meet those workloads, and assign sufficient staff the responsibility for ensuring compliance with each requirement outlined in the federal award. The Department will also ensure the staff responsible for administering the compliance requirements prioritize this responsibility and communicate anticipated compliance deficiencies to management. 5. Update the form it uses to determine whether other parties receiving program monies have the role of a subrecipient or contractor to include guidance for how to determine each characteristic of a subrecipient and contractor relationship and require a conclusion to be documented. In addition, train staff to properly complete the form and perform supervisory reviews of it. The Department will revise its Contractor/Subrecipient Determination form to clearly identify the final determination of a pass-through entity. The Department will also provide guidance to accompany the form that shows how to determine each characteristic of a subrecipient and contractor as well as how to make the final determination regarding the contractor versus subrecipient relationship. The Department will then provide training to staff responsible for using this form as part of the training outlined in Recommendation #3 above.

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: February 28, 2025 Agency’s response: Concur The Office agrees with this finding and will begin to take corrective action to bring the program fully into compliance with SLFRF Federal grant reporting requirements. The Office recognizes the importance of transparency in utilizing Federal grants and has taken significant corrective action to resolve any inaccuracies in Federal grant reporting. The Office has implemented specific actions to ensure reporting inaccuracies and program expenditure understatements/overstatements do not occur. During fiscal year 2025, the Office is taking corrective action to improve SLFRF reporting, including the following: • Award Reconciliation—The Office has conducted a comprehensive review and extensive reconciliation of all awards to identify reporting inaccuracies. • Expenditure Reconciliation—The Office staff responsible for preparing the SLFRF quarterly reports is completing the reconciliation of all expenditures to the State’s accounting records, which are the official expenditures made for the program. • Enhanced Reporting Mechanisms—The Office will review, correct, and/or resubmit any inaccurately reported information. The staff responsible for preparing the SLFRF quarterly reports is no longer reconciling to the Office’s internal grants-management system. • Update Written Procedures—Based on the comprehensive review noted in the response above, the Office is working to develop improved reporting procedures to ensure accurate submission of grant expenditure data. This may include revised standardized templates, improved guidelines, and enhanced communication channels to improve reporting accuracy. • Ongoing Training—Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of reporting errors. The Office will continue to strengthen internal controls to prevent similar issues from occurring in the future. This will involve strengthening oversight, providing additional training to staff members in reporting processes, and implementing regular quality assurance checks. As of this date, the Office has allocated sufficient resources to comply with the award terms and program reporting requirements by establishing a new Grants Technology and Data team dedicated to the oversight of performing necessary SLFRF program reporting procedures.

Assistance listing numbers and program names: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds 84.425C COVID-19 Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: July 31, 2025 Agency’s response: Concur During fiscal year 2024, the Office took significant corrective action to improve subrecipient monitoring by developing and implementing a comprehensive subrecipient monitoring plan. This plan includes the following: • Financial Report-Reimbursement Requests—The Office reviews the grantee's financial reports to ensure costs align with the approved budget, program objectives, and federal cost principles. • Performance Reports—The Office reviews the submission of programmatic reports. The timelines for submission and frequency of the programmatic activity reports are defined in the terms and conditions of each award. The program activity reports document that all program requirements are being satisfactorily fulfilled. Grantee outreach is conducted when performance activity is lagging. Grantee check-ins and/or additional milestones are set to ensure goals are met. The Office may amend or terminate the grant award if sufficient progress is lacking. • Single Audit Reports—The Office confirms any required Single Audits and reviews a copy of the most recent report. • A Single Audit Questionnaire is distributed to grantees annually to confirm if the entity is subject to this federal audit requirement. • The Office also reviews total payments issued to an entity by the Office in the prior year to confirm if disbursements met the audit threshold. • The Office requests grantees submit their Single Audit Reporting Package (SARP) with any findings and the required Corrective Action Plan. In addition, the Office collects SARPs from the federal clearinghouse. • The Office reviews SARPs for any findings and conducts follow-up monitoring of CAPs that impact any grant funding managed by the Office. Management decisions are issued to grantees as required for specific grant findings. • Risk Assessment (RA)—The Office conducts a Risk Assessment (RA) of grantees when applying for grants to inform the grant award decision and possible grantee oversight or restrictions. Additionally, the Office conducts an annual RA of any grantee currently awarded funding. • The RA contains a self-assessment for the grantee to complete and an internal review conducted by the Office. Scores from both are weighted and used to calculate the overall risk score for each grantee as high, medium, and low risk. • The Office utilizes the RA results to prioritize high-risk grantees, which are reviewed through a desk or on-site monitoring. Medium-risk grantees will receive additional support and be referred to our Compliance and Reporting team for further review if additional concerns arise. Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of waste, fraud, and abuse of federal dollars through our subrecipient monitoring process. The Office has developed and implemented processes for requirements such as single audit review and corrective action follow-up, risk assessment, and subrecipient monitoring to address the specific findings. During the time frame corresponding to this audit finding, the pace and volume of grants management administrative duties required to be executed exceeded staffing capacity, contributing to the findings noted. As of this date, the Office has achieved stability in both manager and staff positions. In addition, the Office has allocated sufficient resources to comply with the award terms and program requirements by establishing a Grants Compliance and Reporting Team dedicated to performing necessary subrecipient monitoring procedures. Furthermore, the Office has implemented all recommendations and would like to specifically highlight efforts to work with subrecipients to resolve the potential disallowed costs of $1,903,858 of program monies that may have been spent in violation of its federal award terms by conducting on-site monitoring visits, desk reviews, and facilitating subrecipient technical assistance. OSPB is committed to continuing these efforts.

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Leanna DeKing, DES Policy Planning Project Manager Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will ensure program costs are properly recorded in the financial system during the period of performance and only obligated costs are spent during the liquidation period. Closeout activities, such as direct administrative costs, will be obligated prior to the end of the award period and spent within the liquidation period, or 120 calendar days after the period of performance ends. The Department will allocate sufficient resources to perform essential grant closeout functions to help prevent inappropriate charges. The Department will also update existing grant closeout procedures to require a review and approval of grant expenditures during the liquidation period to ensure they are allowable and properly obligated prior to the period of performance end date.

Assistance listing number and program name: 21.023 COVID-19 - Emergency Rental Assistance Program Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will prepare and retain detailed documentation including system reports, queries, screenshots, and other evidence supporting the program information being reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its policies and procedures to retain all records relating to federal awards for a period of 5 years after all the federal funds are expended. For future related programs with this requirement, the Department will develop and implement internal control policies and procedures that ensure systems properly display complete and accurate data on the federal reporting dashboard as instructed by the federal agency’s reporting guidelines. Additionally, these policies and provisions will ensure that any future ERAP award funding received by the Department will be separately reported to avoid commingling. Finally, the Department will require that ERAP personnel verify the reported program information to ensure all report element sections are complete and accurate, and that it matches the underlying benefits and financial systems data. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Tracy Raymer, DES Business Analyst Manager Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: Develop and implement written policies and procedures to ensure it prepares and retains detailed documentation, such as system reports, queries, or screenshots, to support the program information it reports to the federal agency for the UI program for a period of at least three (3) years. Beginning July 2024, the Department has assembled and retained all detailed supporting source documentation that supports the data provided in the 9050 - Time Lapse of All First Payments except Workshare report and will retain it for a period of no less than three (3) years.

Assistance listing number and program name: 17.225 Unemployment Insurance Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Jacqueline Butera, DES Administrator Jean Ahumada, DES BAM Manager Anticipated completion date: March 18, 2024 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The controls the Department put in place to address the federal regulation requirements, are multi-year remediation plans. The controls include recruiting and retaining a workforce with a strong knowledge and understanding of Unemployment Insurance Laws, Policies, and Procedures, as well as proper case management skills. From December 2022 through March 2024, the Benefit Accuracy and Measurement (BAM) unit experienced an 18 percent attrition rate. Given the fact that the BAM unit is made up of nine (9) auditors, one of which is a lead who does not receive a full caseload, an 18 percent attrition rate results in a significant impact on the distribution of workloads amongst experienced and new staff, respectively. As of December 2023, the BAM unit was 90 percent staffed with only 67 percent of auditors working a full caseload. This is because new hires with prior program knowledge do not receive a full caseload until three (3) months from their new hire date. During SFY 2023, the Department carefully balanced meaningful recruitments, staff training, and case assignments in order to support staff retention while addressing the federal timeliness requirements. As of March 18, 2024, the Department fully implemented the multi-year remediation plan, and has shown sustainable performance improvement in both the paid and denied claims accuracy measures since September 2023, due to these controls. As of SFY 2024, the Department has met all Paid Case Accuracy and Denied Case Accuracy timeliness performance measures.

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Jacy Wilmes, DES Deputy Business Administrator Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will immediately report the required missing information for its subawards on the FFATA Subaward Reporting System for the WIOA cluster. The Department will also follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than the month-end of the month following the sub-award action. In addition, the Department will implement procedures requiring independent reviews to ensure the sub-award data is reviewed for accuracy prior to and after uploading to the federal government’s reporting system.

Assistance listing numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Agency: Arizona Department of Economic Security (DES) Name of contact persons and titles: Aaron Johnson, DES Fiscal Compliance Manager Tarry Haynie, DES Senior Fiscal Analyst Anticipated completion date: June 30, 2025 Agency’s Response: Concur To ensure the Department’s Division of Employment and Rehabilitation Services (DERS) Finance and Business Operations Administration (FBOA) performs the required monitoring of its sub-recipients and complies with the award terms and program requirements, it has added additional internal controls by updating the monitoring schedule to include backup fiscal monitors. The FBOA will also update its procedures to include the process for backup monitors to take on primary monitoring duties in the event an assigned staff member is unable to perform the onsite monitoring review as scheduled. During fiscal year 2023, the fiscal compliance team within the FBOA consisted of only three staff members. They have since onboarded two additional staff, bringing the total number of fiscal compliance monitors to five. One of these additional staff members completed training and was assigned a full caseload in December 2023. The second new staff member is currently undergoing training and is expected to finish training and absorb a full caseload beginning March 2025. The Department is on track to complete all required onsite sub-recipient fiscal monitoring for fiscal year 2025.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is in the process of developing written policies and procedures to address matching, level of effort, and earmarking. The policies and procedures will address communication with subrecipients and maintaining records and documentation of the amounts used to fulfill matching requirements.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Department will update written policies and procedures related to procurement to incorporate applicable aspects of Federal Regulations 2 CFR §§200.321, 200.322, 200.323, and 200.327. The updated policy will address competition through competitive bids, sole source selections, and retention of procurement documents. In addition, the policy will state the Federal requirements that are to be included in purchase orders and contracts.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department resumed monitoring duties and developed a monitoring schedule to ensure subrecipients maintain program compliance. The Department also established a risk assessment tool that assess risk associated with each subrecipient. Records of subrecipient monitoring will be kept for a period of time to demonstrate monitoring activities were performed.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is no longer reimbursing the subrecipient for unsupported or ineligible costs and is pursuing repayment of funds from the subrecipient. Written policies for reviewing and approving subrecipient reimbursements, as well as, risk assessment were reviewed, updated and amended to ensure ongoing compliance. Staff has been trained and new policies were implemented in FY 2024 subsequent to the period reviewed in this audit. Contract Specialists in the Special Needs Division have received additional training through HUD TA support on CoC standards to ensure all request for reimbursement from subrecipients are eligible, reasonable and appropriately documented, including any allocations and purchasing requirements.

Assistance listing numbers and program names: 14.231 Emergency Solutions Grant Program 14.231 COVID-19 - Emergency Solutions Grant Program 93.558 Temporary Assistance for Needy Families 93.558 COVID-19-Temporary Assistance for Needy Families Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department will stop the reimbursement of costs to all nonprofit and contracted subrecipients for items that are disallowed and/or restricted by the regulations of the federal Emergency Solutions Grant (ESG) program and Temporary Assistance for Needy Families (TANF) grant, including payments to personnel that violate the conflict-of-interest disclosure requirements. The Department will revise its expenditure review procedures to ensure compliance with these regulations prior to disbursing any ESG and/or TANF funding to any subrecipient for any purpose. These revisions will include review and approval by applicable management personnel prior to disbursement of federal funding. The Department is also in the process of establishing a divisional Monitoring and Compliance Policy and Procedure Manual which will establish procedures specific to subrecipient monitoring. The Department will continue to assess the risk of noncompliance violations for each subrecipient and establish a plan of action to address noncompliance. The plan of action will include an array of training and educational processes to ensure applicable personnel are knowledgeable of programmatic compliance requirements and Department contracts. The Department will also monitor subrecipients per its updated policies and procedures and will ensure proper oversight of federal expenditures as required by federal regulations. The Department has amended its contracts with the applicable subrecipients to more clearly outline the regulatory requirements and expectations for expenditures under the ESG and TANF grants. The Department will also continue to resolve the unallowable costs reimbursed to subrecipients as deemed appropriate by the applicable federal agencies.

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

Eastern Carolina Human Services Agency, Inc. Corrective Action Plan For FY Ending June 30, 2023 Section II. Financial Statement Findings. 1. Finding 2023-001 - U.S. Department of Health and Human Services, Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: Internal control processes over financial accounting did not ensure that all transactions were properly recorded. Internal control processes over financial accounting did not ensure that key accounts were reconciled or received on a periodic basis. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director. Action Plan: After review/monitoring of the previous Finance Officers duties and responsibilities, it was determined that the internal control processes of the finance department were not carried out properly to meet the requirements of 2 CFR Part 200 Section 200.302. Therefore, the agency terminated the Finance Officer. The agency immediately began the search for a new Finance Officer via Indeed and other employment hiring agencies. This process took much longer than expected which left an unexperienced Accounting Technician to operate the Finance Department along with limited finance knowledge of the Executive Director. After several advertisements for the vacant position the agency interviewed numerous applicants and was finally able to hire the current Finance Officer. The Finance Officer has worked continuously to insure that the internal control process of the department is implemented by making sure all accounts are reconciled and reviewed with supporting evidence of each review. With this process back in place, management and the Board of Directors will review and sign off on each account's financial statements. Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-002 - U. S. Department of Housing and Urban Development Voucher Cluster, Assistance Listing #14.871/14.879 Statement of Condition: For the year ended June 30, 2022, the Organization did not submit their audited financial statements to HUD by the required deadline. For the year ended June 30, 2023, the Origination did not submit their unaudited or audited financial statements to HUD by the required deadline. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: The submittal of the GAAP-based unaudited and audited report for FY ending June 30, 2022, was a management oversight due to the lack of a Finance Officer in place. The agency currently has a Finance Officer in place who will submit timely GAAP-based unaudited and audited financial information electronically to HUD via the Financial Assessment Sub-System (FASS-PH). Additionally, the agency has approved and scheduled HUD training for the Finance Officer through Nan McCay. Further, financial and accounting training for the Finance Officer/ Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Finding 2023-03 - U.S. Department of Health and Human Services Community Services Block Grant, Assistance Listing #93.569; U.S. Department of Housing and Urban Development, Housing Voucher Cluster, Assistance Listing #14.871/14.879. Statement of Condition: The origination did not submit the data collection form and required reporting package to the Federal Audit Clearinghouse (FAC) for the year ended June 30, 2023, by the required due date. Contact Person: Ashlee Graziano, Finance Officer, or Trudy Murray, Executive Director Action Plan: Management will ensure that the audit and data collection forms are completed timely and the data collection form and required reporting package are submitted electronically to the FAC each fiscal year going forward. To further ensure this finding is resolved, training for the Finance Officer/Finance Department has already been requested through the agency's local HUD Field Office analysis in Greensboro, NC. Section II - Findings relating to the financial statements which are required to be reported in accordance with generally accepted government auditing standards. 1. Finding 2022-001 Statement of Condition: Controls over the vendor payment process were not properly followed. Action Plan: Submitted previously with Financial Statements and Independent Auditor's Report FY Ended June 30, 2022. Current Status: Corrected The Management Department (Finance Officer and Executive Director), with the supervision of the Board of Directors Finance Officer, will continue to make every effort necessary to meet all HUD submission as required, in order to be in compliance with all HUD rules and regulations. Respectfully submitted, Trudy Murray Executive Director

Finding: 2023-009 All Programs Description of the Findings: During the review of the procurement compliance requirement related to major program, it was determined that the USWA did not have a document procurement policy in place until August 2023. Views of Responsible Official(s) and Planned Corrective Actions: While the Alliance did not have a standalone procurement policy in place until August 2023, it did have purchasing policies embedded in its Accounting and Finance Manual that covered purchases relative to our work at that time. No further corrective action is needed however policies are reviewed annually to ensure compliance under 2 CFR 200.516(a). Completion Date: August 2023 Responsible Official(s): ShaQuina Davis

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County obtain certifications from vendors stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has ensured that any entity that receives American Rescue Plan (APRA) funding is registered on SAM.gov before any funds are disbursed by the County. An addendum will be added to all current and new contracts that will require signed certification from the vendors/contractors related to debarment and registration with SAM.gov. Name of the contact person responsible for corrective action: Sherri Crow, Director of Budget and Finance Planned completion date for corrective action plan: February 1, 2025

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends that the County review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding and that appropriate monitoring is performed for each subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that all subrecipients of American Rescue Plan (APRA) funds are monitored by using appropriate subrecipient monitoring procedures to ensure compliance with the grant awarded throughout the contract period. This process was started in 2024 as part of the 2022 Corrective Action plan and many of the subrecipients were in compliance for 2023. Due to a change in personnel early in 2024 this was not followed up on until later in the year. Name of the contact person responsible for corrective action: Sherri Crow, Director of Budget and Finance Planned completion date for corrective action plan: December 1, 2024

Finding Number: 2023-005 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 - Coronavirus State and Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Chad Van Santen, Grant County Auditor Karl Lindquist, Grant County Coordinator Corrective Action Planned: Grant County management will review vendor payments requiring checking for suspension and debarment in accordance with requirements of funding in the future. Anticipated Completion Date: December 31, 2024

Finding 2023-003 Finding Summary: In connection with the audit performed, it was noted that there was an instance where a patient received more federal assistance and another patient received less federal assistance than allowed based on federal poverty guidelines. Responsible Individuals: Kathryn Boyd, President and CEO Corrective Action Plan: The use of applying slides automatically, without reviewing the account first, has been prohibited by billing staff. In addition, clinic staff are not to apply any payments until the slide has been applied. If there are any issues with the slide, the clinic staff has been instructed to contact the billing staff for review and resolution. The Director of Revenue Cycle will randomly audit staff throughout the year to ensure additional slides are not applied and report out to the Chief Executive Officer. Anticipated Completion Date: 12/02/2024 (disallowing application of slides was previously implemented in 2023)