Corrective Action Plans

Finding Reference: 2023-001 Finding: During testing of student loan notifications, it was identified that one of forty students selected for test work did not receive a notification for three loan disbursements during the year. The item that was an exception described above did not result in changes to the amounts awarded or disbursed to students by the College for the current fiscal year. The condition identified was the result of a student that selected to opt-out of College email notifications, which resulted in federal loan notifications to not be delivered. The College did not have adequate processes in place to ensure appropriately notification in accordance with federal regulations when a student selected to opt-out of receiving College communications. Endicott College Responsible Contact: Bryan Cain, Senior VP for Student and External Engagement Corrective Action Plan: This finding was the result of students being allowed to opt out of all notifications from Endicott College, which are initiated thru a notification system called EMMA. EMMA is the system of record used for notifying students of loan disbursements and as a result of students being able to opt out of all EMMA notifications this student was not notified of their loan disbursements. As a result of this finding the college has disabled the ability for students to be able to opt out of all EMMA notifications and thus being unable to opt out of student financial notifications such as loan disbursements. Anticipated Completion Date: February 2024

This finding was self-identified and addressed. Procedures allocating payroll expenditures in accordance with actual time records and wage amounts were implemented during the year ended June 30, 2023.

Finding 2023-001 Condition The Corporation lacks proper segregation of duties with respect to the calculation of lost revenue. Proper segregation of duties is necessary to prevent a situation where one individual handles a transaction from beginning to end in order to reduce the potential for noncompliance due to error or fraud. During the audit of the lost revenue calculation, six months out of fifty-six were input incorrectly into the calculation from the source documents in error. Using the correct revenue amounts for those six months results in a higher total of lost revenue for the period. As a result of the lack of proper segregation of duties, noncompliance due to error or fraud could occur without being detected and corrected, timely. Corrective Action Plan Corrective Action Planned: The Corporation will have more than one person complete a full review of the lost revenue calculation for each report submission. After the information is gathered and reported by the Chief Financial Officer (CFO) but before the information is submitted, the Controller will be asked to review the data. After review and documentation that there has been a review, the reporting will be submitted. Name(s) of Contact Person(s) Responsible for Corrective Action: Brent Foster, Chief Financial Officer Anticipated Completion Date: Review process will be implemented immediately.

We are in agreement and have educated staff by reviewing the “Time and Effort” information provided by KSDE along with the “Time and Effort Clarification Enclosure C”. The Executive Director of Teaching & Learning will review the positions being paid from federal funds to determine if the position is considered a “single cost objective”. Once this is determined, the business office (or assigned staff) will move forward with collecting the Certification of Time or Personnel Activity Report (PAR). These forms will be available to the auditor during the annual fiscal audit.

ection IV – Corrective Action Plan Finding 2023-001 Programs: LIFF Grant Significant Deficiency over Financial Reporting Repeat Finding: No Auditee’s Corrective Action Plan: In the future, when payroll data is imported from ADP, we will include LiFF grant code to track costs on the accounting system. This is implemented for non-payroll related costs. Contact Person: Berhane Ayichew

The personnel activity reports (PARs) for May and June were singed off in the first week of May before the time was charged to the grant. PARs are required to be an after the fact look book. So they should be completed either the last day of the month or shortly after in the preceding month. Response: The district has created a checklist of the requirements for all salaries paid from federal funds that meets the standards outlines in Subsection 8.h. (5) of the 0MB Circular A-87 Part 225 Appendix B. In doing so the district will obtain signatures on the Personnel activity report (PAR) within two weeks of the last day of the previous month. The district has since adopted this practice for the 2024-2025 school year Implementation Date: July 2023 Person Responsible for the Implementation: Kayla Hughes, School District Business Administrator

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) Contact Person Responsible for Corrective Action: Sarah Haven, Director of Finance & Operations Corrective Action: The Winooski School District will implement the following to address finding 2023-001 Implement control processes and procedures to ensure that time certifications are accurate and complete. Anticipated Completion Date: 6/30/2024

SIGNIFICANT DEFICIENCY 2023-003 Section 8 Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the County review and enhance its internal controls, policies, and procedures to ensure that the amounts included on the FDS are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The department will modify its SOP to include a second reviewer before the final FDS figures are submitted. The first submission is due in August and the final submission is due in March. Name(s) of the contact person(s) responsible for corrective action: Mike Kapa Planned completion date for corrective action plan: June 30, 2024

Federal Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF), Assistance Listing No. 93.498 Federal Agency: U.S. Department of Health and Human Services (HHS) Planned Responsible Officials: Mike Crofton, VP of Finance and Interim Chief Financial Officer Corrective Action: TriHealth is committed to ensuring internal controls are implemented to ensure compliance with Section 200.303 of the Uniform Guidance. In response to the findings, TriHealth has or will implement the following policies and procedures: 1. Design and implement controls over our any future PRF reporting, including both General Distributions and Targeted or Rural Distributions, to ensure the necessary documentation is submitted in the HHS Reporting Portal and that the information submitted is complete and accurate based on accounting records and other data. This will include retention of necessary documentation to support reported expenditures and lost revenues and that such documentation is reviewed by TriHealth’s Controller and VP of Finance and Interim Chief Financial Officer. 2. Utilize Internal Audit to perform detail review and testing over the PRF program reporting, as applicable. This will include the use of Internal Audit to review PRF reporting prior to submission to the HHS Portal, as well as appropriateness of lost revenue and allowability of healthcare related expenses. 3. Prior to submission, the Controller and the Executive Director of Internal Audit will review the draft reporting submissions with the Executive Director of Decision Support and Reimbursement prior to submitting the reports in the HHS Portal. As TriHealth and its affiliates did not receive PRF General Distributions in excess of $10,000, individually or in the aggregate, during PRF Reporting Period 6 (payments received from July 1, 2022 to December 31, 2022), TriHealth will not be required to submit any future reporting in the HHS Portal for PRF General Distributions. However, TriHealth will ensure appropriate levels of review occur for any future reporting of PRF or similar federal funding, including PRF Targeted or Rural Distributions.

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: A written federal policy has been prepared and is in the process of final acceptance by the Board of Selectmen. Anticipated Completion Date: June 2024 Contact: Austin Cyganiewicz, Town Administrator

The University updated its DS-2 form and submitted it electronically to the U.S. Department of Health and Human Services on December 4, 2023. The Controller’s Office implemented an annual review of the DS-2 to identify factors that may require amendments to our next filing. In addition, prior to our submission of any DS-2 amendments, University staff other than the initial preparer will re-confirm the accuracy of changes to the DS-2. Tara Thomason, Controller and Assistance Vice President, was responsible for addressing the above.

As noted in our prior year response, the University continued to have cost transfers in fiscal year 2023 as it reconciled its grants. To limit cost transfers in the future, the following steps have been taken by the University: • The Controller’s Office along with the Office of the Vice President of Research configured our accounting system with an automated control that prevents general (non-payroll) expenditures from being charged to the grant after the period of performance end date, one root cause of cost transfers. • For payroll expenditures, post-award specialists updated grant labor costing allocations in our accounting system to contain an end date that coincides with the period of performance end date. This change in Workday restricts labor costs from being charged after the period of performance. The University’s post-award specialist review grant labor costing allocations on a periodic basis. • With collaboration between the payroll department, the Controller’s Office and post-award specialists, before each payroll is processed within the accounting system, grants that have ended are identified and the payroll expenditures are removed from the feed and not charged to the grant. • On-going training on data certification by post-award grant managers has improved grant-expenditure compliance and data accuracy. In addition, the Controller’s Office implemented a process in which post-award grant managers are now reviewing grant level budget versus actual reporting on a periodic basis to identify errors timely (i.e. before the 90 day threshold). Additionally, the University’s Workday team is exploring additional functionality within our Workday grants management module to build in additional expense approvals, specifically for labor, before those expenses are charged to the grant to reduce future cost transfers. As part of the University’s corrective action plan, during fiscal year 2023 the sponsored programs accounting team recalculated fringe and indirect costs on all federal grants to ensure the correct expense was recorded to each grant. During this reconciliation process cumulative award to date errors were identified and corrected. The sponsored program accounting team continues to reconcile fringe and indirect costs on cost transfers at the grant level on a periodic basis to ensure accuracy. Tara Thomason, Controller and Assistance Vice President, is responsible for addressing the above items by June 2024.

Federal Agency Name: Department of Education Pass-Through Entity: State of Iowa Department of Education Federal Financial Assistance Listing #84.287 Program Name: Twenty-First Century Community Learning Centers Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Through review of the indirect costs charged to the federal awards, we noted the following: • The Organization charged an 8% administrative indirect cost rate to the federal awards, however, calculated the 8% on the budgeted grant award rather than on the actual direct costs incurred under the federal award, resulting in overcharging the award by $14,704. • The Organization serves as an employer of record for organizations that need assistance in providing benefits, payroll and human resources to employees. A fixed rate is applied to total payroll wages and charged as additional payroll costs to cover administrative time incurred. In addition to the amount charged above, the Organization charged $49,049 to the federal program under this methodology resulting in an overcharge to the award. Corrective Action Plan: SHIP will make the following changes in Fiscal Year 2024: • SHIP was charging the Employer of Record fee originally with the understanding that it was a direct expense, because the Employer of Record fee was only being charged on the direct staff that are running the programs at the schools. SHIP has had this grant for many years with the same terms. Now that SHIP has had a finding on the current process of the Employer of Record, SHIP will correct the process. This was not an intentional disregard. • Moving forward and currently in FY24, all claims submitted for 21st Century grants will be reviewed to ensure the administrative indirect cost is assigned to direct expenses only. In the event this was charged incorrectly, adjustments will be made to ensure the fee is only assessed on total direct expenses. Responsible Individuals: Mindy Baylor - SHIP Finance Director Anticipated Completion Date: March 2024

FINDING 2023-003 Finding Subject: Title I Grants to Local Educational Agencies – Internal Controls Summary of Finding: The School Corporation did not have a properly developed internal control process over payroll transactions to ensure expenditures were allowed and in conformance with the cost principles. The Program Administrator reviewed a report attached to program reimbursement requests which showed the total amount paid from each fund and account; however, a detailed payroll report was not reviewed which would have identified the employee and related payroll benefits being paid from the grant fund. Contact Person Responsible for Corrective Action: Terry Richey and Chrystal Street Contact Phone Number and Email Address: 812.793.2061 trichey@crothersville.k12.in.us cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 37 The corporation treasurer and superintendent will review current internal controls policies especially segregation of duties and the areas in which we are lacking. We will consider rotation of duties in which employees will learn different roles when possible. We will also consider using technological solutions to enhance the reliability and integrity of processes. Superintendent will start to review the detailed payroll report posted to the Title I funds to match to the reimbursement request. Anticipated Completion Date: April 1, 2024

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over reporting be enhanced to ensure evidence is maintained to support the reports and review performed over the reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of re-evaluating the reporting process to ensure documentation is maintained to support the reporting requirements. Name of the contact person responsible for corrective action: Lisa Katz, Chief Program Officer Planned completion date for corrective action plan: Currently underway and planned to be completed by June 30, 2024.

Recommendation: We recommend that the Department review and enhance its procedures and controls to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A correction will be made to reduce the request by the overstated (by 1 day) amount in the 3/31 payroll report. A credit was issued to FEMA for the amount of $19,871.26 on Monday March 13, 2023 in relation to the finding noted. Name(s) of the contact person(s) responsible for corrective action: Angelia Adediran, Deputy Director City of Richmond Fire and Emergency Services

Finding 2023-003: Overpayments to Landlords (Significant Deficiency) Corrective Action Plan: DHA Management has worked with our financial institution to ensure that the positive pay function is working and duplicate payments will not be posted to Landlord accounts. Name of Responsible Person: Cheron Corbett Completion Date: July 31, 2023

FINDING 2023-002 Information on the federal program: Subject: Child and Adult Care Food Program Federal Agency: Department of Agriculture Federal Program: Child and Adult Care Food Program Assistance Listing Number: 10.558 Federal Award Numbers and Years (Or Other Identifying Number): FY2022, FY2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Procurement and Suspension and Debarment Audit Finding: Material Weakness, Qualified Opinion Condition: There was not an effective control in place to review underlying transaction detail billed by the food service management compliance to verify compliance with Activities Allowed or Unallowed requirements. There was also not an effective control in place to monitor and review the food service management company followed procurement and suspension and debarment regulations. Context: As a result of the COVID-19 pandemic, waivers from the federal government provided free meals to all students through the Summer Food Service Program and allowed meals to be consumed off-site. Due to the changing regulations, the USDA and IDOE required School Corporations to implement an Integrity Plan for any schools providing Grab and Go Meals which includes inquiring of any adult requesting meals without children present as to how many children under the age of 18 would be served. Prior to March 2020, the School Corporation was using a point-of-sale system to record meals served. Starting in March 2020, the School Corporation was authorized by IDOE to utilize a clicker to track meals served. During the summer months of 2021, the School Corporation was also authorized by IDOE to provide meal pickup service on Wednesdays from 3 – 6 p.m. for 5 days’ worth of meal for both breakfast and lunch, resulting in 10 meals being served per child under the age of 18 each week. In June 2021, the Indiana Department of Education performed an unannounced meal site observation and a second, announced meal site review noting several program compliance and administrative issues. In July 2021, the IDOE performed a targeted review of the Summer Food Service Program for the period of March 2020 through May 2021 noting the following program compliance issues. • Meals were distributed without ensuring they were going to children ages 18 and younger as required by SFSP regulations. • Meals were taken off site to be distributed/dropped off at non—approved locations. • Meals were distributed and claimed on days when no meal service was approved, • Meals were distributed outside of approved meal service times. • Some meals were not distributed in household size quantities to the parent or guardian but distributed in bulk to large groups and knowingly transported in unsafe and unsanitary ways. • Meal count records were incomplete, unsigned, or missing required information. • Meal production was not adjusted when attendance fluctuations were noted. • Different menu items were ordered for and distributed to a specific group of individuals that was not the same as the planned menu. • Menu planning did not consider food inventory on hand and MSD of Pike Township’s access to USDA Foods (commodities) to reduce overall food costs. • Unauthorized donation, distribution, and disposal of foods purchased with federal funds was made without MSD Pike administration knowledge or approval. The review also noted a lack of administrative oversight of the food service management company contract including the following issues: • Food service management company representatives were making decisions regarding child nutrition program operations without consulting MSD of Pike Township administration. This practice was ongoing and occurred over several administrations. • Potential unallowable expenditures were noted in a review of monthly itemized invoices presented to MSD of Pike Township for recent payment. Items for personal consumption of food service management employees such as coffee, energy drinks, donuts, lunches, and even unauthorized travel expenses were presented but are considered unallowable expenditures from the food service account. As a result of the review, a total of $623,724 was disallowed for unsupported meal claims from September 2020 through May 2021 from the Child and Adult Care Food Program (CACFP) for At-Risk suppers reimbursed through the CACFP program. The School Corporation and IDOE agreed to a repayment plan to repay the disallowed costs identified which was paid in December 2021. Activities Allowed or Unallowed, Allowable Costs/Cost Principles During the testing of activities allowed or unallowed and allowed costs/cost principles, we selected 6 monthly invoices from the food service management company during the audit period. We noted there was not an internal control in place by School Corporation personnel to obtain and view the underlying support of transactions charged by the food service management company to verify the transaction was for a business purpose. The School Corporation did not obtain and review source documents, such as invoices or proof of payment for vendor transactions or a schedule of employees, assigned locations, salaries, and hours to be worked for payroll transactions submitted by the food service management company for reimbursement. We also selected a sample of 40 vendor transactions charged to Fund 0800 to test which were not related to the food service management company and incurred directly by the School Corporation. For 6 of the 40 transactions tested, we noted transactions for concession fees which were charged to the School Nutrition Program from July 2021 through September 2022 and are deemed unallowable. In October 2022, the School Corporation began recording all concession activity to Fund 2180, Concessions – District. The six concession transactions in our sample total $663 which are considered known questioned costs. Procurement and Suspension and Debarment The School Corporation did not have an internal control in place to monitor the food service management company was following proper procurement standards. School Corporations that contract with a food service management company on a cost reimbursement basis should ensure they are monitoring contracts sufficiently including verifying or reviewing the following: • The School Corporation should receive contract commits to supply. • Reviewing invoices received from the food service management company compared to amounts paid by the food service management company. • Reviewing contracts for compliance with Buy American • Verifying return of discounts, rebates, or credit are properly applied to the School Corporation’s account. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. MSD of Pike Township (Pike) agrees during the audit period effective controls were not in place to review and approve meal counts tracked and submitted for reimbursement, review underlying transaction detail billed, nor monitor and review the Food Service Management Company (FSMC) followed procurement and suspension and debarment regulations. Pike has increased the Business Office oversight of the Food Service Management Company (FSMC). Pike has hired a Food Service Financial Specialist to provide more the detailed review of invoices and operations ledger and the underlying transaction details. Additionally, effective October 2022, MSD of Pike Township hired a Director of Food Service to provide oversight of the Food Service Management Company (FSMC) including but not limited to meal counts, site audits, and compliance with procurement regulations. The FSMC no longer has access to submit claims on the CNP website. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan.

FINDING 2023-001 Information on the federal program: Subject: Child Nutrition Cluster Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (Or Other Identifying Number): FY2022, FY2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Procurement and Suspension and Debarment Audit Finding: Material Weakness, Qualified Opinion Condition: There was not an effective control in place to review underlying transaction detail billed by the food service management compliance to verify compliance with Activities Allowed or Unallowed requirements. There was also not an effective control in place to monitor and review the food service management company followed procurement and suspension and debarment regulations. Context: As a result of the COVID-19 pandemic, waivers from the federal government provided free meals to all students through the Summer Food Service Program and allowed meals to be consumed off-site. Due to the changing regulations, the USDA and IDOE required School Corporations to implement an Integrity Plan for any schools providing Grab and Go Meals which includes inquiring of any adult requesting meals without children present as to how many children under the age of 18 would be served. Prior to March 2020, the School Corporation was using a point-of-sale system to record meals served. Starting in March 2020, the School Corporation was authorized by IDOE to utilize a clicker to track meals served. During the summer months of 2021, the School Corporation was also authorized by IDOE to provide meal pickup service on Wednesdays from 3 – 6 p.m. for 5 days’ worth of meal for both breakfast and lunch, resulting in 10 meals being served per child under the age of 18 each week. In June 2021, the Indiana Department of Education performed an unannounced meal site observation and a second, announced meal site review noting several program compliance and administrative issues. In July 2021, the IDOE performed a targeted review of the Summer Food Service Program for the period of March 2020 through May 2021 noting the following program compliance issues. • Meals were distributed without ensuring they were going to children ages 18 and younger as required by SFSP regulations. • Meals were taken off site to be distributed/dropped off at non—approved locations. • Meals were distributed and claimed on days when no meal service was approved, • Meals were distributed outside of approved meal service times. • Some meals were not distributed in household size quantities to the parent or guardian but distributed in bulk to large groups and knowingly transported in unsafe and unsanitary ways. • Meal count records were incomplete, unsigned, or missing required information. • Meal production was not adjusted when attendance fluctuations were noted. • Different menu items were ordered for and distributed to a specific group of individuals that was not the same as the planned menu. • Menu planning did not consider food inventory on hand and MSD of Pike Township’s access to USDA Foods (commodities) to reduce overall food costs. • Unauthorized donation, distribution, and disposal of foods purchased with federal funds was made without MSD Pike administration knowledge or approval. The review also noted a lack of administrative oversight of the food service management company contract including the following issues: • Food service management company representatives were making decisions regarding child nutrition program operations without consulting MSD of Pike Township administration. This practice was ongoing and occurred over several administrations. • Potential unallowable expenditures were noted in a review of monthly itemized invoices presented to MSD of Pike Township for recent payment. Items for personal consumption of food service management employees such as coffee, energy drinks, donuts, lunches, and even unauthorized travel expenses were presented but are considered unallowable expenditures from the food service account. As a result of the IDOE review, a total of $1,299,365 was disallowed from the Summer Food Service Program. The School Corporation and IDOE agreed to a repayment plan to repay the disallowed costs identified. The School Corporation completed the repayment to IDOE in December 2021. Activities Allowed or Unallowed, Allowable Costs/Cost Principles During the testing of activities allowed or unallowed and allowed costs/cost principles, we selected 6 monthly invoices from the food service management company during the audit period. We noted there was not an internal control in place by School Corporation personnel to obtain and view the underlying support of transactions charged by the food service management company to verify the transaction was for a business purpose. The School Corporation did not obtain and review source documents, such as invoices or proof of payment for vendor transactions or a schedule of employees, assigned locations, salaries, and hours to be worked for payroll transactions submitted by the food service management company for reimbursement. We also selected a sample of 40 vendor transactions charged to Fund 0800 to test which were not related to the food service management company and incurred directly by the School Corporation. For 6 of the 40 transactions tested, we noted transactions for concession fees which were charged to the School Nutrition Program from July 2021 through September 2022 and are deemed unallowable. In October 2022, the School Corporation began recording all concession activity to Fund 2180, Concessions – District. The six concession transactions in our sample total $663 which are considered known questioned costs. Procurement and Suspension and Debarment The School Corporation did not have an internal control in place to monitor the food service management company was following proper procurement standards. School Corporations that contract with a food service management company on a cost reimbursement basis should ensure they are monitoring contracts sufficiently including verifying or reviewing the following: • The School Corporation should receive contract commits to supply. • Reviewing invoices received from the food service management company compared to amounts paid by the food service management company. • Reviewing contracts for compliance with Buy American • Verifying return of discounts, rebates, or credit are properly applied to the School Corporation’s account. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. MSD of Pike Township (Pike) agrees during the audit period effective controls were not in place to review and approve meal counts tracked and submitted for reimbursement, review underlying transaction detail billed, nor monitor and review the Food Service Management Company (FSMC) followed procurement and suspension and debarment regulations. Pike has increased the Business Office oversight of the Food Service Management Company (FSMC). Pike has hired a Food Service Financial Specialist to provide more the detailed review of invoices and operations ledger and the underlying transaction details. Additionally, effective October 2022, MSD of Pike Township hired a Director of Food Service to provide oversight of the Food Service Management Company (FSMC) including but not limited to meal counts, site audits, and compliance with procurement regulations. The FSMC no longer has access to submit claims on the CNP website. Responsible Party and Timeline for Completion: Greg A. Foster, Chief Financial Officer, will oversee the corrective action plan.

Finding 2023-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2023 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.

Planned Corrective Actions: The Community Youth Advance Interim Executive Director will make updates to the Employee Handbook and create a Standard Operating Procedures manual that outlines key responsibilities with regard to record keeping and reporting that will ensure continuity and stability during times of leadership and staff transition. This will be reviewed with staff and our accounting firm to ensure it is comprehensive and addresses the organization’s needs and the recommendations of this audit. The Board of Directors will then review and give final approval of these documents. Name of the contact Person responsible for corrective action: Danielle Middlebrooks, Interim Executive Director, Community Youth Advance Board of Directors (Cassius Priestly, Chair) and Goldin Group CPAs Planned completion date for corrective action plan: The Standard Operating Procedures Manual and the Updated Community Youth Advance Employee Handbook will be completed and approved by June 30, 2024, to take effect July 1, 2024.

Name of Contact Person Responsible for Corrective Action Plan: Jerry Deloach, Chief Risk Officer - Enterprise Risk Management Corrective Action Plan: The City of Atlanta’s Department of Enterprise Risk Management (ERM) is now calendaring the quarterly reports due dates and immediately following the timely filing before transmitting a copy of the report to the City of Atlanta’s Grants Accounting area. Anticipated Completion Date: Fiscal year 2024

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. The County will review CSLFRF claims and verify that all claimed payroll expenditures were incurred or obligated on or after March 3, 2021. Payroll expenditures that were incurred or obligated before March 3, 2021, will be removed from the CSLFRF claims. 3. Anticipated implementation date: June 28, 2024

Federal Agency Name: Department of Treasury Pass‐Through Entity: Equal Justice Wyoming and Wyoming Department of Family Services Assistance Listing Number: #21.023 Program Name: Emergency Rental Assistance Program Finding Summary: The Medical Center was not able to provide supporting invoices for two of the testing selections. An additional selection contained a keying error. Responsible Individuals: Amy Spieker, Director Community Health and Analysis, and Erika Novick, Operations Manager Corrective Action Plan: The Program Director and Operations Manager will ensure all invoices are properly submitted and approved prior to including the expenses in the reimbursement requests. Program Director/Director of Community Health and Analysis will review draws/invoices to ensure amounts on supporting documents agree to the amounts submitted in the reimbursement requests. Finance will also revise Corporate Card Policy by June 30, 2024, to include expense reports being submitted in a timely manner. Finance will review open expense reports with card holder and their supervisor monthly. Anticipated Completion Date: April 1, 2024

Response Two different sets of guidelines were issued for the Coronavirus State and Local Fiscal Recovery Funds. The first set of guidelines were issued in March 2021 (Attachment A). These first set of guidelines allowed undocumented students to receive the award #4 (Attachment A). These are the guidelines that were used to award students monies from this fund. During the audit, it was noted that SBCC incorrectly awarded undocumented students with monies from the Coronavirus State and Local Fiscal Recovery Funds. SBCC was not aware at the time of awarding these monies that a second guidance memo had been issued by the Community Colleges of California Chancellor’s Office (CCCCO) on Friday, January 21,2022 (Attachment B). The updated memo clearly stated that undocumented students were no longer eligible for these funds. SBCC had not updated its protocols to match the second memo due to staffing issues within th e financial aid office. Specifically, the manager of the Financial Aid Office was out on disability leave from January 26 through September 28, 2022. However, no funds were awarded during this absence. Within the new guidance, a new process stated how to corrects awards given to candidates originally eligible (undocumented students) under the first memo, but no longer eligible under the second memo. Per the second memo, any incorrectly awarded funds under the first policy were to be replaced with other funds that undocumented students are eligible to receive. Corrective Action To correct the incorrect awarding of funds to ineligible candidates, SBCC cancelled the awards to now ineligible recipients of Early Action Fund (EMASS/SRFR) and replace d them with awards from AB19 monies, which were rolled over from 22-23. SBCC also used monies from remaining HEERF/CARES funds, which allowed for awards to undocumented students. In total, SBCC corrected 16 awards totaling $48,000. SBCC’s records now reflect that no undocumented students received Coronavirus State and Local Fiscal Recovery Funds. Going forward, SBCC is now awarding under the correct guidelines. No further awards have been made to undocumented students. The fund is winding down and will be spent in full by the end of the 23-24 fiscal year.