Corrective Action Plans

FINDING 2022-002 ? ELEMENTARY AND SECONDARY SCHOOL EMERGENCY RELIEF FUND ACTIVITIES ALLOWED OR UNALLOWED AND ALLOWABLE COSTS/COST PRINCIPLES Contact Person Responsible for Corrective Action: Lisa Baker, Business Manager Contact Person's Phone Number: 765-664-0624 Views of Responsible Official: There is no disagreement with the audit finding. Description of Correction Action Plan: The following phrase will be added to payroll time cards and bus trip sheets when ESSER funds will be used to pay wages and payroll-related expenses: "I hereby certify that this is a true and accurate representation of all hours worked on behalf of ESSER-funded Summer Academy (or ESSER-funded After-School Tutoring) and that duties performed were only for Summer Academy (or After-School Tutoring)." Contract addendums will include the phrase "ESSER-funded Summer Academy" as well. Anticipated Completion Date: March 24, 2023

For 2022, quarterly reviews were being performed; however, due to the transition in personnel in the Accounting and Finance areas, the annual review was not done. The College has updated its procedures to include a review of the annual submission similar to the current practice of reviewing the quarterly submission.

Corrective Action Plan McAlister Institute for Treatment & Education, Inc. Ling & Bouman, LLP Corrective Action Plan prepared by Steve Hubbard, Chief Financial Officer, (619) 442-0277 2022-01 ? Payroll Recommendation We recommend Management require additional training to Human Resources staff and supervisors regarding meal, rest and recovery period compliance and update their policies and procedures to ensure compliant breaks. In the event of a meal break premium that occurs as the direct result of patient care, appropriate documentation should be maintained by the organization. Meal Break premiums should be automatically coded as a non-reimbursable expense and any exceptions should be manually transferred to program expenses once appropriate supporting documentation is obtained. Actions Taken or Planned on the Finding We concur with the recommendation, and it was implemented effective March 23, 2022.

Condition: The Health Center?s Period 2 report to HHS included duplicate amounts for utilities expenses. Planned Corrective Action: Management will continue to refine processes to more diligently review expenses to ensure no duplicate expenses are included in the underlying supporting documentation. However, the Health Center included as eligible expenses in the Period 2 submission only those amounts up to the funding received, plus accrued interest. Had the noted questioned costs been identified prior to submission, the Health Center would have included additional amounts in the eligible expenses reported in the PRF reporting portal to demonstrate satisfactory use of the PRF funding received. The Health Center had $418,778 in additional eligible operating expenses which were not included in the Period 1 submission and $1,916,769 in additional eligible capital expenses not included in the Period 2 submission which would have been used to replace the identified questioned costs. Person Responsible: Wade Eschenbrenner, CFO Anticipated Completion Date: Ongoing

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-004 Community Development Block Grant ? Assistance Listing number: 14.218 Recommendation: We recommend the City establish cutoff procedures for the accrual of grant related reimbursements to ensure expenditures are invoiced within the appropriate contract dates as specified by the agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that grant expenditures processed after the end of the fiscal year are thoroughly reviewed to ensure they are recorded in the correct fiscal year. Name(s) of the contact person(s) responsible for corrective action: Mark C. Mason, CPA, Financial Services Director; Juan G. Guerra, ICMA-CM, CPA, Controller Planned completion date for corrective action plan: December 31, 2023

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-003 Community Development Block Grant ? Assistance Listing Number: 14.218 Recommendation: We recommend that the City design processes and procedures to ensure that all reports are submitted timely as required by grant agreements. We recommend the City develop an internal compliance checklist that includes required reports and due dates to be maintained for tracking and record keeping purposes to assist in monitoring compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: City could not log into the federal system, we have since fixed this problem. Finance will keep a calendar of all reporting requirements and check in prior to the due date to ensure reports are submitted on time. Name(s) of the contact person(s) responsible for corrective action: Mark C. Mason, CPA, Financial Services Director; Juan G. Guerra, ICMA-CM, CPA, Controller Planned completion date for corrective action plan: April 30, 2023

ALLOWABILITY OF EXPENDITURES Department of Health and Human Resources (DHHR) Assistance Listing Number 93.767 Microdyn OPPS quarterly updates for Pricer and Editor Dynamic Link Libraries (DLLs) are commonly received mid-month of the first month in the quarter after the Centers for Medicare and Medicaid Services releases quarterly updates. During 2022, releases occurred on January 15, April 16, July 16, and October 19. Although updates to the DLL were completed timely throughout the year, claims sampled for the audit fell into the periods of delay between the first day of the quarter and the updates to the DLL. Procedures are in place to reprocess any affected claims once the quarterly updates have been uploaded into the system. However, there was an interruption in the procedure to reprocess claims after the quarterly updates were uploaded to the claims processing system. Corrective action has already been implemented that includes automatically opting and populating the "reprocess claims" flag in the Request Management System (RQMS) when the Microdyn OPPS updates are entered to work. (The RQMS is the system used to enter and manage work orders for the Medicaid Management Information System.) Claims processing staff at the fiscal agent have also entered calendar reminders to reprocess claims as necessary after the OPPS quarterly updates are processed. All affected claims including claims sampled for the Single Audit were reprocessed and paid from mid-December 2022 through mid-January 2023.

TRANSPARENCY ACT REPORTING Department of Education (DOE) Assistance Listing Number 84.425C, 84.425D, 84.425R, 84.425U Program management will implement policies and procedures to ensure that Transparency Act Reporting is conducted with proper reviews. In order to comply with the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act), as amended by Section 6202(a) of the Government Funding Transparency Act of 2008 (Pub. L. No. 111-252), that relate to sub-award reporting, the DOE Office of Internal Operations will work with each awarding office to ensure the sub-awards have been thoroughly reviewed and signed before reporting each month. This will comply with 2 CFR 200.303 which requires an entity to "maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award". The timeline for the development and initiation of this process (barring any unforeseen system limitations) is tentatively set for July 1, 2023.

SPECIAL TESTS AND PROVISIONS ? RETURN OF TITLE IV FUNDS West Virginia State University, Pierpont Community College, Bluefield State University, New River Community and Technical College, and West Liberty University Assistance Listing Number 84.007, 84.033, 84.038, 84.063, 84.268, 84.379, 93.264, 93.342, 93.364, 93.925 West Virginia State University (WVSU) response Effective January 2022, a weekly report of complete withdraw students is generated and an initial review and calculations are performed by a Financial Aid Administrator. A second review of the student?s record and calculations are then completed a second time by the Associate Director of Financial Aid or the Director of Financial Aid. After the second review is complete, the initial reviewer will update the student account accordingly and perform any Return of Title IV (R2T4) funds needed. The second reviewer will confirm that updates are accurate. Both the initial and second reviewer will sign off on R2T4 calculation documentation for the student's file. Pierpont Community and Technical College (PCTC) response Communication between the Financial Aid and the Finance offices will be enhanced to ensure Finance has a copy of the student letter and additional Finance Office staff now have access to the return of Title IV (R2T4) tracking sheet. The R2T4 tracking sheet will be monitored by both the Financial Aid and Finance staff to ensure all refunds are returned within the required 45-day time period. This process was implemented in January 2023. Bluefield State University (BSU) response In January 2023, BSU implemented controls to perform the Return of Title IV (R2T4) withdrawal and calculation to ensure that records comply and that return of R2T4 funds are within the required time frame of 45 days. Controls include the review of ?Permit to Withdraw? forms to ensure they are completed with all signatures of the offices involved and the sign-off of R2T4 calculations. All reviews will occur within the time frame of 45 days by the Interim Financial Director along with Business Office and Accounting. In December 2022, the Interim Financial Aid Director spoke with the Registrar and the Financial Aid Counselor in separate meetings regarding the late submission of withdrawal forms and performing the R2T4 calculations. The Registrar understands they must submit the completed withdrawal forms to the Financial Aid office the same day they are completed by her office. When the forms are received by Financial Aid an R2T4 will be completed within the same week of receipt and sent to the Business Office if a return of Title IV Aid is required. The Business Office will then review the calculations and perform the necessary repayment of Title IV Aid to the Department of Ed, utilizing the refund process through G5 within the required 45 day timeline. All adjustments to the students account will be made within the same time frame. New River Community and Technical College (NRCTC) response The Registrar's office will request the error report from IT. At that point the Registrar?s office will work on correcting the errors on the report. The Registrar?s office will request IT to run the error report again to make sure all errors are clear. Once all errors are clear from the report the Registrar?s office will request IT to send the enrollment report so that it can be submitted to the National Student Clearinghouse (the Clearinghouse). Once the enrollment report is received from IT someone in the Registrar?s office will upload the report in the Clearinghouse. The Registrar?s office will make sure the Clearinghouse report is submitted by the due date and errors sent by the Clearinghouse are corrected in a timely manner. The Registrar's office will run a random selection of 20 students from the National Student Loan Data System (NSLDS) to make sure students are correct in the Clearinghouse, which will be done at least 50 days out from the time students were initially reported. IT and someone in the Registrar?s office will sign off on these processes when the report is run, when the report is reviewed, and once the report is sent. The Registrar's will run the Failure Irregular Withdrawal report daily, instead of weekly to ensure all students who have not attended classes are taken out within a timely manner as soon as they are reported by the instructors. These procedures were implemented in August 2022. West Liberty University (WLU) response When the Registrar Office is recording and entering data for Withdrawal (WD) students, a review and approval process has been implemented to ensure dates and information are entered accurately and timely.

DHHR INFORMATION SYSTEM AND RELATED BUSINESS PROCESS CONTROLS Department of Health and Human Resources (DHHR) Assistance Listing Number 10.551, 10.561, COVID-19 10.561, 10.542, 93.558, COVID-19 93.558, 93.568, COVID-19 93.568, 93.575, 93.596, COVID-19 93.575, 93.658, 93.659, 93.767, 93.775, 93.777, COVID-19 93.777, 93.778, COVID-19 93.778, ARRA 93.778 Enhancing the Quality Control process (by adding other programs to the overall scope and expanding the populations for sampling to include payments that have case data that is initiated and approved by the same person as well as case data that is entered by one person without another level of approval) would prove costly for the DHHR due to the additional staff throughout the DHHR that would be required to accomplish such a task. Although enhancing the Quality Control process is still a possibility, upon further discussions within the DHHR, it was determined that prior to considering such an enhancement, the Bureau for Social Services, Bureau for Family Assistance, and other DHHR units should work together to perform the following: outline the existing internal controls over payments by payment type or program, determine the number of payments per month whereby one employee initiates and approves a payment (in relation to the population of all payments) and conclude on the risk of those payments being improper. Management can then identify areas of focus to conclude on the adequacy of the internal controls and make revisions to policies and procedures, if necessary. In short, although there are existing controls in place, the controls have not been documented and communicated to the State?s independent auditors in an effective manner.

Finding Number: 2022-002 Condition: The College did not obtain affirmative written consent from students before using emergency financial aid grants to satisfy a student's outstanding account balance. Planned Corrective Action: The grant funding applied incorrectly as a result of this finding has been returned to the Department of Education. The amount of the grant funding returned was $2,707,692. In response to this finding, the College?s current Financial Aid Director, Chief Counsel, Chief Student Enrollment Officer, and Chief Financial Officer developed remedial action to implement an appropriate application process to obtain affirmative consent from all students on future application of grant monies to outstanding tuition balances. This new process was implemented as of August 17, 2022, and forward. To ensure compliance, the student grant application now includes functionality that requires positive affirmative consent from all applying students before grant monies are applied to an outstanding tuition balance. Now that the updated application is live on the College?s scholarship website, the College is currently accepting applications for the remainder of the award and only applying the funds to student accounts with the student?s affirmative consents. If students select either the tuition & fees or prior balances selections, funds will be applied to their outstanding tuition balance accordingly. If students do not affirmatively select either of these options, the funds will be distributed directly to the student as an emergency grant. Contact person responsible for corrective action: Lisa Brooker (Director of Financial Aid) Anticipated Completion Date: August 17, 2022

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: It is highly unusual for the district to utilize federal funds for construction projects; the Covid-19 Education Stabilization Funds were an anomaly. The District?s Director of Business and Operations was unaware that prevailing wage clauses are required to be included in all public works contracts over $2,000 that are paid with federal funds. She was aware that prevailing wages need to be paid. The audit finding does not dispute that prevailing wages were paid appropriately, just that the clauses were not included in the contracts. To be very clear, this finding is for not having required language in contracts. The District is now aware that inclusion of the clauses is a compliance requirement. Going forward, it is unlikely that federal funds will be used for construction projects; however, when federal funds are utilized for construction projects, the District will either include the required prevailing wage rate clauses in its contracts or will obtain a separate signed clause with the required prevailing wage rate information. Anticipated date to complete the corrective action: Immediately

Finding ref number: 2022-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: The Chehalis School District does not concur with the finding or the questioned costs. The State Auditor?s Office (SAO) reviewed various types of documentation and did not accept documentation presented by the District to reduce or eliminate questioned costs. The standard of documentation required by SAO to satisfy ?unmet need? would have been hard to meet even if the District hadn?t been in the midst of a pandemic. The District has internal controls over asset inventory and provided equipment only to students and staff with unmet needs, and all costs were allowable, reasonable and necessary. We continue to communicate with other agencies with the ultimate goal of helping the Federal Communications Commission (FCC) understand that they should not seek any recovery of funds resulting from ?documentation? issues considering the massive public health response, deployment logistics, vague federal guidance, and the effective return to in-person learning. Along with countless other districts across the State of Washington, we look forward to working with the FCC to resolve this finding. We appreciate the guidance that was provided by the FCC, as noted below. Guidance from the FCC Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. The following guidance from the Federal Communications Commission, titled ?Emergency Connectivity Fund Common Misconceptions?, ?Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus are eligible for Emergency Connectivity Fund Support.? From the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: ?We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.? And from question 53: ??we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students?with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.? Corrective action the auditee plans to take in response to the finding: The Chehalis School District does not concur with the finding or the questioned costs. The State Auditor?s Office (SAO) reviewed various types of documentation and did not accept documentation presented by the District to reduce or eliminate questioned costs. The standard of documentation required by SAO to satisfy ?unmet need? would have been hard to meet even if the District hadn?t been in the midst of a pandemic. The District has internal controls over asset inventory and provided equipment only to students and staff with unmet needs, and all costs were allowable, reasonable and necessary. We continue to communicate with other agencies with the ultimate goal of helping the Federal Communications Commission (FCC) understand that they should not seek any recovery of funds resulting from ?documentation? issues considering the massive public health response, deployment logistics, vague federal guidance, and the effective return to in-person learning. Along with countless other districts across the State of Washington, we look forward to working with the FCC to resolve this finding. We appreciate the guidance that was provided by the FCC, as noted below. Guidance from the FCC Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. The following guidance from the Federal Communications Commission, titled ?Emergency Connectivity Fund Common Misconceptions?, ?Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus are eligible for Emergency Connectivity Fund Support.? From the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: ?We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.? And from question 53: ??we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students?with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.? Anticipated date to complete the corrective action: We will work with the FCC to resolve this issue according to their timeline.

Finding 2022-005: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services CFDA #93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: Employees did not enter all nonfederal hours within the ClickTime system and the secondary review of the employee ClickTime timecards did not identify the missing hours. In addition, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. The Center?s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. A sample of expenditures selected for testing, noted the following items: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (7 instances). b) Calculation errors for expenses allocated to the grant (2 instances). Responsible Individuals: Staff Supervisors (Abbie Tesch, Amber Utesch, Christina Eggink-Postma, Karen Rosengreen, Jason Low, Missy Martini, Rebecca McCrackin, Sarah Heinrichs, Stephanie Pohar) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. Anticipated Completion Date: In November 2022, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

Finding 2022-003: Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services CFDA #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: The Center?s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. During testing of expenditures, the following items were identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (3 instances). b) Calculation errors for expenses allocated to the grant (4 instances). Responsible Individuals: Staff Supervisors (Christina Eggink-Postma, Monica Rosenthal, Sarah Heinrichs, Stephanie Pohar) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare all ClickTime reports and payroll reports to ensure they match and are accurate. Anticipated Completion Date: In November 2022, the Center began reconciling ClickTime reports with payroll reports using an excel spreadsheet to identify discrepancies between the ClickTime timecards and the payroll register to help ensure all hours are accurately reported.

Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management reported all the general distributions received by the subsidiaries under the Parent entity in the portal, including the general distributions received by CaroMont Regional Medical Center (?Hospital?). Management listed the TINS of the subsidiaries, including the Hospital, in the Subsidiary Data section in the Parent?s portal. Management reported lost revenues utilizing option i, 2019 Actual Revenues, for the subsidiaries in the Parent?s portal. Reporting Period 2: During Reporting Period 2, the Hospital received both general and a targeted distributions (High Impact Area) from the CARES Act PRF. Management was unsure how to report so it contacted the HRSA Provider Support Line. HRSA opened case #00025470 and on January 18, 2022, Management had a phone conference with a representative of HRSA to discuss Period 2 reporting. HRSA advised management to report as follows: ? Hospital ? report the targeted distribution. Only report revenue, expenses, and data for the Hospital. ? Parent ? report general distributions. Don?t change any numbers from Period 1. Report revenue, expenses, and data for all subsidiary TINS listed in the portal. Management specifically remembers explaining to the HRSA representative that this approach would result in double counting of Total Unused Lost Revenues because Hospital revenues would be reported in both portals. The HRSA representative said that would be okay because Management answered YES to ?Is the parent entity reporting on your General Distribution payments?? in the Hospital portal, because the Hospital?s TIN is listed in the Subsidiary Information section in the Parent?s portal, and because the Parent?s TIN is listed in the Subsidiary Questionnaire section in the Hospital?s portal. Management documented these instructions in their notes made during the call. Management also specifically remembers asking the HRSA representative if the Hospital revenue should be removed from the prior quarters in the Parent portal when reporting Period 2 to which the representative replied, ?don?t change any numbers?. Management documented these instructions in their notes made during the call. Management filed the Period 2 reports for the Parent and the Hospital in accordance with HRSA?s instructions received during this phone conference. Management reported lost revenues under option i, 2019 Actual Revenues, for the listed subsidiaries in the Parent portal and for the Hospital in the Hospital portal. However, since Management was concerned this approach would result in double counting of unused lost revenues, they created a reconciliation spreadsheet on February 1, 2022. This spreadsheet documented unused lost revenues from the PRF Financial Reporting Summary Reporting pages in the Parent and Hospital portals for Period 1 and Period 2 and calculated the correct total unused lost revenues when the reports were combined and the double counting was eliminated. Management?s intent was to update this reconciliation during Period 4 reporting to ensure the remaining unused lost revenues in both the Parent and Hospital portals exceeded the combined reconciled lost revenue ? thereby ensuring there would be no double counting of lost revenues after all PRF reporting was completed. Reporting Period 4: During Report Period 4, several subsidiaries of the Parent received general distributions from the CARES Act PRF and targeted distributions from the American Rescue Plan (?ARP?). By the time the Portal Reporting opened for Period 4, CaroMont?s auditors were conducting the Single Audit for the year ended June 30, 2022, and reached out to Management to discuss their concerns about potential double counting of lost revenues in the Period 2 portal reporting. Management explained their process for reporting Period 2 and shared with the auditors their reconciliation spreadsheet that was created on February 1, 2022. The auditors had also performed a reconciliation that resulted in the same outcome. The auditors and management subsequently had several discussions on the different alternatives available to correct the Period 2 overstatement. Management evaluated the alternatives and ultimately decided to change its calculation of Lost Revenues in the Parent portal for Period 4 from option i, 2019 Actual Revenue, to option iii, Alternative Method of Calculating Lost Revenues Attributable to COVID-19. However, management continued to report lost revenues in the Hospital portal for Period 4 utilizing option i, 2019 Actual Revenue, as it had in Period 2. Management created another reconciliation spreadsheet on February 23, 2023 that demonstrated the Hospital revenue was excluded from the Parent?s lost revenue calculations in Period 4. This spreadsheet was uploaded as supporting documentation for option iii in the Parent?s portal. By changing from option i to option iii for lost revenues in the Parent portal for Period 4, management corrected the overstatement of lost revenues identified in the Audit of Federal Awards Performed in Accordance with U.S. Office of Management and Budget Uniform Guidance for the year ended June 30, 2022.

The District concurs and will review current year?s indirect rates for ESSER reimbursements.

2022-003 200 CFR Subpart F Audit Requirements Views of Responsible Officials and Corrective Action Plan: Responsible Officials: Maggie Boland, Managing Director Valerie Bunns, Director of Finance and Administration Corrective Action Plan: Signature will incorporate federal grant compliance training for appropriate personnel.

2022-002 2 CFR Part 200 Cost Principles for Non-Profit Organizations Views of Responsible Officials and Corrective Action Plan: Responsible Officials: Maggie Boland, Managing Director Valerie Bunns, Director of Finance and Administration Corrective Action Plan: Due to unexpected turnover in accounting personnel some procedures were not followed consistently. Signature will update their procedures and training to have consistent procedures followed.

Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: VillageReach has reallocated questioned costs and these are correctly reflected in FY22 audited financials. VillageReach will update and implement internal audit procedures. VillageReach will continue to monitor compliance with data entry processes. In addition, VillageReach has retained external consultants for assistance with process improvements. Anticipated completion date: 1/23/23 Name(s) of the contact person(s) responsible for corrective action: Arin Ricchiuti, Controller and Ann Holmes, VP Global Operations

Views of Responsible Officials and Planned Corrective Actions - Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the parent organization. Organization contact persons responsible for corrective action: Richard Greene, CFO Anticipated completion date: Correction action has been completed and is awaiting feedback from HRSA on how to submit updated lost revenue calculation.

CORRECTIVE ACTION PLAN February 2, 2023 U.S. Department of Housing and Urban Development (HUD)--Continuum of Care Program Lafayette Transitional Housing respectfully submits the following corrective action plan for the year ended September 30, 2022: Name and address of Independent Public Accounting Firm: Huth Thompson LLP P0 Box 970 Lafayette, IN 47902-0970 Audit period: September 30, 2022 The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS--FINANCIAL STATEMENT AUDIT (MATERIAL WEAKNESS) 2022-001: PREPARATION OF FINANCIAL STATEMENTS Recommendation: The Organization should follow established controls to ensure proper recognition of restricted net asset sources. Action Taken: LTHC acknowledges discrepancies in recognition of restricted net asset sources. Recommendations in the Corrective Action Plan dated February 2, 2023 were adopted and phased in beginning February 2023. We will continue to use a separate spreadsheet to track all restricted funds, which is reviewed monthly by Executive Staff. FINDINGS AND QUESTIONED COSTS-- MAJOR FEDERAL AWARD PROGRAMS AUDIT U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD)?Continuum of Care Program 14.267: REPORTING (SIGNIFICANT DEFICIENCY) Recommendation: The Organization should ensure that it has properly allocated salaries charged to grants. Corrective Action: LTHC acknowledges discrepancies in recognition of salary allocation. Recommendations in the Corrective Action Plan dated February 2, 2023 were adopted and phased in beginning February 2023. We have added an additional step to the detailed time report from APS that will verify the hours documented on the timesheets. All Corrective Actions have already been implemented. If the Department of Housing and Urban Development has questions regarding this plan, please call Jennifer Layton, President and CEO at 765-423-4880. Sincerely, Jennifer Layton President/Chief Executive Officer

Finding 2022-003 Federal Agency Name: Legal Services Corporation Program Name: LSC Basic Field Grant; LSC Technology Improvement Grant. CFDA#: 09-542026 Finding Summary: Total hours and LSC hours worked used to drive monthly allocation of indirect expenses by grant did not agree to total hours and LSC hours worked in the Organization?s timekeeping software for eight of the twelve months. Additionally, one instance identified in which the rate of pay paid to an employee did not agree to the approved rate of pay. Responsible Individuals: Kathy Schroeder, 3rd party accountant, and Lea Wroblewski, Executive Director. Corrective Action Plan: Additional procedures are being followed to ensure that the timekeeping software is completed on a timely basis and locked down by the Executive Director or Technology Consultant when all entries have been made and reviewed. The time report used for the indirect expense allocations is not processed until the software is locked down. All changes to employees pay calculation are made after the submission of an approved Personnel Action Form is provided to the staff accountant. Each payroll is then reviewed by the Executive Director and a board member before processing. Completion Date: 06/30/2023

Finding 2022-002: Coronavirus State and Local Fiscal Recovery Funds Reporting Corrective Action Planned: The Lincoln County Board of Commissioners will discuss establishing a policy for reporting requirements. They will also discuss who will file reports for the county going forward and perhaps someone to review the document before submission who is not involved in the preparation of the report. Anticipated Completion Date: Ongoing ? preferably by the next reporting date in April 2023 Responsible Party: Christopher D. Bruns, Lincoln County Board Chairman

View of Responsible Official and Planned Corrective Action: Oversight of time cards has been established and assigned. Southeast Health Group management is confident that there were no erroneous invoicing charges nor inaccurate requests for reimbursement. SHG?s time and effort reporting guidelines ensured proper accounting and compliance standards were followed and oversight has been added to ensure proper documentation.