Corrective Action Plans

Unallowable Costs Planned Corrective Action: This finding occurred due to the fact that hours entered on a form-stack form by several contractors on our Community Navigator Program with the SBA were charged to the SBA before invoices were received from the contractor for those hours. This led to payment being received prior to the contractor being paid. Although this was officially approved by the SBA prior to submitting the quarterly bill for our services under the contract, we recognize that this is not how it should be done according to government and accounting rules. Thus, we will undertake the following corrective action to ensure that this does not occur again. 1. We will ensure that invoices for these identified charges are received from the contractors and the contractors are paid the full amount owed. 2. We will ensure that reimbursable expenses are not charged on government contracts and grants until they are actually paid or spent. This does not include expenses that are allowed by contract to be billed in advance. 3. Both the lead accounting person and the Compliance Officer will review and authorize all charges for allowability on all programs prior to submission of a request for payment. 4. A periodic review of the process and process adherence will be conducted by the finance committee of the Board of Directors. Person Responsible for Corrective Action Plan: Jamie Thomas, Compliance Officer Anticipated Date of Completion: October 15, 2023

Finding Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-001: ? Reid Hospital and Health Services, Inc. plans to monitor controls related to reporting to ensure amounts are appropriately stated. ? Reid Hospital and Health Services, Inc. has maintained documentation under a revised calculation which supports adequate expenses and lost revenues in excess of funding reported for all periods of Provider Relief Fund reporting.

Condition/Context: The District spent $12,772 of federal funding on video conferencing, COVID-19 testing, charging stations, fire and alarm testing, palm tree trimming, ADEQ monitoring, and a printer. These expenditures were not explicitly authorized within the budget approved by the passthrough agency for the related grant. In addition, the District expended $31,500 in payroll for retention stipends that were not explicitly written into the budget approved by the passthrough agency. Lastly, for eleven of 25 general disbursements tested, an approved purchase order or requisition was not maintained to support the authorization of the purchase. Among those eleven purchases, five did not have invoices approved for payment. Action planned in response to finding: The District will establish proper internal controls over processing expenditures to ensure that only those expenditures that are allowed and approved within the budget be spent out of grant funds. Those expenditures should be approved within a purchase order and requisition and the related invoices should be approved for payment. Planned completion date for corrective action plan: For the period ending June 30, 2023.

The Town of Simla is in the process of creating a Procurement Policy.

In October 2021, the Organization created a full-time staff position whose primary responsibilities were to collect, review, and track invoices and receipts. The individual was instructed to use the Journal Ledger Spreadsheet provided by MDE. However, the spreadsheet does not include a cross-check to verify that the receipts and invoices entered into the spreadsheet have associated images or scans of receipts. The Organization will begin utilizing the My Food Program software to enter invoices and receipts to track the nonprofit food service. The software will be configured to require the upload of a photo or scan of the actual receipt or invoice in order to create the expense, thus guaranteeing that documentation of the expense exists and is appropriately maintained. This procedure will also resolve any issues with corrupted files as the reports can be generated from the cloud-based software. The Organization abruptly ceased operations in January 2022. It is our understanding that sponsored sites must prove that they expended all program funds on approved program-related expenses, but are not required to do so in the month the funds were received. In other words, sponsored sites would have had all of fiscal year 2022 to document the expenditures of all funds received in fiscal year 2022. It is reasonable to assume that sites with an excessive balance in their food service account would have been able to document appropriate expenditures if given sufficient time. The Organization is confident that the systems in place in fiscal year 2022 would have allowed the Organization to monitor the appropriate use of excessive nonprofit food service program balances in future periods; most notably through the Organization?s policies and procedures contained in the Management Plan and approved by MDE. The Organization holds future claims if the balance in the food service account exceeds a three-month average of expenditures. Monitoring forms were completed on paper during fiscal year 2022. Staff were instructed to scan and save an electronic copy of the monitoring form on the Organization?s cloud-based storage system. In some cases, staff failed to save an electronic copy and the only verification of the monitoring visit is contained in paper files that are currently in off-site storage. The Organization believes that staff adhered to the monitoring requirements, despite the documentation of those visits not being readily available. Going forward, all monitoring staff will be required to complete site visits electronically using the My Food Program software. The software will store the monitoring form electronically on the cloud, inclusive of sponsor and site staff signatures with date-time stamps. There are also comprehensive monitor tracking reports available to assist with monitoring frequency compliance. In the event of a loss of internet service, the monitors will be required to complete the visit on paper and upload a copy to the My Food Program software. The Organization agrees that the retained administrative fee should reflect the administrative fee percentage stated in the Sponsor Agreement. However, the Organization would like to note that the USDA Guidance for Management Plans & Budgets states that, ?A sponsoring organization may retain a portion of the reimbursement for costs associated with administering the CACFP. It may retain up to 15 percent of the total CACFP reimbursement received, or the actual net administrative costs incurred, whichever is less.? Further in the same document, it states, ?There is a concern that sponsoring organizations of centers may spend more on administrative costs than on food. The state agency?s review should investigate how reimbursements are disbursed and whether the food service is supported appropriately.? The Organization would like to emphasize that additional funds, in a miniscule amount, were spent on operating costs, such as food, and it did not retain additional administrative funds. The Organization?s policy in fiscal year 2022 was to track the administrative fee percentage in the claims tracking spreadsheet in lieu of referencing a signed agreement each month. This is supported by the Organization?s disbursement allocation policy, which is included in the fiscal year 2022 Management Plan and approved by MDE. In fiscal 2022, the claims staff would alter the administrative fee percentage upon the written direction of the Executive Director or Director of Operations based on their verbal or written interactions with the site. Going forward, claims staff will not be allowed to change the administrative fee percentage in the claims tracking spreadsheet unless a revised Sponsor Agreement is signed. The Site Information Form was used as a supplement to other operational information about the site. This form is not a federal requirement, nor a form provided by or required by the state agency. During fiscal year 2022, the processing time for the approval of site applications by the state agency was beyond the normal thirty business days. Therefore, sites interested in participating under the sponsorship of the Organization would often complete the Site Information Form as early as possible so that the Organization could submit the site application with MDE. Oftentimes, at the time the Site Information Form was completed, the site may not have finalized site operating times and meal times. The Organization maintained a complete record of all required site information at all times. Contact names and dates of birth of responsible individuals at the sites were documented in the Google sheet used to track information during the intake appointment. In addition, the hours of operation and licensed capacity were maintained in My Food Program software. Lastly, the sites? food preparation methods were also documented on the Google sheet with site information. Catering contracts with vended meal providers are maintained on-file as they are required to be uploaded to the state agency with the site application. Going forward, the Organization will no longer use the Site Information Form or the Google sheet to track required site information. Instead, all data to ensure that the sites are eligible to participate in the CACFP, and the information required to effectively perform subrecipient monitoring procedures, will be retained in the My Food Program software.

CSC?s management concurs with the finding. See Section IV- Current Year Corrective Action Plan.2022-002 Allowable Costs/ Cost Principles Name of Contact Person: Brenda Chandler and Johnny Mammen Corrective Actions: CSC has implemented a policy as of July 10, 2023, that ensures that personnel are hired after the positive background compliances confirmations are obtained along with the modification of internal controls to ensure CSC?s compliance with Federal statutes, regulations, and the terms and conditions of the federal award as stated in the grant requirements. The Human Resources Director will be responsible for implementing and monitoring this policy. Due to the new personnel in finance effective July 17, 2023, CSC will be able to ensure that all grants? receipts are supported by appropriate documentation for expenses incurred. The Senior Accountant will be supervised by the Director of Finance who will be responsible for the implementation of the corrective action. Proposed Completion Date: July 10, 2023 and July 17, 2023 Telephone Number: 202-517-6737

Federal Award Finding: 2022-003 Allowable Costs/Cost Principles - Significant Deficiency in Internal Control over Compliance Name and Contact Person: Tanya Ballot, Tribal Administrator Corrective Action: Management will ensure that policies and procedures are properly followed, and related activity will be documented. Policies will be reviewed on an annual basis and adjustments for federal procurement requirements will be made as necessary. Proposed Completion Date: September 30, 2023

Finding: 2022-001 ALN and Title: 10.565 ? Commodity Supplemental Food Program Cluster Name: Total Food Distribution Cluster Federal Agency: U.S. Department of Agriculture Passthrough Entity: State of Nevada Department of Agriculture Name of Contact Person: Sue Saunders, Director of Finance Corrective Action Plan: Management has implemented a filing system to ensure the collection of current clients as well as a recertification process. CSFP/SNW created a monthly, site specific, year and alphabetized list filing system to aid in the assurance of the certification & recertification. Certification and recertification are occurring at CSFP/SNW distribution sites. In addition, we have a tracking system in our TJOP Salesforce Software System. Currently, we are working towards establishing a digital certification application process. Proposed Completion Date: September 30, 2023

U.S. Department of Labor 2022-001 Earmarking for WIOA The Workforce Innovation and Opportunity (WIOA) Cluster - Assistance Listing No. 17.259 Recommendation: The City should implement procedures to ensure actual program expenditures stay in line with the earmarking requirements throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: To ensure that the WIOA program spends 75% of the allocated WIOA funds on Out-of-School participants, staff will implement the following procedures: ? Staff will monitor the expenditures after each month of billing to the grant and will make adjustments as needed on a regular basis; and ? Staff will limit enrollment of In-school youth, in order to keep the expenditures to this program at 25%; until out-of-school youth participants and spending can maintain the target of 75% of spending. Name(s) of the contact person(s) responsible for corrective action: Diane Gomez, Employment & Training Manager; Kimberly Albarian, Community Services Manager Planned completion date for corrective action plan: June 30, 2023

Finding Summary: For one employee tested, there was no formal documentation of a secondary review of the payroll allocation calculation. Responsible Individuals: Lisa Gochanour, Accounting Manager ? Stephanie Kilian, CFO Corrective Action Plan: Going forward the Accounting Manager will ensure that any payroll allocation changes have an appropriate status change form accompanying the change in payroll allocation. Any change in allocation lacking an approved status change form will be reported to the CFO who can work with the appropriate manager to secure the necessary documentation. All new employees will have the initial allocation documented on the status change form as part of the new hire process. Anticipated Completion Date: 08/01/2023 ? 12/31/2023

Finding: The Chilton County Board of Education (the "Board") prepared an Indirect Cost Proposal in accordance with Title 2 CFR Part 200, "Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal A wards", Subpart E, "Cost Principles". The Indirect Cost Proposal was approved by the Alabama Department of Education in accordance with the U. S. Department of Education Delegation Agreement #2019-116. An indirect cost rate of 9 .62% was approved in the Indirect Cost Proposal for unrestricted programs. This allowed the Board to charge the unrestricted indirect cost rate of9.62% against the indirect cost base for the Elementary and Secondary School Emergency Relief (ESSER) Fund, one of the subprograms of the Education Stabilization Fund. The Board did not calculate the indirect cost base in accordance with the Indirect Cost Proposal, and thus charged indirect costs in excess of those allowed by the Indirect Cost Proposal. Controls were not in place to ensure that the indirect cost base and indirect costs charged were calculated correctly. As a result, indirect costs were charged against the ESSER fund in excess of what was allowed by the Indirect Cost Proposal. Recommendation: The Board should implement controls to ensure the indirect cost base and indirect costs charged are calculated correctly. Response/Views: The board agrees with this finding. Corrective Action Planned: Controls have been put in place to ensure the indirect cost base is calculated correctly. Spreadsheet was created to verify allowable expenditures. Calculations will be checked no less than quarterly and verified at fiscal yearend. Anticipated Completion Date: Verified FY23 indirect cost is being calculated correctly in September 2023. Contact Person: Cheri' Miley Wright, Interim CSFO

The District submitted, for reimbursement via the Emergency Connectivity Grant Fund (ECF), approximately $210,000 dollars for ipads, which had been received prior to the eligibility date of the grant, July 1, 2021. These ipads having been received by the IT department, at the Districts main Education Center office, after July 1, 2021, were reported and recorded as July 2021 eligible transactions. It was subsequently determined this shipment was actually received on June 29, 2021 at the Districts distribution center, therefore making this specific shipment ineligible for grant reimbursement. Upon identification of this error, the District immediately contacted the grant management organization, appraised them of the situation, and were allowed to provide other eligible ipad purchases, as reimbursement backup. Management has proposed additional cutoff testing processes as part of our year end processing, including review and audit of material transactions to ensure recording in proper year. Management has also provided additional training to staff members, on correct cutoff processing and the requirement for original shipping documents and receiving support. The District has also implemented a change in process, whereby all technology purchases will be delivered directly to the IT department at the main Education Center location to ensure appropriate receipt dates and documentation is provided.

Finding 2022-005 Allowable Costs-Premium/Hazard Pay NIT reply: Due to NIT not receiving appropriate guidelines, we were unaware that the premium/hazard pay totals was cumulative of years 2021 and 2022 not consecutive. Speedi Burrell, Director of Finance, Narragansett Indian Tribe

Finding 2022-004 internal Controls and Compliance over Allowable Cost and Allowable Activity - Expenditures NIT reply: NIT will add another signatory/ reviewer to ensure NIT is compliant with our existing policy. Speedi Burrell, Director of Finance, Narragansett Indian Tribe

ARP Earmarking Planned Corrective Action: The Office of Financial Aid called students and conducted in-person interviews as outreach to communicate the opportunity for an income adjustment professional judgement. However, we admittedly did not document the outreach in a manner that we can readily produce for audit purposes. Students were notated on a case-by-case basis. The employee leading these efforts is no longer employed by the University. The Office of Financial Aid will send out a new mass communication to all students to ensure students are still aware of the opportunity to submit a professional judgment based on COVID related income adjustments for FY23. Person Responsible for Corrective Action Plan: Shondra Dickson, Ryan Opfer Anticipated Date of Completion: 4/30/2023

Action planned in response to finding: Management is aware of the situation and has contracted with a CPA firm who will provide additional resources to the internal accounting team and will work to strengthen internal controls. Management has implemented new internal procedures to properly document the time and effort of staff on all grant projects that includes the review and approval of supervisors and management. Name of the contact person responsible for corrective action: Jennie Pinkwater, Executive Director Planned completion date for corrective action plan: Immediately

Oversight Agency: U.S. Department of Health and Human Services Turning Point Behavioral Health Care Center respectfully submits the following corrective action plans for the year ended June 30, 2022. Auditor: Dugan & Lopatka, CPA?s 4320 Winfield Road Suite 450 Warrenville, IL 60555 Audit Period: For the year ended June 30, 2022 The finding from the schedule of finding and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings ? Federal Award Programs Audit 2022-001 Auditor?s Recommendation: We recommend Turning Point Behavioral Health Care Center remind its employees that the personnel activity reports are required to be completed. Action Taken: We agree with the finding, and we will be implementing additional staff training for the Personal Activity Reports to be completed by February 24, 2023. In addition to staff training, we have also created a new process to review all Personal Activity Reports. This process will be completed monthly by payroll staff to ensure all personal activity reports are completed accurately. If the funding agency has questions regarding this plan, please call me at 847-933-0051 ext. 417.

2022-001 Child Nutrition Cluster ? Assistance Listing No. 10.553 & 10.555 Recommendation: Recommendation: We recommend the School review its procedures to ensure it retains documentation sufficient to detail the history of all procurements in accordance with the Uniform Guidance. We also recommend the School review its procedures over procurement controls to ensure all controls are also sufficiently documented with records that include, but are not necessarily limited to, the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review policies and procedures to ensure compliance with Uniform Guidance and MN Statute regarding contract and bid laws. Institute a schedule of periodic review of existing contracts to determine if contract costs are still competitive. We will ensure all award documentation is retained for five years or until the contract is reawarded. Name(s) of the contact person(s) responsible for corrective action: Lynn Peterson, CEO Planned completion date for corrective action plan: September 1, 2023

Corrective Action Plan: VDH has updated its accounting structure and cost allocation plan to ensure that costs not otherwise eligible under federal grant awards are not attributed to the VDH administrative cost pool and allocated to federal grant programs. Scheduled Completion Date: 10/1/2022 Contacts for Corrective Action Plan: Megan Hoke, Financial Director, Vermont Department of Health Peter Moino, Director of Internal Audit, Vermont Agency of Human Services

Finding Number: 2022-003 Program Name/Assistance Listing Title: Indian School Equalization Program, Administrative Costs Grant for Indian Schools, Twenty-First Century Community Learning Centers Assistance Listing Number: 15.042, 15.046, 84.287 Contact Person: Irene Casias, Human Resources Anticipated Completion Date: March 31, 2023 Planned Corrective Action: The need for improved record keeping and scheduling of such action has been stressed to the new person responsible for such actions. The individual is aware and will strive to make sure that the School is in compliance with the requirements.

Condition During the process of identifying expenses eligible under the COVID-19 Testing and Mitigation for Rural Health Clinics program, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare. Views of responsible officials and planned corrective actions Management will continue to refine processes to ensure only allowable costs are reported.

Condition During the process of completing the HRSA PRF reporting form, various reporting errors were made. Views of responsible officials and planned corrective actions We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met.

Condition During the process of identifying expenses incurred to prevent, prepare for or respond to the coronavirus pandemic, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare and included certain cost items reimbursed through the COVID-19 Testing and Mitigation for Rural Health Clinics program (Federal Assistance Listing Number 93.697). Views of responsible officials and planned corrective actions Management will continue to refine processes to ensure only allowable costs are reported. Additionally, we have other costs in our cost tracking workbook we believe are allowable and sufficient to cover the $264,243 of questioned costs. We had intended to report these in the unreimbursed expenses section of the PRF reporting portal but inadvertently missed inputting them. Anticipated completion date Ongoing

2022-003 Education Stabilization Fund: Higher Education Emergency Relief Fund Student Portion and Institutional Portion? Assistance Listing No. 84.425E, 84.425F Recommendation: We recommend the University design controls to ensure an adequate review and approval process is in place and documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The University will design and implement internal procedures with staff (accountant, interim VP, and president) to ensure adequate review and controls are in place. Name(s) of the contact person(s) responsible for corrective action: John Nisbet, Interim Vice President of Administration & Finance Planned completion date for corrective action plan: April 2023

2022-003 FINDING Contact Person ? Reggie Engebritson, Superintendent Corrective Action Plan ? The District will review and update their policies and procedures. Completion Date ? March 30, 2023