Corrective Action Plans

Finding No. 2023-003: Compliance Controls Responsible Individuals: Stephanie Mayfield, Executive Director Corrective Action Plan: The Organization is continuing to evaluate its internal control systems to ensure proper segregation of duties surrounding various compliance with grant programs. After the Department of Labor review in fiscal year 2024, the Organization implemented new processes and internal controls to improve segregation of duties and address eligibility documentation issues. Anticipated Completion Date: Ongoing

Major Program: 93.568 - Low Income Home Energy Assistance (Grantor - Department of Health and Social Services) Condition: The 2023 program year heating funds reconciliation report was not completed and submitted to the State of Delaware in a timely manner. Corrective Action Plan: Charities DEAP program has revised and implemented reconciliation procedures to ensure the program year 2023 heating reconciliation benefit report is completed on April 6, 2024. The final reconciliation report for the 2023 heating benefit refund will be remitted to the State of Delaware Office of Community Services (OCS) in accordance with the established guidelines by April 14, 2024. Process of completion is performed manually: 1. The collection of delivered and non-delivered fuel vendors’ unexpended benefits reports has been obtained from the non-delivered vendors. Completed November 2023. 2. Inter-Agency households’ report of benefits returned to the State of Delaware OCS for the heating season 2023 by the county and by invoice number is in process of being manually completed. 3. The documents noted in procedures 1 and 2 must reconcile with the DEAP billing supervisor report of heating benefits issued - funded and refunded by the vendors. The agency finance unit reporting of paid benefits vs refunded benefits must be compared to the noted reports to verify all report totals equal. 4. The unused benefit report noting the total amount to be returned to the State OCS, is completed once the agency finance unit verification of totals reported in procedures 2 and 3 are accurate for the 2022-2023 heating reconciliation. The program year 2023 reconciliation report will be completed according to OCS’s format and submitted along with the check from the agency for the total amount of the refund. Contact Person Responsible for Corrective Action: Samantha Wallace, Interim Executive Director Anticipated Completion Date of Corrective Action: April 6, 2024

Major Program: 10.558 - Child and Adult Care Food Program (Grantor - Department of Agriculture) Condition: We tested 18 provider files and identified two billing errors within the May 2022 claim submissions. For each instance of error, the number of meals served was incorrectly determined and submitted for reimbursement. Corrective Action Plan: Catholic Charities Program Manager, Joanne Varnes, conducted a training on December 19, 2023 with all staff involved in the CACFP that included income eligibility/enrollment categorization and meal count accuracy. Catholic Charities staff will review each income form/enrollment and double check that children’s reimbursement rate is properly categorized based on their family’s income. Staff members will review each claim before it is entered for reimbursement to ensure the claim is accurate. Program Manager, Joanne Varnes, will oversee this process and conduct case record reviews quarterly for all providers under Catholic Charities Sponsorship. Contact Person Responsible for Corrective Action: Samantha Wallace, Interim Executive Director Anticipated Completion Date of Corrective Action: Immediately

Office of Admin.–SSBG: The Bureau of Financial Operations (BFO) will continue conducting during-the-award subrecipient monitoring for the SSBG based on the results of the documented risk assessment. As it relates to the cash management portion of the finding, given the relatively small amount of funds involved and the number of counties affected, DHS has determined that it is not economically feasible to change the payment methodology at this time. Anticipated Completion Date: 06/30/2024 Contact Name: Kelly Graham, Director, Div. of Financial Policy and Operations OPD-SSBG: Due to the COVID-19 global pandemic as well as staff turnover and vacancies in OPD, regular monitoring of SSBG grant recipients was not performed on schedule. However, with the hiring of a full complement of staff for the DHS Policy Office, including a Grant Administrator, we are in the process of creating and implementing a robust monitoring plan for all 19 of our grantees for calendar year 2024, including in-person monitoring, desk monitoring, data collection, and analysis. Anticipated Completion Date: 12/31/2024 Contact Name: Jessica Schneider, Exec. Policy Specialist I, Grants

DEP will ensure appropriate language as per 31 CFR Section 205.33 (a) of the Treasury-State Cash Management Improvement Act (CMIA) to be included in all Delegation Memorandum of Understandings (DMOU) and Letter of Commitments (LOC) for all future Capital Budget Projects to ensure the expenditure of federal monies is consistent with the progress of the project. Anticipated Completion Date: Completed Contact Names: Patrick Webb, Director, Bur. of Abandoned Mine Reclamation; Tim Golding, Exec. Assist., Office of Admin. and Management

PDE agrees with the portion of the finding pertaining to the lack of required signature on an expenditure report. To address this error, PDE will retrain staff and update “Tool Tips” in PEARS so that it is clearer for field advisers. PDE disagrees with two of the conditions of the finding, as stated by the auditors. First, regulation 7 CFR 226.6 (o), cited and summarized by the auditors as requiring PDE to resolve and close reviews within a specific timeline, does not include this requirement in the text. The regulation requires that subrecipients resolve any issues with a timeframe specified in their corrective action. Second, the first bulleted condition, states that “these reviews did not include any complex findings that would have required more time to close.” PDE procedure for closing reviews states that “any exception must be communicated and approved by the Supervisor…” The procedure does not qualify or limit these exceptions to “complex findings.” Accordingly, PDE will continue to follow its procedures as written. Anticipated Completion Date: 06/30/2024 Contact Names: Vonda Ramp, Chief, Div. of Food & Nutr., Bur. of Bdgt. & Fiscal Management; Clayton Carroll, Audit Coord., Bur. of Bdgt. & Fiscal Management

Program: AL 93.778 – Medical Assistance Program; AL 93.778 – COVID-19 Medical Assistance Program - Allowability Corrective Action Plan: DHHS will work in collaboration with the APA to improve prevention of improper payments and to implement processes to improve the identification of and actions taken against potential fraud, waste, and abuse. In addition, DHHS has established recurring meetings to review each of the conditions in depth and identify mitigation strategies to implement. This could include a combination of policy, business rules, and technology changes, as well as interim and long-term mitigation strategies. Contact: Kathy Scheele Anticipated Completion Date: 12/31/2024

Program: AL 12.401 – National Guard Military Operations and Maintenance (O&M) Projects – Cash Management & Reporting Corrective Action Plan: The Agency will increase continued trend analysis efforts and shift functional responsibilities back to the State Services Support Division for more detailed oversight moving forward now that vacancies have been filled. The Agency will explore the feasibility of increased frequency of funding requests to decrease the amount of time between the Federal draw and the disbursement of funds by the State. Contact: Lauren Hargreaves Anticipated Completion Date: Ongoing

Program: AL 10.555 – National School Lunch Program – Allowability Corrective Action Plan: In the future, the FNS640 report will be checked monthly by two team members: Director of Child Nutrition Programs and the Program Specialist who is responsible for Administrative Review quality control effort. The FNS640 report identifies if an AR did not have the claim validation completed; if this is discovered, the Program Specialist will be notified and required to complete the claim validation and accompanying information within 10 working days. Contact: Kayte Partch, Assistant Administrator, Office of Coordinated Student Support Anticipated Completion Date: Immediately

2023-001 ALN 14.872 – Public Housing Capital Fund Program – Cash Management The CEO agrees with the finding and will follow the Auditor's recommendations as listed on the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Mr. Robert Dull, CEO Projected Completion Date: June 30, 2024

The school has implemented the recommendation by reviewing the eligible expenditures with the appropriate administrative staff to ensure they are following the proper procedures and reporting only allowed expenses.

FINDING 2023-004 Information on the federal program: Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistance Listings Numbers: 10.553, 10.555, 10.559, 10.582 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Chris Akers, Treasurer Contact Phone Number and Email Address: (219) 838-1819 cakers@lakeridgeschools.net Condition: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to the monthly sponsor claim for reimbursement. Context: School Food Authority’s (SFA) and sponsors must submit monthly claims for reimbursement for meals and snacks served to eligible students within 60 days following the last day of the month covered by the claim. The Food Service Management Company employed Food Service Director prepared the monthly claim for reimbursement on the Indiana Department of Education Child Nutrition Program website based on meal count reports from the point-of-sale system. The School Corporation did not implement a system of internal control to ensure what was claimed for reimbursement agreed to the point-of-sale system meal count reports. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Before the monthly claim for reimbursement is submitted by the FSMC, the Treasurer will reconcile the claim with the meal count report generated by the point-of-sale system. Anticipated Completion Date: Immediate

U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: July 1, 2022 – June 30, 2023 The findings from the 2023 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 None Finding 2023-002: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Condition: The required deposit of $1,556 for the year ended June 30, 2022 was made after the 60 day deadline. Recommendation: Lucille Apartments should ensure residual receipts are made within 60 days of year-end in accordance with the HUD Regulatory Agreement. Action Taken: The required deposit was made in September 2022. Completion Date: September 2022 Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO (315) 424-1821

Finding 2023-001: late deposit of residual receipts. Corrective action plan: none required.

Finding 2023-004 – Reporting Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: State of Illinois Department of Public Health Ascension Ministry Market: Illinois Pass-Through Award Numbers: 38080717K, 38080718K Pass-Through Award Period: 07/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that nine reports were not submitted to the State as required by the grant terms. Ascension Living management will coordinate with the State representatives regarding any past reports that are needed and submit them timely according to the agreement requirements. The System implemented a team calendar that tracks due dates of all reports required to be submitted under federal and state programs. This calendar is accessible to all team members, including management. However, Ascension will reinforce the importance to management of oversight and accountability of oversight and accountability to submit required reports. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024

Finding 2023-002 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Information of the federal program: Federal Grantor: United States Department of Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that internal controls were not working effectively regarding review of the calculated limitations and allocations. Ascension has reserved the questioned costs and has communicated with the State on their desired method of repayment. For future grants, Ascension Living will implement controls for appropriate review and approval and to have a secondary review to validate calculations. St. Agnes Healthcare, Inc., Maryland - This finding pertains to retroactive grants where expenses were incurred in previous periods but were subsequently eligible for grant reimbursement. Management is working on creating a report to identify timecards lacking manager approval for exclusion as allowable grant expenses. Grant Accounting is incorporating Time and Effort tracking features a separate approval control to mitigate the issue of timecards lacking manager approval. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024, and July 01, 2024

The Financial Aid Office concurs with the audit finding of the monthly SAS reconciliation requirement to be done internally was not in compliance. Whittier College Financial Aid Staff failed to send the SAS files monthly to our Accounting Department for reconciliation. As of September 2023, Whittier College Financial Aid Office has calendared a monthly reconciliation report to be sent to the Accounting Department to meet the guidelines set forth by the Department of Education. This reconciliation report will be sent monthly through out the calendar year. In the summer months of June and July we may not have any funds to reconcile, however, a report will be sent regardless for compliance. Person Responsible: Jesse Marquez, Associate Director and Information Specialist of Financial Aid Anticipated Completion Date: Implemented as of September 2023

FINDING 2023-003 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program COVID-19 - National School Lunch Program Assistance Listings Numbers: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): SY22, SY23 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Eligibility, Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP), Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Finding: Material Weakness Condition and Context The School Corporation had not established effective internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. Eligibility The School Corporation's policy is to have the Treasurer review and initial paper applications processed by the individual school treasurers to ensure that the eligibility determination was correct. However, six of the ten applications tested lacked documentation of this review. In addition, there was no internal control in place over applications submitted online. INDIANA STATE BOARD OF ACCOUNTS 18 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) The Treasurer performed the verification of free and reduced price applications without a documented review or oversight process in place to ensure that applications selected for verification were in compliance with requirements related to the program. Special Tests and Provisions - Non-Profit School Food Service Accounts The School Corporation did not have an internal control in place to ensure that reimbursements for meals served were properly credited to the School Lunch fund. The lack of internal controls for Eligibility and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) was isolated to the second year of the audit period. The lack of internal controls over Special Tests and Provisions - School Food Accounts was systemic throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and 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. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." Cause A proper system of internal controls was not designed by management of the School Corporation, which would include segregation of key functions. Embedded within a properly designed and implemented internal control system should be internal controls consisting of policies and procedures. Policies reflect the School Corporation's management statements of what should be done to effect internal controls, and procedures should consist of actions that would implement these policies. Effect Without the proper design or implementation of the components of a system of internal controls, including policies and procedures that provide segregation of duties and additional oversight as needed, the internal control system cannot be capable of effectively preventing, or detecting and correcting, material noncompliance. Questioned Costs There were no questioned costs identified. INDIANA STATE BOARD OF ACCOUNTS 19 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Recommendation We recommended that management of the School Corporation design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.

FINDING NO. 2023-002 - TRANSFER OF FUNDS BEYOND THE REQUIRED TIME LIMITS CONDITION During our field work in the cash management area, we noted funds that were requested to G-5 but not disbursed by UPM to minimize the time elapsing between the transfer of funds and disbursement as follows: Descriotion Dates Amount Funds received from G-5 on June 8, 2022 6/8/2022 $610,710.35 Funds disbursed during 2022-2023 Fiscal vear 2022-23 (525,362.27) Available balance from funds received in 6/8/2022 6/30/2023 $75,348.08 Funds received from G-5 on June 22, 2023 6/22/2023 $319,251.71 Funds disbursed at the end of fiscal year 2022- 2023 6/30/2023 (45,000) Available balance from funds received in 6/22/2023 6/30/2023 $274,251.71 RECOMMENDATION The University should reinforce the procedures the draw down of funds to comply with the regulation applicable for the transfer of funds through the G-5 system. Corrective Action Plan: "Corrective Action Plan: UPM acknowledges that recommendation 2023-002 by Mr. Santiago is correct; however, the Dean of Administration and Finance, who assumed this position on February 21, 2023, wishes to explain the reasons behind this occurrence. UPM managed the HEERF funds without prior experience and knowledge of their administration. The officials at that time were unclear about the rules and procedures for managing these funds because the contract details were not received by UPM, preventing them from establishing spending and disbursement policies. Additionally, UPM was without a president for 6 months, and after appointing a president, it operated for approximately a year without a permanent Dean of Administration and Finance. The employees in the Dean's office were not authorized for this level of decision-making, while time continued to pass. Furthermore, there were several changes in the members of our Higher Education Council. As soon as the Dean of Administration and Finance was appointed, consultations with the president were held to make decisions regarding the disbursement and expenses of these funds, which were implemented in June 2023. As a corrective action plan for the future, we will review all certifications related to federal funds management, prepare a comprehensive folder, and administer these funds while adhering to each of these measures. We will proactively identify our needs and align them with the award, clearly defining each process and protocol with the intention of compliance." During the last fiscal year. the Council of Theological Education approved new regulations for: 1. Regulation for the Acquisition of Equipment, Materials, and Non-Personal Services at UPM. 2. Regulation for the Administration of Movable Property (Equipment) at the UPM. hese new regulations complement the existing rules to ensure the integrity, preservation, accessibility, legibility, and legality of our financial actions. We will continue to work together to standardize our processes and address any non-compliance on our part.

Management agrees with the finding. The Organization will enhance internal control policies to ensure all employee timecards are reviewed and approved prior to payment to ensure that all payments are necessary and correct.

Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over cash management and reporting. In the future, management will ensure that documentation of the approval process for reimbursement and reporting is kept.

EF is strictly enforcing a policy that AMEX receipts from staff are due three days after the statement is posted. With this clear policy in place, the period end is accurate with drawdowns reflecting the activity incurred in that period. All supporting schedules are being saved.

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Reporting Finding Summary: Winneshiek Medical Center claimed expenses that had been reimbursed by another source. The Medical Center is a critical access hospital which means that a portion of their expenditures are covered by Medicare. The Medical Center did not decrease their expenses for the portion that was reimbursed by Medicare. The Medical Center’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420680487 reported these expenses that were reimbursed by other sources which made the report inaccurate as well. Responsible Individuals: Ben Stevens, CFO Corrective Action Plan: Management agrees with the finding. The Medical Center created a “Federal Reporting Review Policy” dated March 9, 2023 as a result of working with HRSA and the 2021FY audit. This policy was approved and is now in process. Anticipated Completion Date: No future reports are anticipated to be filed under this program.

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the finding. 2. Actions Planned in Response to Finding The District's internal controls related to payroll will continue to improve. 3. Official Responsible for Ensuring CAP Linh Phan, Manager, Accounting and Finance, Grants Accounting 4. Planned Completion Date for CAP The planned completion date for the CAP is June 30, 2024. 5. Plan to Monitor Completion of CAP The Finance Department management will be monitoring the corrective action plan.

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the finding. 2. Actions Planned in Response to Finding The District's internal controls related to payroll will continue to improve. 3. Official Responsible for Ensuring CAP Linh Phan, Manager, Accounting and Finance, Grants Accounting 4. Planned Completion Date for CAP The planned completion date for the CAP is June 30, 2024. 5. Plan to Monitor Completion of CAP The Finance Department management will be monitoring the corrective action plan.