Corrective Action Plans

Name of Responsible Individual: Mary Beth Schiller-Schwenke, Controller Corrective Action: The FWS Program instances were the result of a minor type error on the federaldraw reconciliation worksheet. To prevent a similar error in the future, the Business Office has modified its draw recordkeeping process to require the employees that record or approve the draw journal entry also review the draw worksheet for accuracy and correct if needed. The FSEOG Program instances resulted from reversals of student awards in fiscal year 2024 for the fiscal year 2023. The Business Office routinely monitors the general ledger for award transactions, however, reversals of student aid awarded in a prior fiscal year can be offset by current year activity and missed. The Financial Aid Office will be responsible to notify the Business Office when they initiate prior award transactions. In addition to the weekly monitoring of the related general ledger accounts, the Business Office will also generate financial aid award reporting and monitor for changes. Anticipated Completion Date: February 28, 2024

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance

Views of responsible officials and planned corrective action: The Authority acknowledges that this error occurred. When we identified this issue, we contacted the grantor agency for guidance. They explained how to submit a refund and acknowledged that since the grant was still open, we had the ability to correct an incorrect draw. This refund has been processed and the Authority has put additional internal controls in place to ensure the proper match is calculated for each grant draw in the future. Additionally, upon final grant closeout, all the numbers are verified and reconciled back to the grant agreement, including the match.

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Jackson Public School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2023: Finding 2023-001 Corrective Action Plan Details A.    Contact person responsible for corrective action: Name: Marc Rowe Title: Executive Director B.    Description of corrective action planned: The district will implement and strengthen its internal control systems over reporting and submitting its monthly claims for reimbursement to ensure claims are submitted within established reporting deadlines. C.    Anticipated completion date of corrective action: 6/30/2024

Name of Contact Person: Suzy Johnson, Director of Finance & Operations Corrective Action: All grant billing projection sheets will be completed on a monthly basis and given to the appropriate program director for review and approval before any grant draws are initiated. Completion Date: On or by June 30, 2024

Program: COVID-19 Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No. and Year: Various Compliance Requirements: Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees with the recommendation to strengthen the established policies and procedures to ensure that the sliding fee discount program schedules are applied to patient charges consistent with its sliding fee discount schedule, and to ensure that County personnel strictly adheres to policies and procedures. View of Responsible Officials and Corrective Action: HCA management recognizes that the sliding fee discount schedule/discount grid established in 2020 was complex and may have contributed to errors in adjustments. A new fee schedule was developed in 2023 to establish flat fees that are more inclusive of services. The grid established in 2020 was in effect until the new grid was approved by the Board of Supervisors on March 15, 2023. Most of the encounters selected for review were encounters dated prior to the new grid’s effective date. HCA management has strengthened its sliding fee policy and procedure, approved by the Board of Supervisor on March 15, 2023. HCA management will implement the following internal control process to ensure that adjustments are consistent with the sliding fee discount program fee schedule: 1. All Medical Billing Specialists responsible for enrolling patients into the sliding fee program will be retrained on eligibility and adjustments. 2. To ensure that patients have received the correct adjustment, we will run a report of all patients under the sliding fee program with at least one encounter, year to date. All applications, proof of income, program eligibility, and adjustments will be reviewed for each patient. Corrections will be made, if applicable. 3. For the remaining of FY 22/23, a monthly report of all encounters under the sliding fee discount program will be pulled and reviewed monthly for accuracy. Corrections will be made and staff will be trained, as needed. 4. Starting in FY 23/24, a random sampling of sliding fee discount program encounters per Federally Qualified Health Center will be audited monthly to ensure accuracy and timely adjustment of encounters. Results will be trended to address any additional process improvements. COUNTY OF VENTURA, CALIFORNIA CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2023 6 Name of Responsible Persons: Lizeth Barretto, Ambulatory Care COO – Ms. Barretto will ensure that the activities listed in the Corrective Action Plan are executed until an Ambulatory Care CFO and/or Ambulatory Care Patient Revenue Manager is hired. Ambulatory Care CFO (Vacant) – Establishes sliding fee discount program policy, procedures, and fee schedules. Ambulatory Care Patient Revenue Manger (Vacant) – Responsible for the oversight of the Medical Billing Specialists responsible for sliding fee discount eligibility and adjustments. Implementation Date: April 15, 2024, Training of Medical Billing Specialists and monthly encounter review and corrections. April 22, 2024, Year to date report and internal audit August 5, 2024, Monthly sampling of encounters

Views of responsible officials and planned corrective action: Areas of focus will be to put in place written policies and procedures for the Financial Aid office, including the area of disbursements that includes additional controls and documentation of such. Our objectives will be that all current and incoming Financial Aid staff will be required to maintain documentation of any drawdowns of funds related to student financial aid. We have put in place a shared an electronic folder with restricted access to provide confidentiality and provide documentation of the shared communication between offices. Documentation of drawdowns and/or returns will be maintained within this folder. Staff will be trained on using the daily generated reports from Poise to watch for students who have withdrawal on their records so that this can be updated and proper calculations done. Measurable targets will be achieved by documenting the records within a shared electronic drive between the Financial Aid office and the Business Office, who handles the return of funds. This will become of a part of the weekly duties of staff.

Views of responsible officials and planned corrective action: Areas of Focus will be in the documentation of polices and procedures to provide clear expectations of internal control documentation used to complete the drawdowns from the Department of Education and for a process of record retention. Our objective would be to formalized the policies and procedures be updated in the Financial Aid policy manual with shared access between the Financial Aid office who approves the aid, the Business Office who ultimately pulls down from the Department of Education, and with the Cashier who distributes any refunds. We have put in place an electronic folder with restricted access to provide confidentiality and provide documentation of the shared communication between offices. The POISE system already generates a listing of students. That workflow will be amended to retain that documentation to be available. Measurable targets will be to do this weekly or as batches are prepared for draw-down. This documentation will be found in the shared electronic folder, which has already been implemented. The transfer of student records into the financial system is being done weekly and documentation is retained of students for which transactions occur.

Planned Corrective Action Plan: The District has hired a new business manager as well as engaged a third party accountant with considerable experience. The individuals will work together to process financial transactions and record resulting financial information going forward. Controls have been implemented to ensure that source documentation is retained to support all t ransactions. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Rocio Humphreys, Business Manager

Finding 2023-003: Lack of Review Procedures of Cash Management for Grants Finding: NCBHS management stated that cash reimbursement requests were reviewed prior to submission to the grantor, but there was no verifiable evidence that the reviews took place. Corrective Actions Taken or Planned: The issue related to the monthly reimbursement requests for the DMH grants not being reviewed and approved by the CEO before they are sent to the State of Illinois. All reimbursement requests for both the State of Illinois and federal grants will be reviewed and approved by the CEO before they are sent to the appropriate parties for payment. Name of person responsible for corrective action: Diane Garland, CFO/VP of Finance Anticipated completion date: March 1, 2024

Corrective Action Plan The one student found with a disbursement reported late to COD was the result of a correction which was posted past the deadline. This was the result of staff turnover in the Financial Aid Office and the use of temporary employees as we began the job search for permanent replacements. Going forward, training will be provided to all new employees including temporary employees. Timeline for Implementation of Corrective Action Plan The College plans to implement the corrective action plan by April 1, 2024. Contact Person James Ryan, Ph.D. Vice President of Enrollment Management

Education Stabilization Fund – Higher Education Emergency Relief Fund –Student Portion, and Minority Serving Institutions – Assistance Listing No. 84.425E, 84.425L Recommendation: We recommend that the University review the current assignment of duties for individuals and incorporate review processes for individuals where appropriate. Action taken in response to finding: The Finance department implemented an approval process for drawdown. The Controller will obtain drawdown approval from the VP of Finance and CFO. Name(s) of the contact person(s) responsible for corrective action: Shalini Patel, Controller Planned completion date for a corrective action plan: June 30, 2023

Planned Corrective Action: Implement accounting system to track federal awards; Reconcile general ledger to award amounts and to reimbursement requests.The organization purchased and is currently implementing a new accounting system which utilizes fund accounting and separate general ledger accounts for each award. Processes and procedures will be implemented to reconcile award amounts and reimbursement requests to each award within the general ledger. Additional supporting schedules will also continue to be maintained to reconcile to the general ledger.

FINDING NO. 2022-003 Statement of Condition: Management made an unauthorized withdrawal of $4,400 from the residual receipts account during the fiscal year ended June 30, 2022; the funds have not been returned to the residual receipts account. Auditor Recommendation: Management should deposit $4,400 into the residual receipts account to refund the unapproved withdrawal. S3800-150: Action Taken: Management agrees with the finding, and has taken corrective actions which include communication with the Project Accountant and Regional Manager and will transfer $4,400 from the operating account to the residual receipts account.

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan. Recommendation (2023-300): Eligibility for the Children’s Health Insurance Program We recommend the Wisconsin Department of Health Services work with the federal government to resolve these improper payments, including the determination of the total amount of improper payments, and return these amounts to the federal government, as appropriate. Wisconsin Department of Health Services Planned Corrective Action: The Division of Medicaid Services (DMS) acknowledges that we maintained eligibility under the Children’s Health Insurance Program (CHIP) for individuals who had turned age 19, including SCHIP participants. It was our overarching policy to not terminate health care coverage upon certain changes in circumstances for Medicaid participants during the federal public health emergency (PHE). To comply with this policy, DHS made system changes at the beginning of the pandemic to maintain eligibility for all participants. After CMS provided additional information specific to SCHIP, DHS considered whether to make the necessary system changes to terminate SCHIP participants who turned 19 during the public health emergency. Because of the system limitation and DHS’s overarching goals to maintain continuous coverage, amongst other reasons, DHS decided to temporarily keep all CHIP participants enrolled until the public health emergency ended. DMS leaders met with CMS leaders on May 11, 2022, to discuss this compliance issue and related systems limitations. During that meeting, CMS indicated that they understood the system and communication challenges of having a single program that combines Medicaid and CHIP. CMS also acknowledged that the federal public health emergency was likely to end at any time, so making the required system changes would not be prudent. CMS said they would follow up with Wisconsin if they determined that further state action was needed, but they did not communicate to us after the meeting that they felt the compliance issue needed to be addressed. This confirmed the Medicaid Director’s decision to not pursue costly systems changes to support a change that might only be needed for a short period of time. After the PHE ended, DHS took proactive steps to identify aged-out CHIP participants and ensure that their eligibility was redetermined in the first two months of unwinding. In contrast to the rest of the CHIP and Medicaid population, whose renewals were distributed over a 12-month period from June 2023 through May 2024, these members’ renewals were accelerated to June and July 2023, so that their CHIP coverage would end as soon as possible after the end of the PHE. While we agree conceptually with the finding, the questioned costs identified do not consider that many (if not most) of the ineligible members would have been eligible for Medicaid as childless adults upon aging out of the CHIP program. We will discuss this likelihood with CMS and if necessary, use data available in our CARES eligibility system to assess how many of these members did retain eligibility as childless adults or in other categories of Medicaid after completing renewals in June and July. Anticipated Completion Date: March 31, 2024 Person responsible for corrective action: Jori Mundy, Director Bureau of Eligibility and Enrollment Policy, Division of Medicaid Services jori.mundy@dhs.wisconsin.gov. Rebuttal from the Wisconsin Legislative Audit Bureau - As stated in the finding, and as acknoledged by DHS, DHS maintained continous eligibility for SCHIP participants who were over age 19. This eligibility requirement continue through the public health emergency. Since CHIP and MEDICAID are separate programs, consideration of whether these participants could have been eligible for the Medicaid program would not have been part of our audit. Payments to providers for these participants were funded by SCHIP and not the medicaid program.

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-301: Social Services Block Grant – Subrecipient Contracts. This is the department’s Corrective Action Plan.  Recommendation (2023-301): Social Services Block Grant – Subrecipient Contracts We recommend the Wisconsin Department of Health Services update its procedures for contract development to ensure information provided in its subrecipient contracts identifies the Social Services Block Grant as the federal funding source for the basic county allocation of the community aids program related to the transferred Temporary Assistance for Needy Families funds. Wisconsin Department of Health Services Planned Corrective Action: DHS will change the Assistance Listing Number (ALN) for Temporary Assistance for Needy Families funds transferred to the Social Services Block Grant (SSBG) to the SSBG’s ALN, 93.667, for future Basic County Allocation contracts. Anticipated Completion Date: July 31, 2024 Person responsible for corrective action: Rebecca Mogensen, Section Chief Managerial Accounting, Bureau of Fiscal Services, Division of Enterprise Services rebeccaj.mogensen@dhs.wisconsin.gov

Planned Corrective Action: The DCF Bureau of Finance will update current subrecipient contracts containing Social Services Block Grant (SSBG) funds to include information required under 2 CFR section 200.332. The bureau will incorporate the SSBG fund source into existing procedures which identify the federal assistance listing numbers for subrecipient contracts. Anticipated Completion Date: The bureau will complete this work by June 30, 2024. Person responsible for corrective action: Rachelle Armstrong, Director Bureau of Finance Rachelle.Armstrong@wisconsin.gov

The Director of Nutrition Services, hired August 2023, has been trained on the verification process and procedures along with timeline compliance requirements.

Management concurs with the auditor's findings and recommendations. The management agent is making several organizational changes to help track and monitor compliance with contracts and agreements.

Contact Person Rhonda LaBatte, Comptroller Corrective Action Plan Management recognizes the deficiency and plans to change the process for how the College calculates the drawdown. This will eliminate an extra manual calculation step removing the potential for human error. Planned Completion Date for CAP Immediately

Finding: 2023-001 Condition: The Organization drew down the FY 2023 Bridge Access Program grant funds in full upon receipt of the award in the amount of $19,507 in advance of incurring federal expenses. The Organization identified allowable expenses which were incurred prior to receipt of the grant award and during 2024, management worked with HRSA to submit and obtain approval for a budget revision, enabling the Organization to apply the funds to the pre-award costs. lndividual(s) Responsible for Corrective Action: Kim Harrison, Chief Financial Officer Planned Corrective Action: 1. For any grant award, the person developing the budget, most often the CFO, will refer to the Grant Allocation file and ensure that any salaries charged to the grant are not covered by another grant for that same time period. 2. The CFO will review the budget with the Controller and Senior Accountant together and ensure the expenses to be charged to the grant and the time period for the grant is clear. 3. Prior to any HRSA drawdown, the CFO will request a list of expenses charged to the grant in question to ensure the money has been expended. 4. The CFO will share the drawdown data with the Controller. Anticipated Completion Date: Some of this is already occurring but the entirety of this will go into effect immediately.

This error occurred during a time of transition from one outsourced accounting firm and accounting system to another. The new outsourced accounting systems were not fully in place or automated at the time of the reporting error and there was no internal review process. The outsourced accounting firm is now fully transitioned, all systems are fully integrated with the accounting software, and the accounting team provides the program managers and organization managers with the reports needed to prepare drawdown requests. Cure HHT has developed and fully implemented a corrective action plan. The organization has communicated with the cognizant agency and all expenses eligible for submission for payment through grant funding will be submitted to and paid from the overdrawn funds. Once these funds are depleted, the organization will resume monthly draw submissions for all eligible expenses. The organization will reconcile all eligible expenses prior to requesting grant funds to avoid future duplicate and/or incorrect requests for grant funds. In addition, pending proper internal approvals of all submitted expenses, grant funds received will be dispersed within 3-7 business days from the date received.

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

Finding 2023-002: Internal Control over Compliance and Compliance with Cash Management Federal Programs ALN: 93.575, 93.596, 93.558 Criteria: In accordance with the grant agreement, and Division of Early Learning (DEL) Program Guidance 240.01, Cash Management Procedures, any advance that cannot be expended or offset by September 18, must be returned to DEL by September 30 of the following year. Condition: The Coalition did not timely remit the unexpended advance related to the 2022-2023 fiscal year in compliance with the grant agreement and DEL Program Guidance. Cause: Lack of effective controls surrounding cash management and review of controls to ensure compliance with grant and DEL Program Guidance. Effect: The Coalition did not timely remit the unexpended advance related to the 2022-2023 fiscal year to DEL until January 8, 2024. Recommendation: We recommend the Coalition implement procedures to ensure that all advances are reconciled on a monthly basis and remitted to DEL in accordance with the grant agreement and DEL guidance. Corrective Action Plan: ELC Management will make sure that measures are in place to ensure all advances are reconciled monthly and paid timely back to DEL. Responsible Party: Felicia Milton, CFO Anticipated Completion Date: March 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 Cash Management Material Weakness in Internal Control over Compliance Finding Summary: No support could be provided for the third quarter draw requests to substantiate a secondary level of review was completed prior to submission of the draws. Documentation to support the review of draw requests prior to submission was not retained during the transition period in the Finance Director role. Corrective Action Plan: SHIP had a one-month period of transition in 2023 in which there was no one in the Finance Director role. The Executive Director took over those duties and also contracted for higher level review and approval from a third-party accounting firm during the transitional period. All draws were reviewed, approved and even supported by the Executive Director and the contractors. SHIP did provide current auditors with the time tracking from the contracted accounting firm that they did review the 3rd quarter report, the report was just not officially signed off on. Staff requesting the draw forgot to get one approval signature for quarter three, all others were signed. Moving forward, SHIP will re-train staff to ensure all draws are signed off on. Responsible Individuals: Mindy Baylor - SHIP Finance Director Anticipated Completion Date: September 2023