Corrective Action Plans

2022-001 Inaccurate Meal Count Recommendation: Established procedures should be followed closely to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Action Taken: The CACFP at The Russell Child Development Center, Inc. is aware of the oversight and will continue to strive to improve its review process. A review of meal count sheets, including verification of input into the CACFP?s system and capacity, has been implemented, and the CACFP will continue to work to ensure an accurate meal count is submitted for every provider each month. All actions have been taken as of the date of this notice. In addition, as of January 1, 2023, the CACF moved to a new software, My Food Program, that counts a provider?s own children in the total meal count, which the old software did not do. The new providers are currently working with the CACFP to ensure software programming meets KDHE standard exceptions. These changes will significantly reduce capacity errors.

2022-002 Written Policies Required by the Uniform Guidance Due to the number of grant programs the organization is managing, written policies will be developed and implemented to meet the requirements under the Uniform Guidance within the next year. The purpose of the policies will be to ensure that all grant funds, including reimbursable grants, are tracked and recorded appropriately, Our contracted accountant is responsible for managing journal entries and recordings and will participate in these reviews. The quarterly reviews will be held on or about the third week of September, December, March and June. It is my expectation that this process will ensure appropriate controls over the grant funds flowing into and out of the organization, including federal and state grants. Please contact me at (810) 982-9511 or dcasey@edascc.com if you have any questions.

Finding Number 2022-004: Corrective Action Required by the Board: Prior to submitting reimbursement claims to the New Jersey Department of Agriculture, the meals claimed should be verified to the meal count activity records and Edit Check Worksheets and/or tally sheets. Method of Implementation: The Food Manager will verify all meal counts and reconcile all discrepancies prior to the submission of claims on a monthly basis. All claims and the reconciliation of meals must be submitted to the BA prior to the certification of claims on a monthly basis. Person Responsible for Implementation: Business Administrator, Assistant Business Administrator, Food Service Manager. Planned Completion Date of Implementation: May 1, 2023

Finding: 2022-001 84.425U - ARP ESSER Criteria: The School should only request funds for reimbursement that relate to qualifying expenditures. Condition: The School utilizes a software to track all allowable expenses incurred during the period for reimbursement. Cause: During the year ended August 31, 2021, the School incorrectly submitted for reimbursement $78,606 in excess of qualifying expenditures. Effect: The School submitted for reimbursement and recognized federal awards revenue in excess of qualifying expenditures for the year ended August 31, 2021. Correspondingly, the School reduced the amount of expenditures submitted for reimbursement for the year ended August 31, 2022. Questioned cost: No questioned costs requiring disclosure. Recommendation: We recommend that management perform a detailed review of expenditures before submitting for reimbursement to ensure that all expenditures submitted are allowable. Views of responsible officials: RAPS agrees with the above finding. Corrective Action Plan: RAPS has put into place a procedure in which the bookkeeper will prepare the monthly federal reimbursement requests and provide a reconciling report and general ledger report to the CFO for review and verification of costs before the reimbursement request is submitted to TEA for payment. 1020 Elm Ave Waco, Texas 76704 11 (254) 754-8000 ***.rapoportacademy.org

Recommendation: The Organization should perform its own calculation of surplus cash and remit required deposits to the residual receipts account within 60 days after year-end as required by HUD. Action Take: The deposit that was due for the year ended September 30, 2021, the year under audit, of $28,545 was not made until January 7, 2022.

Agency: U.S. Department of Agriculture passed through State Department of Education

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The residual receipts account deficiency was funded on October 15, 2021 in the amount of $9,505. Management will ensure that the residual receipts account is properly funded in the future. Completion Date: October 15, 2021

Management is implementing an enhanced, more detailed invoice review process where invoices will be reviewed irrespective of materiality by leadership on the RETAIN team. In addition, the invoice process will include periodic meetings to go through expenditures in detail prior to invoice submission. The contacts for this finding are Kori Smith, RETAIN Program Manager, KASmith4@mercy.com and Alice Parisi, Foundation System Director, Alice_Parisi@mercy.com.

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The excess funds were accrued to submit to HUD. Completion Date: August 29, 2022

FINDINGS AND QUESTIONED COSTS - FEDERAL AWARDS PROGRAM 2022-001 Higher Education Emergency Relief Fund (HEERF) Institutional Portion Assistance Listing Number: 84.425F Criteria According to the Department of Education Higher Education Emergency Relief Fund III Frequently Asked Questions (FAQs) question 26, institutions may discharge student debt or unpaid balances by discharging the complete balance of the debt as lost revenue and reimbursing themselves through their HEERF institutional grants or by providing additional emergency financial grants to students (with their permission). This is available for the institutions for students who were enrolled in an institution at any point on or after March 13, 2020. Condition There was a lack of review procedures that led to not adhering to the HEERF requirements. Context A portion of HEERF institutional grant funds was improperly used to discharge student debt and/or unpaid balances, including debt and/or unpaid balances of students that were enrolled prior to March 13, 2020. Cause Insufficient monitoring of grant rules and regulations. Effect Lost revenue was calculated using an alternative method that fit within the regulations. Questioned Cost There were no questioned costs related to this finding. Recommendation We recommend that the University closely monitor all grant requirements and ensure that there are proper review processes in place to catch any potential noncompliance. Planned Corrective Action The Fiscal Staff will review and recommend to reduce / inactivate the number of accounting classifications that are no longer used, and therefore the chart of accounts will be more streamlined. The new chart of accounts will then be deployed without the same unnecessary legacy monthly closing protocols. Existing fiscal staff will now have more bandwidth to help with monthly analysis and accounting close protocols. Implementation Date Effective date: 7/1/23 for fiscal year 2024. Responsible Personnel Arlene Cash Interim Vice President for Enrollment Management awcash@ndnu.edu

As stated in the audit findings, there were errors made in reporting lost revenue, which included pharmacy and grant revenue. Jefferson Center agrees there were errors made and are providing a solution for the corrective action plan. It?s every important for Jefferson Center for Mental Health to report accurately and timely information. All future reporting and correspondence on provider relief funding will be reviewed by multiple fiscal staff, including the Controller, Director of Finance and the Chief Financial Officer. Having multiple qualified staff to review and agree that the correct procedures have been followed and that the information being reported is accurate, will ultimately meet our goal of reporting 100% accurate information. In the future, the Controller will prepare the reporting information, the Director of Finance will assist the Controller in reviewing the reporting guidelines and timelines as well as assist with populating the reports with the correct data. The Chief Financial Officer will review the reports and data sources to ensure that we follow the correct reporting guidelines. Jefferson Center will also make sure that we have the latest Post-payment Notice of Reporting Requirements from the HRSA website to ensure we?re aware of the latest reporting requirements. Projected Completion Date: February 15, 2023 CLIENT RESPONSIBLE PARTY: Name of Contact Person: David A. Goff, MBA Vice President of Administration and Chief Financial Officer. 4851 Independence Street, Wheat Ridge, CO 80033. 303-432-5164, Davidg@jcmh.org

Management Response: The Neighborhood House is undergoing an internal review of all payroll and payroll allocations. Adjustments and corrections to program allocations will be made accordingly. The payroll report will be reviewed annually for revisions.

Recommendation: The Company should ensure that finance staff is adequately trained as well as revising and monitoring internal controls. Corrective Actions: The Company will ensure that finance staff is adequately trained as well as revising and monitoring internal controls by engaging an outside certified public accounting firm for assistance.

The Organization billed the federal government for amounts of costs that had not yet been incurred and is at-risk for noncompliance with allowable activities and allowable costs, as well as cash management requirements. Statement of Concurrence or Nonconcurrence: Flower Hill has been billing the US Department of Agriculture 100% of its annual expenses in equal monthly amounts whether the total amount billed was expensed or not. According to audit, this is not allowable under a cost reimbursable contract. The organization agrees with, understands this finding and has already implemented corrective action to this finding. Questioned Costs $186,089 Corrective Action: Corrective action has been taken. FHI has discussed this finding with grantor (USDA Department of Agriculture) as has Auditor. To date, there has been no action taken by the USDA. As of July 2023, FHI has been billing only reimbursable amounts for direct costs incurred and for the approved 10% indirect rate. Name of Contact Person: Person responsible for completing the corrective action plan is Nicole Mast, Director of Operations, nmast@flowerhill.institute. Projected Completion Date: July 2023 Oversight: Billings will be monitored on a monthly basis to ensure full implementation through the end of the current contract (currently March 2026).

Finding 2022-003: Information on the Federal Program: 84.42SF - Higher Education Emergency Relief Fund - institutional Portion, 84.42SE- Higher Education Emergency Relief Fund - Student Portion Compliance Requirement: Cash Management Type of Finding: Material Weakness Criteria: Under 2 CFR Section 200.303(a), non-federal entities must establish and maintain effective internal controls to provide reasonable assurance that the entity is managing the federal awards in compliance with statutes, regulations, and the terms and conditions of the award. Additionally, under HEERF award, grantees are under an obligation to minimize the time between drawing down funds from GS and paying obligations incurred by the grantee (liquidation). If a HEERF grantee is using HEERF grant funds to make financial aid grants to students, the Department may evaluate for compliance with the rule grantees who have not drawn down the funds from GS and not paid the obligations (the financial aid grants to students) to the students within fifteen calendar days. The Supplemental Agreement published by the U.S. Depaitment of Education pe1tammg to Supplemental Grant Funds identifies that funds not disbursed within 3 days of being drawn down may be subject to heightened scrutiny by the U.S. Department of Education, the institution's auditors, and/or the Department's Office of the Inspector General. Internal controls over compliance with direct and material compliance requirements should be sufficient to prevent or detect and correct material noncompliance in a timely manner. Condition: During testing of cash management compliance requirements, it was noted that Jacksonville College had drawn down the entirety of the HEERF awards in 2021 and recorded $1,302,078. In 2022, the College had expended the majority of the funds but continues to report a deferred liability of $42,887 related to prematurely drawn-down HEERF funds. Context: Jacksonville College did not review compliance requirements related to drawing down of grant funds and over-drew funds related to the HEERF grant. Questioned Costs: $42,887 remaining in Deferred Income. Cause: A material weakness in internal control over compliance exists relating to cash management. Personnel responsible for maintaining compliance with cash management did not have sufficient education on the cash management requirements. In addition, there was no review over compliance with cash management requirements to monitor compliance. Effect or Potential Effect: The College was not in compliance with Federal requirements of the COVID-l 9 Education Stabilization Fund. 44 Repeat Finding: Not a repeat finding. Recommendation: We recommend that the College put into place controls that require review of grant requirements prior to drawing down funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College regrets that this was the process that was used. The failure to review the requirements for the draw-down of HEERF funds was managed by a previous administration. When it was discovered that the proper process was not used by the previous administration, immediate controls and policy reviews were put into place to avoid any further issues of non-compliance. Specifically, Cabinet held weekly meetings where the Executive Vice President was responsible to update Executive Administration with the current status on the utilization of funds. Since that time, a new president has been put into place by the Board of Trustees. The president is committed to following whatever requirements are mandated for all federal programs. In collaboration with all Cabinet members, relevant departments on campus, and a financial consultant, the College will avoid any further issues of non-compliance.

Finding 2022-003 Federal Agency Name: Department of Education Program Name: Special Education-Grants for Infants and Families Federal Financial Assistance Listing #84.181 Compliance Requirement: Other Federal Agency Name: Department of Health and Human Services Program Name: HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Federal Financial Assistance Listing #93.431 Compliance Requirement: Other Federal Agency Name: Department of Homeland Security Federal Emergency Management Agency Program Name: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Federal Financial Assistance Listing #97.036 Compliance Requirement: Other Finding Summary: SRHC does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. Therefore, significant federal programs were excluded from the schedule. Responsible Individuals: Kevin Hoffman, Controller Corrective Action Plan: Management will implement controls to ensure a complete and accurate schedule of expenditures of federal awards and that the schedule will be reviewed by an individual independent of the preparer. Anticipated Completion Date: 9/30/2023

The District will expend any excess funds as soon as administratively possible and monitor profitability (or lack thereof) of the food service program on a quarterly basis to ensure revenues do no exceed expenditures.

Purchase Needed Equipment

We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.

The HIDTA Financial Manager, in conjunction with the City's Finance Assistant, will request smaller dollar amounts with new advances in order to liquidate the prescribed HIDTA guideline of 21 days.

Management deposited $1,875 back into the Project?s Reserve for Replacement account on December 9, 2022.

The School Lunch fund has excess fund balance on hand due to the additional reimbursements provided during the COVID-19 pandemic. The District is currently reviewing the programs aging equipment and will create a plan to use these funds to support the program's infrastructure in addition to it facilitating minimal increases in school lunch prices.

COVID-19 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: The Organization should review all expense amounts entered into the reporting portal submission to ensure the amounts are accurate and agree to internal supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented a process that should ensure all future reports are accurate and reviewed prior to submission. This includes a review and verification of expenses that are being reported to ensure they are accurately entered and supported by internal records. Further, management has identified additional infection control related costs which were not claimed during the reporting periods submitted. These costs have been isolated to ensure they are not available for use in future periods. Name of the contact person responsible for corrective action: Mark Sperka, CEO Planned completion date for corrective action plan: March 2023

2022-002 Significant Deficiency Name of contact person: Erin Benson, Executive Director Corrective Action: The Organization has been placed on high-risk status by Maine DOL and adopted new policies in conjunction with Maine DOL. The Organization is working with Maine DOL to develop a program to properly train and oversee staff and board members to ensure drawdowns are filed timely and accurately. Proposed implementation date: The corrective action plan has been implemented and is being followed at this time.

Finding 2022-001: Reporting ? Significant Deficiency/Non-Compliance Federal Program ? Airport Improvement Program Federal Agency ? U.S. Department of Transportation Pass-Through Entity ? Not Applicable Assistance Listing Number ? 20.106 Federal Award Year ? December 31, 2022 Criteria: The Uniform Guidance requires written policies/procedures in order to comply with certain requirements. These areas include allowability of costs, cash management, procurement, subrecipient monitoring and conflicts of interest. Condition: As part of our audit of the Authority's Airport Improvement Grant Program, it was noted that the Authority did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance. Questioned Costs: Not applicable. Context: The Authority does not have in place a number of written policies/procedures surrounding their administration of federal awards. Cause: Authority management failed to adopt the required written policies/procedures. Effect: The Authority is not in compliance with the written policy/procedure requirements of the Uniform Guidance. Corrective Action Taken: Since the finding was identified during the audit, the Authority has initiated a plan to prepare and file the written policies/procedures required of the Uniform Guidance. Expected Completion Date: December 31, 2023 Designated member responsible for corrective action plan: James Meyer, Authority Director