Corrective Action Plans

2022-011 Recommendation: The School Board requested grant reimbursement for amounts paid by the self-insurance fund to cover claims for COVID-19 hospitalizations. In accordance with grant guidelines, the funds may be used to implement public health protocols, such as COVID-19 testing and vaccination, meant to decrease the spread of COVID-19. Payment for hospitalizations to treat infections does not appear to be allowable within the grant guidelines of implementing public health protocols. The School Board should implement policies and procedures to ensure that all expenditures under grant programs are allowable under grant guidelines. Corrective Action Plan: The Lafayette Parish School System (LPSS) Self-Funded Group Health Insurance fund paid $756,609 in hospitalization claims that were directly caused by Covid-19 according to the hospitals that provided hospitalization services to our employees. Had the Covid-19 pandemic not occurred, LPSS would not have experienced an increase in claim expenses that were directly caused by Covid-19 which is categorically tracked by hospitals. During the covid pandemic, LPSS had several conference calls with Louisiana Department of Education (LDOE) representatives concerning the allowability of Covid Testing, Vaccinations and Covid Hospitalizations. The objective was to remain compliant with all federal guidelines concerning these special funds. After many hours of conference calls and consultations with LDOE staff, we were informed these expenditures were allowed in addition to a written response. In anticipation of these charges, LPSS submitted an ESSER II budget to the LDOE, which included Covid Hospitalization claims, and the budget was approved. Based on LDOE?s budget approval and prior verbal and written responses, LPSS staff believed they were clear to proceed and recover from these unplanned Covid-19 hospitalization expenditures. As a result of this audit finding, LPSS will appeal to the LDOE and the Federal Government for relief and an eventual inclusion of guidelines for self-funded entities such as LPSS. Unlike other school districts, LPSS is self-insured and assumes the financial risks and obligation of each employee?s medical and prescription claims. We believe the writers of the federal guidelines / FAQs may not have been privy to the operational affairs of school districts that are self-insured to carve out language specific to our operations. On December 13, 2022, a request for review was sent to LDOE in response to this audit finding. The LDOE plans to utilize their resources and contacts while enlisting the help of their contracted attorneys who specialize in federal grants to provide an initial opinion on the allowability of Covid Hospitalization expenditures. It may take several months before an official response is provided by the Federal Government.

Finding ref number: 2022-001 Finding caption: The District overcharged indirect costs and fringe benefits to the Education Stabilization Fund Program. Name, address, and telephone of District contact person: Kira Acker 905 West 9th Street Port Angeles WA 98363 360-565-3755 Corrective action the auditee plans to take in response to the finding: The district has removed all 2022-2023 payroll expenses associated with fringe benefits charged against ESSER III. In addition, the unrestricted indirect percentage rate of 13.17% will be charged against the remaining ESSER III reimbursements. Anticipated date to complete the corrective action: 6/1/2023

Finding 2022-001 ? Allowable Costs/Cost Principles The District concurs with the finding 2022-001. Corrective Action: The District understands the importance of compliance with all federal grants and will make the appropriate steps to ensure compliance. Moving forward, the District will develop a monthly sign off for all teachers to complete if any of their salary is being covered under any Federal grant. This documentation will be housed will all grants applications and resources for annual review. Contact Person: Ryan Smith, School Business Administrator 518-537-6281 rsmith@germantowncsd.org

We will contact DESE for guidance regarding this matter and implement proper controls over program expenditures. Misti Flowers, District Treasurer June 1, 2023 Action Started June 30, 2023 Action completed

Finding 2022-004 ? Lack of Data Available to Audit the Federal Allowable Activities, Allowable Costs, Cash Management, Procurement or Special Tests and Provisions Compliance Requirements (Other Matter) Capital Fund Program ? Assistance Listing No. 14.872; Grant period ? fiscal year ended March 31, 2022 Corrective Action The Commission will maintain, and make available for audit, data applicable to the Capital Fund Program Allowable Activities, Allowable Costs, Cash Management, Procurement and Special Tests and Provisions compliance requirements. Laurie Ingram, Executive Director, has assumed the responsibility of maintaining and making available for audit, data applicable to the Capital Fund Program Allowable Activities, Allowable Costs, Cash Management, Procurement and Special Tests and Provisions compliance requirements and expects the deficiencies which led to this Finding to be resolved by February 28, 2023.

FISCAL YEAR OF FINDING: June 30, 2022 AUDITOR FINDING: 2022-003 FINDING: Reporting and Activities Allowed or Unallowed, Allowable Costs/Cost Principles CFDA No. 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution The Organization included direct expenses from 2020 and 2021 that had already been included on reporting Period 1. In addition, there was an audit entry recorded for fiscal year 2021 that had not been updated with the Period 3 report calculations. Direct expenses from 2020 and 2021 should not have been included and overstated the direct expenses applied to PRF funding by $170,246. The audit entry not included in the Period 3 revenues, reduced revenue by $110,000 along with a keying difference between general ledger data and the report of approximately $26,000. CLIENT PLANNED ACTION: Amy Cooper, VP of Operations and Aaron Hancey, Interim CFO will establish quality reviewing and approval processes so proper reporting can be done effectively and timely. CLIENT RESPONSIBLE PARTY: John Sheehan, CEO COMPLETION DATE: September 22, 2023

2022-001 Higher Education Emergency Relief Fund ? CFDA No. 84.425E; 84.425F Recommendation: We recommend that the College implement controls related to cash management that designates a different reviewer and signer of drawdowns that occur within a given year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As a result of audit finding and 2022-001, the College implemented a process that includes formalized review and approval of drawdowns of federal awards. Name(s) of the contact person(s) responsible for corrective action: Jacob Wheeler Planned completion date for corrective action plan: 6/30/23

Finding 2022-002 Federal Agency Name: Department of Agriculture Passed through State of South Dakota Department of Education Program Name: Emergency Food Assistance Program (TEFAP) CFDA# 10.568,10.569 Finding Summary: Emergency Food Assistance Program (TEFAP) pounds distributed to passthrough agencies didn't agree to underlying inventory reports. This resulted in monthly draw requests to be misstated. Responsible Individuals: Christy Carr, Chief Financial Officer Corrective Action Plan: Internal controls have been revised to include additional cross referencing of distributions reporting. As well as additional training for employees involved in the process and updated standard operating procedures.

Corrective Action Plan and Views of Responsible Officials The District will continue to implement the following procedures, which were initially put in place in December of 2021, after the meal counting error was identified in October of 2021: 1. Site Numbers will be collected via a clicker counter or tally sheet. This information will be documented on paper and sent to the Claim Preparer to verify and ensure accuracy. 2. The data from the counters and Tally sheet will be entered into the back-office Point of Sale software system instead of a spreadsheet. 3. Monthly reports will be generated when creating the claim and an Edit Check will include auditing daily participation numbers to ensure days have not been skipped. 4. The claim will be entered in CNIPS following standard ?Meal Counting & Collecting Procedures? as approved by the State. Implementation Date: Fiscal Year 2021-2022

(#2022-003) Allowable Costs ? Documentation to support the estimates for lost revenue was not provided to management timely for review and approval. Corrective Action Plan BOCES will ensure that clear and appropriate supporting documentation is in line with grant terms and is provided by the department and reviewed with the Finance Office prior to any submission for grant disbursement. Responsible Party Ms. Amy Windus, Executive Director of Finance Anticipated Completion Date June 30, 2023

(#2022-001) Cash Management ? Funds drawn down by BOCES during its fiscal year ended June 30, 2022, for emergency financial aid grants to students were not disbursed within 15 calendar days. Corrective Action Plan BOCES will ensure that conditions for draw down are met by referencing grant compliance materials and verifying timelines with the department prior to any action. Responsible Party Ms. Amy Windus, Executive Director of Finance Anticipated Completion Date June 30, 2023

U.S. Department of Agriculture: Octorara Area School District respectfully submits the following corrective action plan for the year ended June 30, 2022: Name and address of independent public accounting firm: Herbein + Company, Inc. 2763 Century Boulevard Reading, PA 19610 Audit Period: Year ended June 30, 2022 Anticipated Completion Date: December 31, 2022 Contact Person: Jeff Curtis, Business Manager Finding - Federal Award Findings and Questioned Costs 2022-001 ALLOWABLE ACTIVITIES - SIGNIFICANT DEFICIENCY Federal Program Child Nutrition Cluster COVID-19 - National School Lunch Program ALN 10.555; passed through the Pennsylvania Departments of Education and Agriculture; Grant Period 7/1/21-6/30/22 COVID-19 - School Breakfast Program ALN 10.553; passed through the Pennsylvania Department of Education; Grant Period 7/1/21-6/30/22 Criteria Title 7 CFR 210 covers the reimbursement process under the Child Nutrition Cluster. It requires the submission of claims for reimbursement that include the number of reimbursable meals served by category and type during the period (generally a month) covered by the claim. As a subrecipient of funds passed through the Pennsylvania Department of Education (PDE), Octorara Area School District must submit monthly claim forms to PDE, which include the number of reimbursable meals served by category (free, reduced, paid) and type (breakfast, lunch). Condition/Cause The District manually inputs the amount of meals served by location into a spreadsheet in order to obtain totals to type into the monthly claim reimbursement form. A data input error, failing to include a location in the spreadsheet for certain days, led to an incorrect number of meals reported on one claim report from our sample. Controls in place over claim reporting did not detect and correct this error before submission. Effect As a result of the claim report not being filed accurately, the District lost approximately $730 of federal subsidies that would have been received if the correct meal count was used. Questioned Costs Less than $25,000 Context We examined 4 of the monthly reimbursement claim reports submitted during the year by the District and noticed the deviations noted above in one of those reports. Total subsidy revenue for the District for the year ended June 30, 2022 was $981,173. Had the District filed an accurate claim report for the month noted above, subsidy revenue would have been $981,903. The lost revenue is 0.074% of total federal subsidy revenue for the year. No statistical sampling was used in our testing. Repeat Finding No. Recommendation We recommend that the District revisit the current procedure for verifying accuracy of meal counts prior to claim submission for areas where the control could be strengthened. The review should include comparison of the report to meal count reports for all locations to verify accuracy. The review should also include a comparison to prior monthly reports for reasonableness. We recommend that the reviewer initial the report draft or otherwise maintain support of this review. Management Response The Food Service management team will enhance their current procedure to include the recommendations listed in this corrective action plan. Meal count hard copy reports by location will be submitted to the Food Service Supervisor each month to be tallied and compared to the meal count summary reports in the PrimeroEdge management system. The Supervisor will also confirm that hard copy reports are received for each group of students at each location and will initial the reports after the review. After confirmation from the Supervisor, that all locations are accounted for and the totals are correct, The Food Service Director will review the reports to ensure that the total meal counts are reasonable by comparing the reports to prior monthly reports adjusted for differences in the number of days in each month. Jeff Curtis, Business Manager

Corrective Action Plan FINDING 2022-005: Cash Management Contact Person: Randy Cates rcates@yesomaha.org 402.345-6704 Regarding Cash Management?The process we have put in place includes the following: ? All fund receipts will be reviewed by Development Team and CFO for authenticity and accuracy. ? All approved fund receipts and invoices will be coded by the CFO. ? All fund receipts information will be forwarded to our CPA firm. ? Our CPA firm will: o Scan all deposits and create a file for which the CFO and Executive Director will also have access. o Input all fund receipts into our Accounting Software ? CFO will review all Fund Receipts monthly with Executive Director Reasonable completion date: Process is place as of July 7, 2023 Responsible Party: Randy Cates, CFO

Corrective Action Plan Contact Person: Randy Cates rcates@yesomaha.org 402.345-6704 FINDING 2022-004: Allowability Regarding Allowability?The process we have put in place includes the following: ? All invoices and fund receipts will be reviewed by the Director of Operations and/or CFO for authenticity and accuracy. ? All approved fund receipts and invoices will be coded by the CFO. ? All coded invoices will be forwarded to our CPA firm. ? Our CPA firm will: o Scan all invoices and create a file for which the Director of Operations, CFO, and Executive Director will also have access. o Input all invoices into our Accounting Software ? CFO will review all Receipts and Expenses monthly with Executive Director Reasonable completion date: Process is place as of July 7, 2023 Responsible Party: Randy Cates, CFO

U.S. Department of Health and Human Services Olmsted Medical Center (the Medical Center) respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: (PRF Phase 3 and 4 Reports) The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD SINGLE AUDIT U.S. Department of Health and Human Services 2022-001 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the PRF and ARP guidelines to make sure amounts requested for reimbursement are supported by paid invoices. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Medical Center will review reporting requirements to ensure proper reporting in future periods. However, it is noted that there was unreimbursed expenses to support the PRF and ARP distributions received. Name(s) of the contact person(s) responsible for corrective action: Matthew Peterson, Controller Planned completion date for corrective action plan: Implemented If the U.S. Department of Health and Human Services has questions regarding this plan, please call Matthew Peterson, Controller at 507-529-6615.

Current Finding on Schedule of Findings, Questioned Costs and Recommendations See Schedule of Findings and Questioned Costs for the year ended September 30, 2022.

Finding 2022-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: Management?s internal controls over the review and interpretation of instructions related to the input of lost revenue into the HRSA PRF portal were not sufficient to ensure the lost revenue recorded in the General Distribution portal ?Total Lost Revenues for the Period of Availability (January 1, 2020 to December 31, 2022)? line did not include the lost revenues that had been transferred from the Parent to subsidiaries and recorded in the portal for the subsidiaries Targeted Distributions. Corrective Action Plan: When populating the Period 4 HRSA PRF portal for Spectrum Health System, Corewell Health West management was aware that the inputs were not considering the System lost revenue attributed to the affiliates appropriately. In order to communicate to the users of the portal and other auditors, Management included an excel tracking worksheet which was uploaded on the HRSA PRF portal showing the total lost revenue used as an organization and the remaining balance left to be used. When populating the Period 5 filing, due September 30, 2023, Corewell Health West Management will correctly input the lost revenue in the Parent submission in order to reflect the lost revenue used by the individual subsidiaries. Individual responsible for the corrective action: Cindy Brink, Director, System Accounting & Reporting Timing of the Corrective Action Period 5 HRSA PRF portal filing, due September 30, 2023.

FINDING 2022-003 (Medical Assistance Program) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Internal controls are being updated and will be adopted by the Board. The Township and Fire Department have worked on division of duties. Now the Fire Department will process a payment and will be approved by someone else in Fire Department. Then, the bill will be reviewed by the Township Accounting Specialist and will be paid by the outside accounting service. After the check is written, the Trustee will sign. If an invoice is over $5000 the Trustee will sign off prior to the payment. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted in the accounting software and coded to the proper account. The accounting software is reconciled on a monthly basis to ensure all transactions are accounted for properly and accurately. Anticipated Completion Date: 9/30/23

FINDING 2022-002 (Medicaid Cluster ? Activities Allowed or Unallowed) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. Since the audit is just completed for 2019, this comment be repeated until we receive the funds for 2023 which will probably occur in 2026. Anticipated Completion Date: 9/30/23

Finding 2022-006 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of the finding: Management did not retain evidence to support their review over the patient data submitted to Sponsor for the per diem billings from February 1, 2022 to December 31, 2022 was complete and accurate. Corrective action plan: The current attestation memo control will be replaced as follows: There are two categories of study activity that required review and approval by the appropriate individual (i.e., Principal Investigator, Clinical Research Manager (CRM) or a delegate): (1) at the time of enrollment to assure that the study participant met sponsor-defined eligibility requirements and (2) subsequent study activities that may include but are not limited to a study visit, data collection, follow-up phone call, questionnaire completion, laboratory testing, biospecimen collection, or some combination of these. Verification of eligibility at the time of enrollment will continue to be reviewed and approved by the study PI, CRM, or appropriate delegate per sponsor requirements. Documentation is maintained in study-specific binders, per FDA audit standards and internationally-accepted Good Clinical Practice principles to assure that only patients meeting the sponsor?s defined eligibility criteria are enrolled into the study. Review of study activities subsequent to the study participant enrollment will be conducted monthly by the CRM or their delegate. Sponsored Programs Administration (SPA) will prepare and send each CRM a Transaction Report downloaded from the institutional clinical trial management system for each federally funded study, at least quarterly, that includes a listing of study visits associated with enrolled study participants that occurred within the defined period of time. The CRM/delegate will review the report detail provided and, upon approval, sign, and date the report. To assure that the information in the report is consistent with what was submitted to third parties which generates reimbursement, the CRM/delegate will conduct an audit of a sample of patients from a random selection of studies included in the Transaction Report. Each sample will be verified against documentation maintained in the study binder. Audit results affirming document review will be recorded in an audit tracking log which will be retained with the study activity report in their Clinical Trial Office (CTO) file as evidence of their review of study activity for federally funded fixed fee/per patient studies. For those federally funded fixed fee/per patient studies that do not utilize the standard institutional clinical trial management system, a similar study activity report downloaded from the clinical trial management system utilized for the study will be used for review, signed and dated upon approval and kept in the CTO files as evidence of review. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: September 1, 2023 and going forward.

Finding 2022-003 Information on the Federal Program: Federal Agency: U.S. Department of Health and Human Services, United States Department of Defense Assistance Listing: Various, Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Management?s policy over effort reporting for Corewell Health West was designed to only require the documented review and approval of the grant effort and not 100% of an employee?s effort, which includes effort spent on non-grant work. Management?s policy related to Corewell Health East over effort for physicians who are not the principal investigator who charge time to the R&D grants does not require their effort report be reviewed and approved by someone who is knowledgeable of the grant. Corrective action plan: Corewell Health West utilizes Workday Grants Management to document the employee self-certification for 100% of each employee?s effort. In addition to the employee self-certification, Management will enable Workday functionality to route the effort certification for approval to a reviewer with knowledge of 100% of the employee?s effort. Corewell Health East will update their Research Time and Effort Reporting policy to reflect that review of the monthly RI Time and Effort Report for Physicians submitted by physicians who are involved as key personnel on federal grants or applicable direct expense reimbursement mechanisms, whether or not compensation is received, will be reviewed by an individual who is familiar with the technical/scientific progress of the award. Individuals responsible for corrective action: For Corewell Health West: Joseph Fugitt, Sr. Director, Research Finance & Operations, Corewell Health West, Emily Guzman, Director, Research Finance, Corewell Health West For Corewell Health East: Giacomo DeChellis, Sr. Director Research Operations, Corewell Health East Timing of corrective action: For Corewell Health West: For calendar year 2023 and going forward. For Corewell Health East: September 1, 2023 and going forward.

Finding #2022-002 Comments on Finding and Recommendation: The Corporation's required deposit into the residual receipts account of $27,293 per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all required residual receipts deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after the fiscal year end. Action(s) taken or planned on the finding: Agree. Management deposited $27,293 into the residual receipts fund on February 16, 2022. No further action is required.

Statement of Condition #2022-002: For the year ended March 31, 2022, the Corporation paid management fees to the Agent in excess of the fees earned resulting in prepaid management fees of $1,122 at March 31, 2022. Recommendation: The Agent should repay the prepaid management fee balance. Action(s) taken or planned on the finding: The Corporation concurs with the finding and agrees with the auditor's recommendation. The Agent repaid the prepaid management fees on July 20, 2022.

Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.

Finding 2022-004 Cash Management ? Significant Deficiency in Internal Control over Compliance Federal/State Agency Name: Department of Justice and State of South Dakota Department of Public Safety Program Name: Crime Victim Assistance CFDA # 16.575, 2022-COMBO-00022, 2022-COMBO-00011 Finding Summary: One instance was noted in which an independent review of a grant draw request was not completed prior to the draw request being submitted for reimbursement. Responsible Persons: Shannon Clark, Chief Financial Officer; Lynn Peterson, Controller; Amy Carter, Program Director; Janice Lee, Finance Administrator Corrective Action Plan: Independent review of grant draws will be completed prior to submission for reimbursement and formally documented to support that the review occurred prior to submission. Anticipated Completion Date: June 30, 2023