Corrective Action Plans

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end date of the PHE, as MDHHS completes renewals for existing cases. MDHHS could not terminate Medicaid benefits during the PHE, and annual renewals have not been completed since the start of the PHE, resulting in most Medicaid cases not being touched until the 14-month unwind period allotted by the Centers for Medicare and Medicaid Services at the end of the PHE. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children?s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 31, 2024 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Erin Emerson, MDHHS

Contact Person ? Jeannie Mayer, Superintendent Corrective Action Plan ? The District will review policies and procedures for submitting meal counts for reimbursement. Completion Date ? November 1, 2022

Comments on Findings and Recommendation: The Corporation's required deposit into the residual receipts account 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 $10,879 into the residual receipts fund on May 2, 2022.

Finding 2022-056 Low-Income Home Energy Assistance, ALN 93.568 - Recertification of Clearance Patterns Management Views Treasury agrees with the finding. Unforeseen reorganizational efforts and staffing turnover in fiscal year 2022 resulted in a disruption to the continuality of the Cash Management Improvement Act program. Corrective action implemented to address prior audit findings enabled newly appointed staff to replicate queries for most of the programs that required clearing pattern review. As a result, the number of programs exhibiting significant deficiencies in their clearance pattern review decreased compared to fiscal year 2021. Planned Corrective Action Treasury will continue updating the procedures pertaining to the verification processes of clearing patterns and will prioritize the examination of queries from SBI to ensure that Treasury data includes all required clearing patterns for review. Clearing Pattern Recertification is mandated by the federal government every five years. Internally, annual reviews of clearing patterns will be conducted to ensure adherence to the program's objectives. State agencies will continue to provide the necessary coding and date range information for the development of clearing patterns. Anticipated Completion Date Treasury will make updates to the procedures and complete the clearing pattern review by September 2023. Responsible Individual(s) Andrew Silva, Treasury

Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Organization?s documentation. In addition, there was no indication that a review was performed of the information submitted for one of the four months tested, which resulted in the reimbursement amount from the pass-through entity being more than the support maintained by the Organization for three of the 12 months and no documentation of the review for one of the months. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: Schedule meetings with 3rd party vendor to identify the significant rounding errors occurring. Develop an agreement on rounding procedures to be used by both parties ensuring reconciliation. Anticipated Completion Date: 12/31/23 ? Note- this system of reimbursement terminated on 3/31/23

Finding 2022-026 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Long-Term Care (LTC) Facility COVID-19 Testing Reimbursements Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will enhance written procedures to reflect the process in place to ensure that LTC facility COVID-19 testing reimbursement requests are reasonable and appropriate. MDHHS will also improve documentation of the procedures performed as part of the current process. Anticipated Completion Date MDHHS expects completion of the written procedures and improved documentation going forward by June 15, 2023. MDHHS expects to process all remaining payments for costs incurred during the PHE by September 30, 2023. Responsible Individual(s) Shannah Havens, MDHHS

Airport Improvement Program ? Assistance Listing No. 20.106 Recommendation: We recommend all reports submitted to grantors be reviewed by knowledgeable personnel before submittal. A copy of the review, approval, approval date, and submittal date should be maintained as evidence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Staff will ensure that all reports submitted to grantors be reviewed by knowledgeable personnel before submitting. A copy of the review, approval, approval date, and submittal date will be maintained as evidence. Name(s) of the contact person(s) responsible for corrective action: Budget and Grants Director Johnathan Blanco. Planned completion date for corrective action plan: September 30, 2023.

Corrective Action Plan Year Ended December 31, 2022 Name and Number of Project: Cedar Lane Senior Living Community I, Inc. HUD Project Number 052-11225 Auditor/Audit Firm: PKF O?Connor Davies LLP Audit Period: December 31, 2022 Finding 2022-001 ? Use of Project Funds Federal Assistance Listing Number Name of Federal Programs 14.155 Mortgage Insurance for the purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Project-Based Cluster Section 8 Housing Assistance Payments Program A. Comments on Finding and Recommendations Recommendation ? We recommend that management reconcile and repay intercompany activity in a timely manner. B. Actions Taken or Planned The Entity has instituted policies and procedures to reconcile and rectify intercompany activities timely and is working with their HUD representative to consolidate their Federal Programs which will rectify the issue and simplify the intercompany activity. C. Status of Corrective Action on Prior Findings N/A Eric Golden, President and CEO Cedar Lane Senior Living Community I, Inc.

RE: HELP HOUSING FOR THE DISABLED, INC. 26900 Euclid Avenue Euclid, Ohio 44132 SUBJECT: Corrective Action Plan 042EH430 HELP HOUSING FOR THE DISABLED Reporting Period Ending Date ? June 30, 2022 Finding 2022-001 CFDA: 14.157 Section 202 Direct Loan Criteria: Internal controls over compliance should be in place to ensure the deposit of surplus cash amounts into the residual receipts account occurs within ninety days after year end. Condition: A deficiency in internal control over compliance existed due to the prior year excess surplus cash amount not being deposited into the residual receipts account within ninety days after the end of the annual fiscal period for which the surplus cash was calculated. Recommendation: The Project should establish procedures to ensure that surplus cash is deposited within ninety days after the end of the annual fiscal period for which the surplus cash is calculated. CORRECTIVE ACTION: Management has agreed to implement the process of depositing surplus cash on the day the audited financial statements are issued. Thorough review of financial statement notes and conversations with audit team during the review process will establish the amount of funds to be deposited. Once this internal review is complete and audited statements are issued the internal management team will routinely make the required deposit and follow up by providing payment confirmation to the outside audit team. This accountability confirmation process will ensure that the deposit is made timely and routinely. Any questions regarding this plan should be directed to: Belinda Glavic Grassi MA, CPA Chief Financial Officer Help Housing for the Disabled, Inc. (216) 432-4810

The Organization has implemented a full review of the contracts at year end to make sure all expenses are assigned to a funder code in the accounting system. In additional, as a final control procedure, Accounting will run a final report for all contracts that have been identified as federal vs actual invoiced expenditures and further compared to what has been expensed per the financial statements and provide to the Chief Program Officer to compare and reconcile to the SEFA. 39

Finding 2022-001 Federal Agency Name: U.S. Department of State Program Name: Refugee Admissions - Reception and Placement CFDA # 19.510 Finding Summary: In connection with the audit procedures performed over the Refugee Admission - Reception and Placement program, we noted instances when indirect cost calculations included an insignificant amount of ineligible costs. Responsible Individuals: Rose Olivas, Contract Compliance Director and Dawn Miera, Finance Director Corrective Action Plan: Contract Compliance and Finance will meet every time we receive a new type of grant. The two teams will go over allowable costs and which costs are allowed to be applied to the de minimis rate. All applicable spreadsheets will be updated separately for each new contract and training for billing preparers and reviewers will be ongoing. Anticipated Completion Date: Ongoing

2022-003 Accuracy of Federal Reports Throughout the Single Audit process, management discovered that the pandemic caused issues concerning the organization of cash disbursement receipts. In lieu of this finding, management has decided to develop and implement the following procedures: 1. Management will develop a written policy and procedure for a cloud-based document saving subscription, that will be utilized to scan and to upload all invoices/statements/bills/receipts into specific grantor, vendor, and program folders. 2. Management will create a unique email address strictly used as a landing site for pay request, vendor invoices, and receipts. 3. Management will train all current staff and provide training to new hires as a part of orientation in use of the system. 4. Management will monitor the site on a weekly basis, at which time request, payments and receipts will be allocated to the appropriate budget lines.

Compliance requirement ? Reporting Institutional Comments on Findings and Recommendations: 1. The institution does not concur with the auditor finding because the institution strictly followed and used the recommended HEERF methodology and reporting guidelines to prepare the quarterly and annual reports. Since the institution used the reimbursement method, the drawdown were the actual expenditures/costs incurred and requested for reimbursement. The HEERF reporting requirement does not make any indication nor reference to GAAP. The Institutional aid portion expenditures were supported by the proper invoice or check. The evidence was available to the auditors. 2. The institution concurs with the auditor finding. The institution inadvertently, did not include a line item from one of the quarterly reports. The period to make corrections was closed and we sent an e-mail to the department to amend this annual report. 3. The institution concurs with the auditor finding. The annual report contains detail statistical information that not necessarily is supported by our institutions data base and programs. As the ED expressed, this information was unique and challenging, and accordingly, the institution made some reasonable estimates and derivatives in the information provided. As you may notice in the referenced table by the auditor, the differences were minimal. 4. a. The institution concurs with the auditor finding on the difference in Item #5 of the quarterly report. The institution will accordingly amend the report. b. The institution does not concur with the auditor finding on the timely and accurate reporting in publicly posting the quarterly Student Aid Portion. The four quarterly reports were timely submitted with an e-mail to the HEERF reporting staff and timely posted in the institution web page as required by the HEERF reporting instructions. The reports were further reviewed by an officer of the Department of Education (ED). The ED expressed that this information may be unique and challenging to an audit, and indicated that for these public reporting requirements, the auditors may accept as evidence of compliance, contemporarily produced e-mails, webmaster logs, or other relevant documentation establishing good-faith indication that the institution posted the required information at approximately the timelines established by the public reporting requirements. Copy of the e-mails were available to the auditors as evidence of compliance. ED understands that this information may be unique and challenging to audit, particularly because auditors are asked to verify information posted on a webpage which may not be accessible during audit fieldwork. For these public reporting requirements, auditors may accept as evidence of compliance, contemporarily produced emails, webmaster logs, or other relevant documentation establishing a good-faith indication that the institution posted the required information at approximately the timelines established by the public reporting requirements (HEERF Grant Program Auditing Requirements, General Requirements and Information - All HEERF Grantees). 5. The institution does not concur with the auditor finding because the referenced payment was made in accordance with the Institution's fund distribution and the student financial needs, among other factors, at the time of the evaluation and distribution of the funds. The student financial circumstances may have change after the distribution and payments of the financial aid. Additionally, this is an immaterial amount as compare to the total amount of the funds distributed ant the quantity of students served (1 out of 460). Actions Taken or Planned: The institution understands that no further is needed or required.

Compliance requirement ? Cash Management Institutional Comments on Findings and Recommendations: 1. The institution does concur with the auditor finding. The institution is revising the accounts' payable structure to ensure future payments falls within the allowed elapsed time. Actions Taken or Planned: The institution is revising the accounts' payable structure to ensure future payments falls within the allowed elapsed time.

1. The institution does not agree, nor concurs, with the auditors on this finding because the institution used the reimbursement payment method. This method was the preferred one when the non-federal entity, as our institution, cannot meet the requirements in 2 CFR, section 200.305(b)(1) for advance payment and the federal awarding agency sets a specific condition for use of the reimbursement. Title 2 of the CFR Part 200.305(b)(1), establish among others: "The non-Federal entity must be paid in advance, provided it maintains or demonstrates the willingness to maintain both written procedures that minimize the time elapsing between the transfer of funds and disbursement by the non-Federal entity, and financial management systems that meet the standards for fund control and accountability as established in this part". Furthermore, 2 CFR Part 200.305(b)(3) states: "Reimbursement is the preferred method when the requirements in this paragraph (b) cannot be met, when the Federal awarding agency sets a specific condition per ? 200.208, or when the non-Federal entity requests payment by reimbursement. " Since our institution was not able to meet 2 CFR, section 200.305(b)(1), and the HEERF guidelines has specific condition on how to use the funds; we choose the reimbursement method in the execution of the funds. Our institution adopted all HEERF instructions and guidelines as their policies to comply with the HEERF requirements, in addition to the CFR's regulations. Below some of the guidelines, instructions ad FAQs we adopted followed" a. Higher Education Emergency Relief Fund III, Frequently Asked Questions, American Rescue Plan Act of 2021, Published May 11, 2021, Questions 7 and 11 updated May 24, 2021, Question 36 updated September 30, 2021 b. US Department of Education, Notice of Proposed Institutional Eligibility Criteria, February 25, 2021 c. Federal Register Notice of Interpretation (NOI), regarding Period of Allowable Expenses for Funds Administered under HEERF Program, March 22, 2021 d. HEERF Notice of Interpretation for Period of Allowable HEERF Expenses (March 22, 2021) e. HEERF Lost Revenue FAQs (March 19, 2021) f. HEERF Period of Allowable Expenses Grant Records Notice (March 19, 2021) g. HEERF Grant Program Auditing Requirements (March 8, 2021) h. CRRSAA HEERF II Section 314(a)(1) Frequently Asked Questions (Published January 14, 2021 and Updated: March 19, 2021) i. CRRSAA HEERF II Section 314(a)(2) Frequently Asked Questions (January 14, 2021) j. CRRSAA HEERF II Section 314(a)(4) Frequently Asked Questions (Published January 14, 2021 and Updated: March 19, 2021) k. HEERF I and HEERF II Comparison Fact Sheet (Published January 14, 2021 and Updated: March 19, 2021) 1. HEERF Lost Revenue FAQ's, Published March 19, 2021 m. HEERF II, Public and Private Nonprofit Institution (a)(2) Programs (CFDAs 84.425K), FAQ's, Published January 14, 2021 n. HEERF II, Proprietary Institution Grant Funds for Students (CFDA 84.425Q) ((a)(4) Program), FAQ's Published January 14, 2021, Updated March 19, 2021. o. HEERF II, Public and Private Nonprofit Institution (a)(1) Programs (CFDA 84.425E and 84.425F), FAQ's Published January 14, 2021, Updated March 19, 2021. p. CAREST Act HEERF Rollup FAQs (issued October 14, 2020 and revised November 20, 2020) q. CARES Act HEERF Round 3 FAQs (Issued October 14, 2020 and revised November 20, 2020) r. CARES Act HEERF Supplemental FAQs (Issued June 30, 2020 and revised September 08, 2020) s. CARES Act HEERF Student FAQ's (Issued May 15, 2020) t. CARES Act HEERF Institutional Portion under Section 18004(a)(1) and 18004(c) FAQ's, (Issued April 9, 2020) u. CARES Act HEERF Emergency Financial Aid Grants to Students under Section 18004(a)(1) and 18004(c) FAQ's, (Issued April 9, 2020) v. CARES Act HEERF Institutional Portion under Section 18004(a)(1) and 18004(c) FAQ's, Issued April 9, 2020 w. COVID-19 FAQ's for Title III, IV, V and VII Grantees, June 16, 2020 x. COVID-19 Letter to HEP Grantees on Flexibilities Available Under CARES Act Section 3518, July 1, 2020 2. The institution does not agree, nor concurs, with the auditors on this finding because, as we mention in number 1 above, the institution adopted and followed the federal award and HEERF guidelines in the execution of the funds. The HEER funds were provided during the special national emergency caused by COVID-19. The DOE and HEERF officials issued many written guidelines, instructions, and FAQ's (Frequently Asked Questions) documents, due to the nature and novel of the national emergency situation. The institution adopted, followed, and relied on the many referenced guidelines and exercise extreme judgment to ensure compliance with the federal requirements and use of the funds. The institution belief this referenced guidelines and instruction were very specific and sufficient to execute the use of the funds. All direct charges to federal awards were for allowable costs under the guidelines and instructions from the Department of Education. Some of the allowable costs were verified and validated by an officer of the Department of Education and reviewed by an independent consultant. 3. The institution concurs with the auditor finding. Actions Taken or Planned: The institution begins in addition to the adopted HEERF guidelines, instructions, and CFRs; to develop additional procurement policies and are in the process of completing those policies. The institution expects to have those completed by May 31, 2023.

The Organization will continue to implement the following measures to ensure compliance with the sliding fee discount program, and consistently assess patient income and family size. The Organization will continue to provide on-going training to clinic staff who evaluate the sliding fee application at its clinic locations. The training consists of reviewing sliding fee program policies and procedures along with all applicable patient forms, sliding fee scale, and patient eligibility. The following quality control measures to ensure compliance will be implemented: 1. Front Desk Peer Review of sliding fee application and verification of patient income and family size. 2. Enhance training materials to support Front Desk Staff with assessing sliding fee applications. 3. Quarterly feedback to Front Desk Staff based on sliding fee applications reviewed. Person Responsible: Kristopher D. Zuniga Position of Responsible Party: Chief Financial Officer Anticipated Completion: April 30, 2023

Area: Cash Management Views of Auditee and Planned Corrective Action: PIU agrees with the finding. PIU will review the requirements of the Uniform Guidance and understand the cash management principal requirements. Once this is done, PIU will implement procedures and update the Business Office Manual. Anticipated Completion Date: May 31, 2023 Name of Contact Person and Title: Celia Atoigue, Director of Finance

2022-001 Significant Deficiency: Internal control over maintenance of documentation of procedures performed Planned Corrective Action: Management will implement additional procedures to maintain documentation of the review and approval of expenses allocated to federal programs. Anticipated Completion Date: March 31, 2023 Responsible Party: Hasan Suzuk (Executive Director)

Finding 2022-004 ? Timely Deposit of Surplus Cash A. Comments on Finding and Recommendations Recommendation ? We recommend that management ensures the surplus cash deposit is done timely in the future. B. Actions Taken or Planned Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Going forward our focus will be to work with the auditor and owner to get the audits finalized earlier so adequate time is left for the deposits to be made. In instances where the final is not going to be issued and allow enough time, the deposit will be made based on the reviewed draft. C. Status of Corrective Action on Prior Findings Finding 2017-001 et seq. remains uncleared.

Finding 2022-003 ? Residual Receipts A. Comments on Finding and Recommendations Recommendation ? We recommend that management evaluate its process and implement policies to mitigate the chances of withdrawing funds from the residual receipts without HUD approval. B. Actions Taken or Planned Auditee agrees with this finding and has taken steps to prevent this from occurring in the future. A new Executive Director has taken over the responsibility for withdrawing funds as well as oversight from the Board of Directors. Auditee has been in discussion with HUD and will submit a letter with justification of withdrawals upon receipt of the notice of violation as requested from HUD. If accepted by HUD, this will clear this finding for the amount transferred during this fiscal year. C. Status of Corrective Action on Prior Findings Finding 2021-004 is uncleared.

Finding 2022-014 U.S. Department of Health and Human Services AL No. 93.568 Total Low-Income Home Energy Assistance Significant Deficiency over Eligibility Repeat Finding: No Auditee?s Corrective Action Plan: The Office of Home and Energy Programs (OHEP) bureau of The Mayors Office of Children and Family Success (MOCFS) agency has implemented a plan to locate needed files from previous and current fiscal years. The agency has implemented a scanning and uploading Standard Operating Procedure (SOP) that requires each case file to be digitally attached to its application and supporting documents. This will remedy this finding in its totality. Contact Person: OHEP Director ? Rigel Moore Completion Date: March 10, 2023

Personnel to Effect Change: Airport Director (Lance Vanderbeck) and Capital Projects & Grant Accountant (Linda Wertman) City Response and Corrective Action Plan: The Airport Director will initially review all Request for Advance or Reimbursement and supporting documentation by the contracted supervisor of the project. The Capital Projects Accountant will then also review the Request for Advance or Reimbursement and supporting documentation before submission for reimbursement. Anticipated Completion Date(s): June 30, 2023

Finding 2022-002 Programs: All Material Weakness over Financial Reporting Repeat Finding: Yes Auditee?s Corrective Action Plan: The City has purchased Workday, an Enterprise Resource Planning (ERP) system, and implemented the software with the assistance of Accenture consultants. Although Workday went ?live? as of August 2022, the City is currently working to refine the software and fully utilize its functionality. The new system includes improved financial reporting and functionality. Specific improvements available are: ? Allocations which were calculated manually, such as overhead allocations, are being automatically calculated and created in Workday. ? There has been an extensive review of the chart of accounts, including the use of hierarchies, which more closely align the financial and budgetary reporting needs of the City. ? The City will be using ?control? accounts for accounts receivable and accounts payable, which requires the subsidiary systems to reconcile to the general ledger. ? The City will be using multi-book accounting, which will allow for GAAP entries to be entered into a separate ledger. ? The City is purchasing Workiva, a cloud-based software, which will interface with Workday and update the Annual Comprehensive Financial Report (ACFR) document. It will provide an audit trail for changes to the ACFR document. This implementation is slated to begin in June 2023, but full implementation may not occur until fiscal year 2024. Contact Person: Michael Moiseyev, Chief Financial Officer, Baltimore City Completion Date: December 2024

Finding 2022-021 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness over Cash Management Repeat Finding: Yes Auditee?s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD's fiscal team enters the drawdown request into the Federal Payment Management System (PMX). Baltimore City's treasury department is notified. After BCHD's fiscal team enters the request into PMX, there is no control over the timing of when the funds are received and when the funds are posted to the GL, as this is the responsibility of the City's Treasury department. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-020 U.S. Department of Health and Human Services AL No. 93.914 HIV Prevention Activities Health Department Based Material Weakness over Cash Management Repeat Finding: Yes Auditee?s Corrective Action Plan: The process for requesting drawdowns begins with the fiscal team managing the grant. A member of BCHD's fiscal team enters the drawdown request into the Federal Payment Management System (PMX). Baltimore City's treasury department is notified. After BCHD's fiscal team enters the request into PMX, there is no control over the timing of when the funds are received and when the funds are posted to the GL, as this is the responsibility of the City's Treasury department. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023