Corrective Action Plans

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Federal Financial Assistance Listing/CFDA #10.766 Program Name: Communities Facilities Loans and Grants Cluster Compliance Requirement: Special Tests - Set aside of a reserve amount backed by the full faith and credit of the United States Finding Summary: Management maintained a reserve account in a pooled investment fund which includes marketable securities backed by the full faith and credit of the United States, but based on the portfolio mix of the investment pool, was not adequate to cover the entire reserve requirement. In addition, we had not established a separate bookkeeping account and/or a separate bank account. Responsible Individuals: Bryan Slaba, Chief Executive Officer Corrective Action Plan: A separate savings account backed by the full faith and credit of the United States and bookkeeping account will be established. Anticipated Completion Date: 12/31/2022

Views of Responsible Officials and Planned Corrective Actions: During this fiscal year, management experienced a turnover in the financial functions as well as new staffing and a new Director of Finance. In addition, the organization changed drastically in size and scope, thereby going through a substantial adjustment period. Corrective actions: 1. Management hired an Assistant Director of Finance in order to share the workload, add an extra layer of review for all documentation, account reconciliations, finance staff oversight, and banking functions. 2. Management hired an Associate VP of the Programs and Operations Division which has oversight over the Finance Department. 3. Monthly reconciliations and reviews and approval processes have been put in place to ensure proper recording of all expenses, revenues, and accompanying Federal Fund drawdowns and AP payments. 4. The federal department this occurred within was notified and the funds were spent on costs incurred in the next fiscal year.

Research and Development Assistance Listing No Various Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs. Departments are entrusted with considerable latitude in determining needs and purchasing products, services, and technical support required to perform educational and outreach duties as well as research with sponsored projects. Because of this, it is reasonable for departments to verify the delivery of these purchases, establish the quality and quantity of the items, and begin the process of paying the corresponding invoices. Delays in the workflow sometimes occur due to valid reasons, and other times are due to a breakdown in the administrative process. Information will be shared with departments regarding delays in invoice processing. This will include sharing the information with academic and research heads in the colleges that processing of invoices must occur quickly, discrepancies affecting the expedient payments will be noted on invoices, and explanations will be recorded. Name(s) of the contact person(s) responsible for corrective action: Robert Dixon, Director of Grants and Contracts Financial Administration Planned completion date for corrective action plan: Spring 2023

MATERIAL WEAKNESS 2022-008 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Cash Management Condition During testing, it was discovered that funding was drawn down and not disbursed within the required timeframes. Recommendation We recommend that the College review its reconciliation process and implement controls to ensure that funding is disbursed within the correct timeframe after being drawn down. Actions Taken As of March 23, 2023, federal funding will only be drawn on a reimbursement basis in order to ensure that funds are disbursed within the required cash management timeframe.

2022-004 Student Financial Assistance Program Cluster ? Title IV ? Cash Management and Special Tests and Provisions ? COD Reconciliation Condition During testing, it was discovered that Pell and Federal Supplemental Educational Opportunity Grant (FSEOG) funds were drawn down and not disbursed within they required timeframe. In addition, funds were drawn down from Direct Loan sources when they were meant to be drawn from alternative sources. Recommendation We recommend that the institution review its reconciliation process and implement controls to ensure that funding is drawn from correct sources and disbursed within three business days of receipt. Actions Taken Upon request by COD, a repayment of Direct Loan funds was made in order to correct the variance that they noted which was caused by the Alternative Loans that were drawn from the incorrect source. In addition, as of March 23, 2023, a new draw-down process will be implemented. Changes include not drawing down any aid until it is approved by the Director of Financial Aid, confirmation throughout the draw-down process, and better communication between the Accounts Payable/Financial Aid Specialist, Accounts Receivable and the Director of Financial Aid.

October 26, 2022 Section III - Federal Award Finding 2022-001: Excess Fund Balance Marysville Public Schools? Proposed Corrective Action: The District is in the process of preparing a spend-down plan to submit to the Michigan Department of Education (MDE). Upon approval by MDE, the District will spend School Lunch excess cash reserves to reduce fund balance to comply with 7 CFR 210.19. Sincerely, Jennifer McKay Director of Business & Finance

Finding 2022-002 Capital Caring Health and Related Entities will modify and enhance their processes and review procedures surrounding grant submissions for reimbursement to ensure that the same expense is not used as the basis for multiple grant submissions. Responsible party: Joe Murray, CFO Anticipated Completion Date: December 31, 2023

Name of Responsible Individuals: Matthew Cooper, VP of Student Financial Services and Tracy Price, Executive Director of Accounting Corrective Action: Liberty acknowledges that there were two instances in which Federal Work Study funds were overdrawn for longer than the permissible time-frames thus creating a scenario in which cash management rules were not followed. While Liberty diligently manages the draw and disbursement of funds, some aspects are dependent on manual data entry. For the two instances in which funds were overdrawn, a data entry error was made which did not include a draw that was completed for 20-21 Federal Work Study that were to be used for 21-22. In response, the Director of Financial Aid Compliance and the Assistant Director of Financial Aid Compliance will implement an additional quality control process in which all campus-based fund draws done through Accounting are manually reviewed for accuracy within 24 hours of the initial draw. This will allow time for any corrections within the allowable time-frames. In addition, whenever funds are carried forward from one aid year to the next, workbooks for both aid years will be presented and reviewed. Anticipated Completion Date: October 31, 2022

Management should implement procedures that client income is verified annually and documentation maintained within the client file. Grant requirements should be reviewed and documented annually with department leads and intake coordinators.

Finding 2022-002 ? Coronavirus State and Local Fiscal Recovery Funds ? Allowable Cost/Cost Principle (Significant Deficiency) Management?s Response or Department?s Response Management agrees with the finding and recommendation. Views of Responsible Officials and Corrective Action The County issued reimbursement based on actuals. The voucher created by the department was for $494,988 and the County reimbursed this amount back to the department. ARPA over claiming started with the payment of the supplemental September 21 invoice that was miscalculated by 23 reducing the Revised September 21 invoice with the Original August 21 invoice, instead of the Original September 21 invoice. This miscalculation was not immediately recognized when the supplemental payment was paid in November 2021. The need to return funds to ARPA was recognized after the DSS Admin completed a reconciliation at end of 2022. This was communicated to DSS Finance in January 2023, thus the discussion between DSS Finance and DSS Admin to finalize the amount. DSS is already in the process of finalizing the amount that needs to be returned to the County ARPA funds. For the corrective action, DSS will be submitting a memo signed by the DSS Director addressed to the CAO for the return of $376,777 to the County ARPA funds. Anticipated Completion Date May 2023 Contact Information of Responsible Official Name: Grace Geo Title: DSS Finance Division Chief Phone: 559-600-2866

Individuals Responsible for Corrective Action Plan: Jason Penegar, Vice President - Controller Nisha Eberhart, Accounting Manager Blanca Ramos, Sr. Manager, Compensation and Benefits Accounting Corrective Action Plan: Management will implement a new quality review process to ensure that correct default fund codes are assigned to staff for the DOL WPY grant. In addition, Management will implement a complete oversight review of all grant time charges in advance of the execution of a drawdown of DOL funds. Anticipated Completion Date: June 30, 2023

Finding 2022-001 ? Major Federal Award Programs Audit a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: During the years ended July 31, 2019, 2020, 2021 and 2022, management did not make the required residual receipts reserve deposit in the amount of $81,489 within 90 days of year ended July 31, 2018, as required by HUD. The residual receipts amount has not been deposited as of the date of this report. b. Action(s) Taken or Planned on the Finding: The residual receipt account will be funded when funds are available.

We are in receipt of the Finding to be Reported by Government Auditing Standards, regarding internal control over compliance and material noncompliance. Management agrees with the finding. The Hospital did not reduce COVID related expenses by amounts reimbursed through patient service revenue in the expense section of the HHS, Provider Relief Funds report. Policy and procedures over accounting of these grant funds will be modified to ensure expenses are reduced by applicable revenues before submission of Provider Relief Fund reports. Caryn Hawthorne, Vice President of Finance/Chief Financial Officer, will submit Period 4 HHS reporting by March 31, 2023. The Period 4 reporting will include lost revenue not previously reported offset by the reimbursed expenses from Period 2.

2022-002 Insurance payments not fully deducted from FEMA funding Cluster: Not applicable Grantor: U.S. Department of Homeland Security Award Names: COVID-19 Disaster Grants - Public Assistance (Presidentially Declared Disasters) Award Year: January 20, 2020 ? July 1, 2022 Award Number: 4496DR-MA Assistance Listing Numbers: 97.036 Pass through entity: Massachusetts Emergency Management Agency (?MEMA?) Management?s Views and Corrective Action Plan Management?s View Management agrees with the Auditors? assessment of the System?s internal controls over compliance specifically related to the estimated third-party insurance deduction calculated for COVID-19 PCR tests administered between March 1, 2020 and June 30, 2021 included with one of the eight FEMA projects obligated during fiscal year 2022. The System calculated the third-party insurance deduction by developing an average third-party insurance payment rate per test. A formula error was present in this calculation. Corrective Action Plan Management will create a formal review process whereby third-party insurance deductions will be verified by an individual other than the preparer as part of the FEMA project workbook submission procedures. As of the date of this report, Management has informed MEMA of the error and discussed with MEMA an alternate methodology to calculate the third-party payment deduction. As a result of the alternate methodology identified, the amount owed back to FEMA in the form of an under-estimated medical payment deduction will be substantially less than the $218,000 in questioned costs noted. These monies will be refunded to MEMA as soon as all parties agree on the amount owed. Responsible Official: Michael Knoll, Executive Director, Financial Planning & Analysis Expected Completion Date: September 30, 2023

3/30/2023 Grant Thornton 10 Almaden Blvd., Suite 800 San Jose, CA 95113 RE: Management?s Corrective Action Plan in Response to Fiscal Year 2022 Item 2022-001 ? Significant Deficiency ? Reporting: Special Reporting 1. Contact person: Syble Allen, Controller 2. Plan of action: The Controller, Director of Institutional Research and Student Accounts Director will all be given copies of the prepared FISAP for review and comment at least 3 days prior to FISAP submission each October 1. 3. Anticipated completion date: This new process will be implemented April 1, 2023.

CORRECTIVE ACTION PLAN December 27, 2022 Valley Community Services Board respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2022 The findings from the June 30, 2022, Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT If the Federal Audit Clearinghouse has questions regarding this plan, please call Devin Foster, Director of Finance, or Dereck Criner, Director of Human Resources and Interim Chief Financial Officer during the audit period, at (540) 887-3200. 2022-007: Emergency Solutions Grant Program - AL #14.231, Controls over reimbursements and program monitoring (Material Weakness) Condition: The Community Based Services Supervisor is the only person involved with submitting reimbursement requests and monitoring the budget and expenditures for the program. A separate review of reimbursement requests is not performed. The accounting department is not involved with managing the program budgets. Criteria: More than one staff person should be involved for accountability and monitoring of the program. Expenditures used to recognize revenue in accounting should correspond to expenses reimbursed or identified for federal and state award programs. Cause: With turnover in accounting staff during the year, items were not reviewed or monitored for the program. Effect: Errors in reporting or misuse of funding could potentially go undetected due to lack of separation of functions and proper oversight. Recommendation: We recommend implementing internal controls over the reimbursement requests and budget monitoring process by involving another person prior to submitting the request. Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or Assistant Director or accounting. Views of Responsible Officials and Planned Corrective Action: Effective February 2022, all requests for reimbursement under this program are submitted by the fund manager to the program's Assistant Director prior to submission to Accounting. Reimbursement filings are provided to Accounting in a timely manner and a fund reconciliation spreadsheet will be created to share with the fund manager and Assistant Director on a monthly basis. Additionally, Accounting now receives a copy of the submitted reimbursement requires and will be including a review of expenses, requests for reimbursement, and reimbursements received as part of the monthly reconciliation. 2022-008: Emergency Solutions Grant Program-AL# 14.231, Controls over cash management and reimbursement requests (Material Weakness) (Continued) Condition: Requests for reimbursement were not submitted timely, with multiple months submitted 80 days after the expenditure had incurred. Amounts recorded for revenue did not accurately reflect final requested reimbursement. Criteria: Reimbursements should be submitted timely and should be provided and reconciled to financial data in general ledger by accounting team. Differences should be resolved, and reimbursement received should ultimately reflect total program revenue in general ledger. Cause: With turnover in staff during the year, items were not always available timely. In addition, management was not always aware of reporting requirements or aware of activity under program reimbursements. Effect: Errors in reporting could ultimately lead to differences in financial accounting vs program activity. Accurate and timely reporting and requests can improve cash flows and ensure program is able to meet funding needs. Recommendation: Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or another individual in the finance department. These spreadsheets should ultimately identify amounts that were submitted for request for reimbursement and be recorded in the general ledger. Amounts recorded for revenue in the general ledger should agree between the two, with monthly or quarterly reconciliations performed to ensure financial reporting accurately reflects spending and reimbursement activity. Views of Responsible Officials and Planned Corrective Action: VCSB will amend the reconciliations process for CHERP to include a documented review and approval of all expenses, reimbursement requests, and reimbursements received. Additionally, the Accountant and Director of Finance are working with the program fund manager to submit requests for reimbursement in a more timely manner. Sincerely yours, Dereck Criner Director of Human Resources

CORRECTIVE ACTION PLAN December 27, 2022 Valley Community Services Board respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2022 The findings from the June 30, 2022, Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT If the Federal Audit Clearinghouse has questions regarding this plan, please call Devin Foster, Director of Finance, or Dereck Criner, Director of Human Resources and Interim Chief Financial Officer during the audit period, at (540) 887-3200. 2022-007: Emergency Solutions Grant Program - AL #14.231, Controls over reimbursements and program monitoring (Material Weakness) Condition: The Community Based Services Supervisor is the only person involved with submitting reimbursement requests and monitoring the budget and expenditures for the program. A separate review of reimbursement requests is not performed. The accounting department is not involved with managing the program budgets. Criteria: More than one staff person should be involved for accountability and monitoring of the program. Expenditures used to recognize revenue in accounting should correspond to expenses reimbursed or identified for federal and state award programs. Cause: With turnover in accounting staff during the year, items were not reviewed or monitored for the program. Effect: Errors in reporting or misuse of funding could potentially go undetected due to lack of separation of functions and proper oversight. Recommendation: We recommend implementing internal controls over the reimbursement requests and budget monitoring process by involving another person prior to submitting the request. Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or Assistant Director or accounting. Views of Responsible Officials and Planned Corrective Action: Effective February 2022, all requests for reimbursement under this program are submitted by the fund manager to the program's Assistant Director prior to submission to Accounting. Reimbursement filings are provided to Accounting in a timely manner and a fund reconciliation spreadsheet will be created to share with the fund manager and Assistant Director on a monthly basis. Additionally, Accounting now receives a copy of the submitted reimbursement requires and will be including a review of expenses, requests for reimbursement, and reimbursements received as part of the monthly reconciliation. 2022-008: Emergency Solutions Grant Program-AL# 14.231, Controls over cash management and reimbursement requests (Material Weakness) (Continued) Condition: Requests for reimbursement were not submitted timely, with multiple months submitted 80 days after the expenditure had incurred. Amounts recorded for revenue did not accurately reflect final requested reimbursement. Criteria: Reimbursements should be submitted timely and should be provided and reconciled to financial data in general ledger by accounting team. Differences should be resolved, and reimbursement received should ultimately reflect total program revenue in general ledger. Cause: With turnover in staff during the year, items were not always available timely. In addition, management was not always aware of reporting requirements or aware of activity under program reimbursements. Effect: Errors in reporting could ultimately lead to differences in financial accounting vs program activity. Accurate and timely reporting and requests can improve cash flows and ensure program is able to meet funding needs. Recommendation: Additionally, spreadsheets used to track grant awards and program expenditures should be reviewed by someone with an understanding of the program such as the Behavioral Health Director or another individual in the finance department. These spreadsheets should ultimately identify amounts that were submitted for request for reimbursement and be recorded in the general ledger. Amounts recorded for revenue in the general ledger should agree between the two, with monthly or quarterly reconciliations performed to ensure financial reporting accurately reflects spending and reimbursement activity. Views of Responsible Officials and Planned Corrective Action: VCSB will amend the reconciliations process for CHERP to include a documented review and approval of all expenses, reimbursement requests, and reimbursements received. Additionally, the Accountant and Director of Finance are working with the program fund manager to submit requests for reimbursement in a more timely manner. Sincerely yours, Dereck Criner Director of Human Resources

As a result of COVID-19 and the unanticipated school closure the Food Service Fund had an increase in funding that was unexpected. As a correction action the Superintendent, Business Manager and Food Service Director will meet on a quarterly basis to review the Food Service budget and monitor the spend down plan.

Item No. 2022-003 ? Cash Management and Reporting Material Noncompliance Material Weakness in Controls Over Compliance Responsible Party: Brian Lim Financial Services Specialist II HCSA Office of the Agency Director Corrective Action Plan: In meetings with the State, HCSA has clarified that encumbrances were submitted as part of the expenditure reporting and claiming and the State has expressed awareness of this reporting and claiming practice, but to date, HCSA has not been able to obtain documented confirmation that permitted reimbursing HCSA for encumbered amounts. HCSA will take measures to adjust monthly expenditure reports within the Spend Plan and include in the next soonest reporting and claim period actual expenditures, and revisit grant award provisions pertaining to reporting requirements to ensure that both the reports and the claims are prepared using the appropriate basis of accounting. HCSA will resolve with CDPH previously claimed encumbrances and ensure alignment with expenditure reporting requirements and claims for reimbursement requirements. Anticipated Implementation Date: June 30, 2024

Finding 2022-005: Material Weakness over Cash Management and Allowable Costs - Review of Cash Drawdowns Information on the Federal Program: Department of Human and Health - Center for Disease Control: Improving Epilepsy Programs, Services and Outcomes Through Partnerships. Finding: The Uniform Guidance requires organizations to establish internal controls to detect potential noncompliance. The Uniform Guidance also requires organizations who receive funds on a cost reimbursement basis to only draw down funds for allowable expenditures under the grant. Management has an established control in place, in that the VP of Finance reviews the calculation of expenditures not drawn down prior to the submission of the drawdown request. However, the control was ineffective to prevent and detect an erroneous expense journal entry, considered an unallowable expense and is an instance of noncompliance, from being included in the drawdown. Planned Corrective Action: A corrective action was taken and the Foundation returned the funds drawn down to the Department of Treasury. The Foundation has implemented an additional confirmation process where reimbursable expenses will be reviewed along with the draw down prior to draw down. This additional step will ensure that erroneous coding does not result in a funds draw down. Name and Person Responsible: Caro Marie Brown (Senior Director of Finance), June Nolan (Accounts Payable Accountant), and Lindey Camerata (Controller). Anticipated Completion Date: February 2023.

Purchase needed equipment

Views of Responsible Officials and Planned Correction Action: The Grants and Business Departments have worked together to create a process with appropriate checks and balances regarding moving expenses across individual grants and major funds. This process will consist of multiple levels of approval and specific documentation. Any entries will be processed in a timely manner and all expenditure reports will be checked for errors monthly. This process will ensure that expenditure reports are accurate at the time they are submitted for reimbursement.

Views of Responsible Officials and Planned Correction Action: The Grants Department was approved by the Nevada Department of Education to submit RFRs on a quarterly basis in FY23. The Grants Department has followed this approval and submitted all requests by the 15th day of the month following the quarter-end.

Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Chief Financial Officer (CFO) understands the importance of recording all revenue and deferred revenue to ensure accurate financial accounting and reporting. The Organization has acquired an accounts receivable module for their accounting software to record accounts receivable monthly. The CFO will be reviewing financial records to make sure all revenue and elimination of intercompany transactions are recorded.

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable completion date: June 1, 2023 Responsible Party: Tanya DeWolf, Director of Refugee Services