Corrective Action Plans

Subject: Corrective Action Plan For: Finding 2022-010 Cook County Health would like to respond to the finding related to the Provider Relief Fund {PRF) Phase 2 Reporting. The FY'22 SEFA amount (including both lost revenues and expenditures) for the HRSA PRF Phase 2 Reporting period was $31,163,323.35. Cause: The cause of this finding resulted from a misunderstanding of the expense data that was rolling/ inputted in the HRSA portal. The Unreimbursed Expenses line should have been inputted as Other PRF Expenses. CCH Management has instituted the following Corrective Action Plan (CAP) to prevent future occurrence. Corrective Action Plan: To ensure accurate data is reported, CCH has implemented the following corrective action plan: ? Any future HRSA- PRF Audit Portal data submission will require multiple reviews. The review will be led by CCH Finance's Associate Chief Financial Officer to ensure the report is accurate and complete prior to submission. Status - Phase 4 PRF Reporting was reviewed on March 28th, 2023, by the CFO and ACFO prior to submission. ? To buttress this CAP, CCH has created a dedicated GL account code to track all PRF activities - lost revenue, cash disbursed, and expenses incurred. Fully Implemented since - (August 30th, 2022) ? A recurring monthly reconciliation meeting has been instituted to track lost revenues, and expenses that were paid with PRF and not through any other type of assistance. Recurring Monthly Reconciliation Leader- Scott Spencer, Associate Chief Financial Officer. Please note that CCH has not received any PRF funding since January 2022.

Findings 2022 ? 002 Emergency Solutions Grant (ESG) Program, Federal Assistance Listing #14.231 Corrective Action Plan: Last year, the ESG program was monitored by the U.S. Department of Housing and Urban Development (HUD) local Office. This year, the ESG-Coronavirus (CV) program will be monitored by HUD. The local HUD office is currently working with DPD staff in various technical assistance workshop to prep for an upcoming session. These meetings have occurred since April 2023. At HUD?s request, DPD rewrote various policies and procedures. We are still awaiting HUD?s final approval on the recommended policies and procedures revisions. DPD will be using the revised policies and procedures to monitoring concerns going forward. ESG has a complicated billing structure which includes five (5) different spending areas from which a subrecipient can choose for payment. Unfortunately, the ESG and ESG-CV program includes one (1) dedicated staff person and support from the Deputy. This complicated billing structure forces DPD, to provide an extensive amount of technical assistance to various subrecipients due to incorrect invoice submissions. Many of the subrecipients are understaffed and lack the capacity to bill properly. On various occasions, DPD staff has spent a considerable amount of time assisting subrecipients with preparing request for reimbursements. The amount of technical assistance dedicated towards these efforts will be reduced as a result of ESG ending in December 2023 and a new grant cycle beginning in January 2024. ESG-CV will close permanently in September 2023. Recommendation/corrective action planning will be taken on future grant awards that may have similar compliance requirements. DPD plans to hire new staff to expedite the payment process as well as to provide technical assistance to our subrecipients. With ESG-CV ending in September 2023 and new staff on board, this should reduce the amount of time for processing payment to DPD subrecipients.

The District concurs with the finding. The District will implement procedures to ensure compliance with the allowability requirements.

Comments on the Finding and Each Recommendation: The required deposit of $66,982, per the December 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the Residual Receipts Fund within 90 days of fiscal year end. The Regulatory Agreement requires Surplus Cash, as defined by HUD, to be deposited into a separate Residual Receipts Fund within 90 days of fiscal year end. As a result, the Corporation was not in compliance with the Regulatory Agreement. Management should monitor the Surplus Cash position and make required deposits to the Residual Receipts Fund within 90 days of fiscal year end. Action(s) taken or planned on the finding: Management deposited the $66,982 to the Residual Receipts Fund on May 13, 2022. No further action is required.

Finding 2022-001 - Special Tests and Provisions, RAD Replacement Reserve - Significant Deficiency, CFDA #14.182 Corrective Action Plan: Will full fund the R4R account in 2023 and going forward as indicated by HUD. Person Responsible: Jennifer Fralish Anticipated Completion Date: YE 2023 and beyond

2022-003 Cash Management Material Noncompliance Cash Management Material Weakness in Internal Control over Compliance U.S. Department of Health and Human Services Passed-through the Arizona Department of Economic Security Refugee and Entrant Assistance State Administered Federal Financial Assistance Listing/CFDA #93.566; ADES18-191650; October 1, 2020 to September 30, 2021 and October 1, 2021 to September 30, 2022 Condition: Eide Bailly LLP (EB) noted that four out of four draw requests did not have adequate support for the class hours included. Management?s Response and Corrective Action Plan: ? Monthly Attendance Report are completed by data specialist using individual teachers? daily rosters. ? The Monthly Attendance Reports are verified by the program manager and corrected if any mistakes are identified. ? Monthly invoices are reviewed, prior to submission, with the Department Manager for additional verification and approval. ? After the student attendance has been reviewed by Program Manager and verified by the Department Manager, a review log is signed off by both the Program Manager and the Department Manager. ? Any changes to either the attendance logs or monthly student attendance will only be made with the authorization of the department manager after data has been verified, with an explanation of why that was needed. ? After the appropriate verifications have taken place, the Program Manager creates the monthly invoice, they will maintain and verify documentation for the student attendance hours reflected on the invoice. ? Management will continue to discuss and explore ways to strengthen our current internal controls, including, purchasing tracking software and/or the creation of a google form/document. ? Management will routinely review and consider any needed modifications to or implementation of new policies and procedures that would strengthen internal controls surrounding the invoicing process, record-keeping, and the management thereof. Contact Person: Jose J. Vaquera, VP of Client Services Anticipated Completion Date: May 15, 2023

The District will develop and implement appropriate controls to ensure accurate and timely reporting of meals served. Management will review the controls put in place on a bi-monthly basis and make any necessary changes if determined necessary. This finding will be resolved as of the date of this report.

Comments on the Finding and Each Recommendation: The required deposit of $15,276, per the July 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the residual receipts fund within 90 days of fiscal year end. The Regulatory Agreement requires Surplus Cash, as defined by HUD, to be deposited into a separate residual receipts fund within 90 days of the fiscal year end. The Corporation was not in compliance with the Regulatory Agreement. Management should monitor the Surplus Cash position and make required deposits to the residual receipts fund within 90 days of fiscal year end. Action(s) Taken and Planned on the Finding: Management deposited the $15,276 to the residual receipts fund on May 31, 2022. No further action is required.

2022-005 Allegations of Fraud Contact: Marusya Lazo Title: Vice President Finance Phone Number: 202 235 1880 Estimated Completion Date ? ongoing Corrective Action PSI continuously manages fraud risk through combination of preventative, detective and monitoring controls, and reinforces PSI?s expectations regarding ethical behavior through training and communications. PSI will continue to proactively report and investigate allegations of fraud and to raise awareness of the actions to be taken when there is s suspicion of fraud. PSI Global Internal Audit and Investigations team will continue to share lessons learned from the work performed and. Given the challenging operating environments in which PSI implements its programs, there is an ongoing risk of fraud, which PSI will continue to monitor, investigate, and mitigate.

2022-004 ? Education Stabilization Fund ? Prevailing wage rate requirements Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborers must be paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL). Nonfederal entities shall include in their contracts, subject to wage rate requirements, a provision that the contractor or subcontractor comply with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the District weekly payrolls and a statement of compliance (certified payrolls). Condition: There was one Education Stabilization Fund construction project performed by a subcontractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $263,826. There was not a prevailing wage clause in the contract and certified payrolls were not received. Cause: The District was not aware that wage rate requirements applied to the construction project until after it was completed. The District did verify that prevailing wage rates were paid by the contractor during the project; however, they did not obtain certified payrolls. Effect: A reimbursement request was made for expenditures that did not comply with wage rate requirements. Questioned Costs: $263,826 Auditor?s Recommendation: Establish controls to comply with wage rate requirements related to the Education Stabilization Fund. Grantee Response: The District will comply with the wage rate requirements for the Education Stabilization Fund going forward. Contact Person: Brian Zaleski Anticipated Completion: June 30, 2023

Name of Contact Person: Samuel A. Jones, President, Amurcon Realty Co., Managing Agent Corrective Action: Residual receipts were not remitted to the residual receipts account in a timely manner. Residual receipts are required to be remitted within 60 days of year-end. In order to avoid this issue in the future, surplus cash will be calculated prior to the audit. Proposed Completion Date: This plan was implemented on September 30, 2022, and will be used for all audits going forward.

Name of Contact Person: Samuel A. Jones, President, Amurcon Realty Co., Managing Agent Corrective Action: Residual receipts were not remitted to the residual receipts account in a timely manner. Residual receipts are required to be remitted within 60 days of year-end. In order to avoid this issue in the future, surplus cash will be calculated prior to the audit. Proposed Completion Date: This plan was implemented on September 30, 2022, and will be used for all audits going forward.

Federal Grants Management/Financial Management System Recommendation: The District will assess its financial management systems and related internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: District personnel will assess existing policies and procedures and determine where new policies should be created or amended and communicate these policies to Administration and employees. Names of the contract person(s) responsible for corrective action: Karl Morrin, District Administrator; Jen Steber, Finance Manager Planned completion date for corrective action plan: June 30, 2023

The district will implement a system of internal controls over grant expenditure reporting and allocate adequate resources to ensure that all eligible grant expenditures are appropriately submitted for reimbursement in a timely manner. Anticipated Completion Date: As necessary Contact: Shannon Anderson, Superintendent, Momence CUSD1

Management agrees with the finding. The Organization is implementing a new Payroll and Human Resources system. This single system will house the data for both time allocations and payroll data, giving the Organization the ability to run reports with accurate hours and compensation allocated to specific grants for any period. This system will report in real time and account for salary increases as well.

Management agrees with the finding. The Organization has implemented a new reporting and approval process for submissions through the Payment Management System: ? A Detailed Statement of Activity is generated by the Director of Finance as soon as it is determined all revenues and expenditures have been recorded for the month. ? Report is reviewed and approved by Co-Executive Director. ? Director of Finance submits the reports in PMS and requests reimbursement. The Organization has hired a new Director of Finance with extensive experience in non-profit accounting.

Finding: 2022-003? Cash Management (repeat) Auditor Description of Condition and Effect: During our audit procedures over the District?s cash management process, we noted that one of the claim requests selected for testing did not agree to the District?s actual meal counts. As a result of this condition, the District does not have proper controls in place over its procedures for submission of claim requests. Auditor Recommendation: The District should establish procedures to ensure that the number of meals being submitted for reimbursement agrees to the actual meal counts. Corrective Action: The District implemented review and approval changes in March 2022 to correct this prior year finding. The process that the District uses currently allows for the correction of errors on meal claims before submission. Responsible Person: Shelbi Frayer, Contracted Finance Director Anticipated Completion Date: June 30, 2022

calculation. Recommendation: The Facility should recompute surplus cash ensuring CARES Act program cash is captured in the calculation and deposit the surplus cash into their residual receipts account. Action Taken: The Facility will update its computation and the owner-certified 2022 Annual Financial Statement submission. Surplus cash will be deposited into the project?s residual receipts account as soon as practicable.

Finding #2022-001: Comments on the Finding and Each Recommendation: The required deposit of $16,084, per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts, was not deposited into the Residual Receipts Fund within 90 days of the fiscal year end. The Regulatory Agreement requires Surplus Cash, as defined by HUD, to be deposited into a separate Residual Receipts Fund within 90 days of the fiscal year end. The Corporation was not in compliance with the Regulatory Agreement. Management should monitor the Surplus Cash position and make required deposits to the Residual Receipts Fund within 90 days of fiscal year end. Action(s) Taken or Planned on the Finding: Management deposited the $16,084 to the Residual Receipts Fund on March 31, 2022. The finding is considered cleared.

Planned Corrective Action: Current policy and procedure in place will be followed and reviewed quarterly by grant accountant and food compliance officer.

Finding 2022-005: Cash Management and Reporting (Significant Deficiency) Information on the Federal Program: U.S. Department of State ALN 19.040 Criteria or Specific Requirement: 2 CFR Section 200.303 requires auditees to establish and maintain effective internal control over federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: FCE did not maintain documentary evidence of the review and approval of either its requests for cash drawdowns or its performance reports in accordance with the internal control requirements. Cause: FCE's management team works collaboratively to prepare the requests for cash draw downs and prepare the performance reports prior to submission. Per discussion with management, the review and approval is performed verbally during this process. As a result, FCE was not able to provide adequate support to document the review and approval of either its requests for cash drawdowns or its performance reports. Effect or Potential Effect: FCE was not able to provide evidence of the implementation of internal controls related to review and approval for cash draw downs and performance reports. Therefore, these submissions may have been inaccurately prepared. Recommendation: FCE should retain documentary evidence of its review and approval process, which should occur prior to submission of the requests for cash draw downs and performance reports. Action Taken: FCE acknowledges the importance of documentation to support review and approval of cash drawdowns and performance reports. FCE will develop and implement formal accounting policies and procedures to ensure that it completes and maintains the proper documentation with respect to requests for an advance or reimbursement (Form SF-270) and filing a progress report (SF-PPR).

Deposits in Excess of FDIC & Pledged Securities Coverage. Corrective action planned: - Cicero Housing will maintain deposits with the bank (BMO Harris) - The Bank (BMO Harris) will provide security as required by applicable law, regulation or rule per the third-party custodian agreement. The custodian (The Bank) agrees to provide safekeeping services and to hold any securities pledged by them in a custodial account established for the benefit of the secured party pursuant to the agreement signed. - The Director (Lillian Gutierrez) will maintain quarterly contact with our bank representative to verify fund balances are fully secure. Contact person: Lillian Gutierrez, Executive Director. Anticipated completion date: August 2, 2023.

The Trust for Tomorrow continues to add compensating controls each year when possible. Further, we will continue to review our processes to determine where duties can be segregated amongst existing staff. Additionally, the board will continue to provide close oversight of the Organization and evaluate that oversight on a consistent basis.

Material Weaknesses identified was from 2022-01 - Housing Quality Standards Inspections During audit procedures, it was identified that the Unit's Inspections were completed but if there was a failure, re-inspections were not completed as required within the 30-day period. The cause was identified that we did not have the necessary internal controls over compliance in place. That we are not re-inspecting units timely. The failure rate of 40 units examined during audit resulted in 14 failures for re-inspection. The recommendation was that we implement internal control processes and procedures to ensure that re-inspections are completed on a timely basis. Management Response: We became aware of a concern and performance issues with our HCV manager in the summer of 2021. She provided her notice of intent to resign effective December 31, 2021. We began a search for a manager in the fall of 2021 through many processes, including posting the position, inquiring of other housing authorities of our open position and networking. Additionally, we brought in a consultant to complete requirements of our contract effective January 1, 2022. This is a specialized position and one that requires experience for the position. We hired an experienced manager in May 2022 to organize the HCV program. During this audit period HUD had in place a moratorium on inspections due to COVID outbreak. We did not at this.time need to inspect units. However we did inspect units, of the 40 that had inspections we recognize as a result of the audit that we failed 14. We requested a listing of the 14 failed inspected units as a result of the audit. Senior Management was not informed during the audit process, rather during the reporting phase of the audit. Once we received the 14 names we reviewed them. Upon first inspection two of the names immediately were known. One of the persons was living in a situation where she would not have been able to pass inspection, she was a Choice for Independent living recipient approved for services by Medicaid. She was assigned to a case manager and should have been receiving services in her existing housing, however area agencies were unable to provide services per her eligibility requirements and therefore we placed her on our waitlist and worked towards housing her. She was transferred to our housing and is receiving services effective January 2022. During her first months with us she received inspections regularly to ensure that she would not fail and be in jeopardy of eviction. She is now receiving services, doing well and passing inspections. The second person was one of our Choice for Independent living residents in one of our units, his unit failed inspection on Sept. 20, 2021 and a work order for repairs was completed on October 14, 2021, which was within the 30 day re-inspection process. However this was not reported in our housing software, rather was in our work order software. We identified that three of the additional tenants that failed inspection had been re- inspected in May of 2021 and had passed within a few days of their inspection which was under 30 days, however once again was not reflected in our software. During our review process it became known to us that there is a flaw in our software package that we have been addressing with PHA Web for some time. We are working towards accurate notifications within our software. Additionally, during the period of time reviewed we had staff shortages due to COVID positive employees and a needed to change work schedules to maintain our properties effectively. We had created a practice of quarantining due to exposure and or symptoms which affected our HCV inspection staff members, both having tested positive with symptoms. Corrective Actions: We recognize and appreciate the information to work towards improvement of our HCV program. In May 2022 we hired a new Manager for our HCV program. The new Manager is working on preparing a new administration plan to be implemented for our HCV program. The new Manager is working on hiring a team and organizing existing staff to ensure that necessary details including inspections and follow up inspections are kept on track as required and documented properly. There is a process in place for HQS inspections to be followed and reports will be utilized. We have worked on training additional staff members and certifying them in HQS inspection process to ensure inspections are done timely. All our current voucher holders will be receiving a scheduled inspection to create a baseline and to move forward effectively. We anticipate completion of inspections according to our plan to be within six months of this report.

The District submitted, for reimbursement via the Emergency Connectivity Grant Fund (ECF), approximately $210,000 dollars for ipads, which had been received prior to the eligibility date of the grant, July 1, 2021. These ipads having been received by the IT department, at the Districts main Education Center office, after July 1, 2021, were reported and recorded as July 2021 eligible transactions. It was subsequently determined this shipment was actually received on June 29, 2021 at the Districts distribution center, therefore making this specific shipment ineligible for grant reimbursement. Upon identification of this error, the District immediately contacted the grant management organization, appraised them of the situation, and were allowed to provide other eligible ipad purchases, as reimbursement backup. Management has proposed additional cutoff testing processes as part of our year end processing, including review and audit of material transactions to ensure recording in proper year. Management has also provided additional training to staff members, on correct cutoff processing and the requirement for original shipping documents and receiving support. The District has also implemented a change in process, whereby all technology purchases will be delivered directly to the IT department at the main Education Center location to ensure appropriate receipt dates and documentation is provided.