Corrective Action Plans

Finding: No. 2022-005- Cash Management Finding: An excess cash balance tolerance is allowed if that balance is less than 1% of the institution's prior-year drawdowns and is eliminated within the next seven calendar days (34 CFR 668.166(a) and (b)). The institution must return immediately any amount of excess cash over the one-percent tolerance and any amount of excess cash remaining in its account within the seven-day tolerance period. Condition: There was one drawdown from the G5 during the year for federal direct loans in which the College was in an excess cash position starting on June 29, 2022, through September 20, 2022. The maximum daily excess cash balance during this time was $51,701. Corrective Action Taken or Planned: Management will review and follow internal control to regularly monitor disbursements and reconcile to drawdowns to ensure applicable requirements are met. Corrective action has been taken to return any amount of excess cash, as of 09/30/2022 completed by the VP of Administration and Finance, William McDonald.

2022-003 ? Assistance Listing Number 10..558 ? Child and Adult Care Program: Provider Monitoring Performance and Documentation - Contact Person: Tavaughn Thomas, Completion Date: 3/15/23. Identified Problem: Out of nine Child Care Center and Home providers tested, the first monitoring report for one provider was not completed and monitoring report for one provider was not completed, and monitoring reviews for two providers were not performed timely causing a gap between reviews to be more than six months. Action: Creation of a master calendar that shows scheduled monitoring for each center and home that is approved by the Director of the program. All staff within program are tasked with ensuring that 100% of monitoring is completed within the required timeframes Director is to report to CEO each quarter compliance with monitoring timelines.

The District will review their current needs for equipment, charges for student meals, etc. and develop a plan for the reduction of cash balances in the lunchroom fund during the current year ended August 31, 2023.

June 21, 2023 Corrective Action Plan Finding Number: 2022-001 Condition: The Organization charged costs to the grant which were associated with individuals who were subsequently discovered to have insurance. In addition, the Organization did not timely refund private pay patients for payments that were paid by HRSA funding. Planned Corrective Action: Management has allocated for staff to review and process credit balances. Additionally, Management has contracted with an outside vendor to expedite these reviews and processing of credit balances in a timely manner. Contact person responsible for corrective action: Dudley Harrington, VP of Patient Financial Services Anticipated Completion Date: 7/31/2023

2022-03: Approval for expenditures Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: A member of management of the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.

2022-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregated certain duties are not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.

Item 2022-005 Condition: During the process of identifying expenses and capital costs that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included capital items for which there was a lack of supporting documentation. Planned Corrective Action: Management agrees with the noted finding. However, the Hospital had also incurred sufficient unreimbursed expenses that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred eligible expenses in excess of the PRF funds received, including interest earned on such funds. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources. Contact Person: Amanda Davidson, Chief Financial Officer Anticipated Completion Date: Ongoing

Item 2022-004 Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, certain expenses that were reported in the PRF submission were not reduced by amounts reimbursed by other sources. Planned Corrective Action: Management agrees with the noted finding. However, the Hospital had also incurred sufficiency lost revenue that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred eligible expenses in excess of the PRF funds received, including interest earned on such funds. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources. Contact Person: Amanda Davidson, Chief Financial Officer Anticipated Completion Date: Ongoing

Reporting views of responsible officials and planned corrective actions Management will ensure that security deposits are tracked so they can be recorded accordingly when there is a move in and/or move out. Management is also in the process of opening a new account for this HUD entity. Moving forward management will put in place controls to ensure that the calculation is done at the end of the fiscal year.

Finding Summary: CFDA 93.224: Valle del Sol, Inc. and Subsidiary submitted and received reimbursement for an expenditure for one program within another. The error was subsequently corrected within the same fiscal year. CFDA 93.829: One of four cash drawdowns tested lacked supporting documentation of management?s review prior to submission. Responsible Individuals: CFO and Director of Management Reporting Corrective Action Plan: Cash drawdown requests and approvals will be documented via E-mail between the CFO and Director of Management Reporting. Anticipated Completion Date: Completed. December 2022.

The following corrective action is regarding the reserve for replacements required deposits not deposited monthly as stated in the operation budget for FY 2021-2022. The required $552 monthly payments as stated in the operating budget for FY 2022-2023 will be deposited monthly. Flinn Place, Inc. will continue to build an operating reserve to enable us to continue required operations should unusual circumstances arise again. Proposed completion date December 16, 2022.

Finding 2022-001 - Based on the 2021 computation of surplus cash, a deposit of $7,473 was required to be made into the residual receipts account. Recommendation: The Company should make the required deposit of $7,473 into the residual receipts account as soon as possible. Policies should be implemented that ensure the required deposits are made in a timely manner. Action Taken: The required deposit will be made as soon as possible.

Elementary and Secondary School Emergency Relief Fund ? Assistance Listing No. 84.425D Recommendation: Recommend that the implement a process that requires receipt of the certified payrolls for contractors and subcontractors prior to requesting reimbursement from federal assistance for construction costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will require certified payrolls be received from contractors and subcontractors prior to requesting reimbursement of construction costs using Federal assistance. Name of the contact person responsible for corrective action: Meggan Sponsler, Chief Financial Officer Planned completion date for corrective action plan: Immediately

Provider files will be reviewed to ensure that files are complete and enrollment forms should be obtained for those not located.

All employees paid by Cost Allocation will be charged to the programs based on time sheets, this was fully implemented June 15, 2022

March 2, 2023 Shenandoah Area Agency on Aging respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, Virginia 22801 Audit period: September 30, 2022 The findings from the September 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 2022-004: Authorized Signer for Bank Accounts Condition: Four bank confirmations signed by the executive director were sent to financial institutions holding SAAA assets as part of our audit were denied due to being signed by an unauthorized individual. Criteria: As part of management's responsibility to safeguard assets, the authorized signer for bank accounts should be documented. Cause: Management was unaware the listing of authorized check signers had not been updated by the bank as requested. Effect: It is critical for an entity to be able to access its cash deposits held by financial institutions. When a listing of authorized signers is not updated, the entity opens itself to opportunities for loss. Terminated employees may still have access to organizational assets or the organization may be prohibited from accessing their accounts at financial institutions if there is no perceived authority to access the funds. FINDINGS-FINANCIAL STATEMENT AUDIT (Continued) 2022-004: Authorized Signer for Bank Accounts (Continued) Recommendation: Management or governance should determine who has access to bank accounts and ensure only the appropriate parties maintain ongoing access for the safekeeping of the organization's assets. Planned Corrective Action: This finding was caused by the bank not updating its signature cards as requested by the Agency. This finding was immediately corrected once identified by the auditors. 2022-005: Material Audit Adjustments Condition: During the audit, we detected one material misstatement in the trial balance presented to us to begin our audit that was considered a material audit correction. Criteria: Generally accepted auditing standards dictates that detection of errors in an audit is a strong indicator of a significant deficiency or material weakness. Accordingly, we are required to communicate this finding as such. Cause: Financial information was missing or inaccurate. Effect: Assets and liabilities were overstated. Recommendation: We recommend that management implement a process to ensure accuracy of balance sheet and statement of activity accounts. Planned Corrective Action: Management agrees with the finding. During the last quarter of the fiscal year, the finance department experienced a vacancy. As a result, we were short-handed. There was one account that was not reconciled in a timely manner. After the year end, the position has since been filled. All significant balance sheets will be reconciled in a timely manner as in previous years. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT 2022-001: Cost Sharing Fees, ALN 93.045 Special Programs for the Aging - Title III, Part Cl - Nutrition services and Special Programs for the Aging-Title III, Part C2 - Nutrition services, Program income Condition: Individuals receiving Title III-C funded services for home delivered meals were charged cost sharing fees. Criteria: Agencies providing services funded under the Title III-C programs may not charge cost sharing fees for the Title 111-C services under Title III-C per 42 U.S. Code? 3030 c-2(a)(2). Cause: No controls or processes were in place to prevent cost sharing fees being charged to individuals receiving services provided under Title III-C programs. Effect: The cost sharing fees for Title III-C services are not allowed under federal guidelines and therefore these fees are considered a questioned cost. Questioned Cost Amount: $4,400 Perspective Information: Noted two fees were charged for Title 111-C services out of a sample of twenty-five cost sharing fees. Recommendation: Cost sharing fees are not allowed to be charged for Title III-C services provided to individuals. Only voluntary contributions may be made for these services. Management should implement procedures to ensure these fees do not continue to be charged. Planned Corrective Action: Management agrees with the finding. As noted in finding 2022-005, the vacant position, which has now been filled, was responsible for compliance review. Additional procedural reviews and corrected report formatting have been implemented to prohibit cost-sharing fees from being charged to the program. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT (Continued) 2022-002: Unallowable Costs, ALN 93.053 Nutrition Services Incentive Program, Allowable Costs Condition: Administrative expenditures were improperly classified as expenditures funded by the Nutrition Services Incentive Program (NSIP). Criteria: NSIP funds may only be used to purchase domestic foods as outlined under Title 7 U.S. Code of Federal Regulations Part 250.68, Nutrition Services Incentive Program. Grant funding received through NSIP may not be used to pay for administration or other services. Cause: Unallowable costs were improperly classified to the financial records supporting NSIP expenditures and allowable costs were improperly allocated to other projects. Effect: Financial records supporting costs expensed under the NSIP award do not reflect the nature of the expenditures requested for reimbursement. Expenditures were misclassified within the financial records to improper programs and thus are considered a questioned cost. Questioned Cost Amount: $98,327 Perspective Information: Noted in one out of a sample of twenty-five expenditures charged to the Aging Cluster. Two of the items in the sample were expenditures charged to NSIP. We reviewed the list of the remaining expenditures charged to NSIP and confirmed the sample was representative of the entire population. Recommendation: It is critical for the underlying financial records to support an organization's claims for costs reimbursements under federal award programs with adequate documentation. Staff must allocate costs appropriately for allowable costs under each federal program and ensure expenditures charged to the federal programs are for appropriate purposes and are properly classified in the records to avoid noncompliance with federal regulations and program requirements. Planned Corrective Action: Management partially agrees with the finding. We agree that certain amounts were misapplied to the NSIP account. However, the funds did purchase food as required by the grant. We believe this to be a reporting error and not a misuse of grant funds. With the vacant position recently filled, we have added additional review procedures to prevent any reoccurrence of misapplication. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT (Continued) 2022-003: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging- Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part Cl - Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting Condition: The 13th Aging Monthly Report required by the pass through agency, Virginia Department of Aging and Rehabilitative Services (VDARS) was not submitted timely and contained inaccurate revenue and expenditure data. Criteria: VDARS requires the annual I3th Month Aging Monthly Report to be submitted by November 15t?h The report must contain complete and accurate information as a restating of the monthly reporting for the fiscal year. Cause: The 131 Aging Monthly Report was not reconciled to underlying financial records, resulting in unexplained differences between the report and trial balance provided as part of the audit. Additionally, the report was not submitted by November 15, 2022. Effect: The submission of the 13th AMR was not performed timely and included data that did not agree to underlying financial records. This should have been caught during the course of a review process before submission. Therefore, it is considered a significant deficiency of internal controls over compliance. Recommendation: Ensure reporting is submitted timely by the deadline stated by VDARS. Implement a review process for each monthly submission, including documentation of the review. Reconcile the federal, state and local totals reported in the Aging Monthly Report to the underlying financial records as stated in the financial system to ensure accuracy before submission to VDARS. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The AMR report was not filed in a timely manner. As noted in finding 2022-0005, the vacated position during the last quarter of the year was responsible for submittals. We note that the report has since been filed. With the position being filled, we believe the 13th AMR will be filed in a timely and accurate manner as in previous years. If the Federal Audit Clearinghouse has questions regarding this plan, please call Cindy Donaldson, Director of Finance at 540-635-7141. Sincerely yours,

2022-002 DOCUMENTATION OF REPORT REVIEW Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Foster Care Title IV-E Program Assistance Listing Number: 93.658 Pass-Through Agency: Minnesota Department of Health and Human Services Pass-Through Numbers: 2201MNFOST Award Period: Year-Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the County implement procedures to ensure that reporting policies are being performed as required by federal standards, including having another member of staff review quarterly reports after they have been prepared, and document this review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County is going to plan a training and informational session with those involved reporting to ensure policies and procedures are followed around reporting. Name of the contact person responsible for corrective action plan: Joua Yang, Deputy Director Accounting and Finance Planned completion date for corrective action plan: December 31, 2023.

2022-004 Unmet Need Emergency Connectivity Fund (ECF) Program, Assistance Listing #32.009 Compliance Requirement: Special Tests ? Unmet Need Material Weakness in Internal Control over Compliance Response and Corrective Action Plan: The Technology Services team did determine the unmet need for the devices utilizing a parent survey but did not have additional documentation to support that a control was in place to ensure unmet need before requesting reimbursement. We will ensure we have documentation that the unmet need still exists with any future requests for federal reimbursement Responsible Individuals: Christy Fisher, Chief Technology Officer Anticipated Completion Date: Ongoing

Finding Reference 2022-008 Contact Person: Emily Matis Views of Responsible Officials and Planned Corrective Action: Adjustments have been made to drawdowns in April and June of 2022 in order to correct for these overdraws. However, even after these corrections, $694.47 was still overdrawn from FY22. This amount will be corrected in a future Title V draw for this amount. Salary drawdowns will be required to have backup payroll documentation for each draw in the future. Anticipated Completion Date: January 2023

2022-007 (Repeat Finding): ALN: 93.568 LIHEAP/COVID-19 LIHEAP - Cash Management, Passthrough from Massachusetts Department of Housing and Community Development Condition: Management drawdowns of LIHEAP grant funds exceeded LIHEAP grant expenses during the fiscal year. Cause: There are two causes. First, management's routine grant drawdowns include more funds than needed for the LIHEAP program for incidentals and anticipated future costs. Therefore some of these LIHEAP drawdowns were not completely disbursed and $1,915,052 remains in deferred revenue at June 30, 2022. Second, a substantial portion of the COVID-19 LIHEAP ARPA grant was for Supplemental Benefits to prior year program participants. A drawdown of $11,675,500 was deposited to NEFWC's deposit account by Massachusetts DHCD in advance of the calculation and payment of client benefits related to these funds. The cash request was prepared and submitted by NEFWC on September 29, 2021 and approved by Massachusetts DHCD on September 29, 2021, and the receipt of funds by NEFWC was dated October 7, 2021. The calculation of the benefit amounts and recipients was subsequently performed by Massachusetts DHCD and NEFWC's payment of the client benefits, totaling $9,567,374, was paid on a check run dated November 1, 2021. As a result, the check run was $2,108,126 less than the advance cash receipt resulting in excess LIHEAP funds on- hand (deferred revenue). The total of these two causes is a deferred LIHEAP revenue balance at June 30, 2022 of $3,815,684. Criteria: Grant drawdowns should be made on a cost reimbursement basis and disbursed in accordance with cash management principles. Effect of Potential Effect: Management did not comply with cash management principles and as a result has deferred LIHEAP revenue of $3,815,684 at June 30, 2022. Recommendation: We recommend that management follow cash management principles and only draw down funds sufficient to reimburse actual expenditures. If excess funds are received they should be returned or accounted for in a subsequent funds request. Views of Responsible Officials: Management agrees with the finding, see Corrective Action Plan. Corrective Action Planned: June 27, 2023. NEFWC entered into a repayment agreement with the Commonwealth of MA on June 27, 2023. Anticipated Completion Date: September 30, 2023.

2022-002 Condition: Funds in the restricted cash account at June 30, 2022 of $1,965,909 are deficient to the same program deferred revenue funds of $3,815,684 by $1,849,775 on June 31, 2022. Cause: Program funds were retained in the centralized deposit account and not transferred to the program checking account. Criteria: Restricted bank accounts should be equal to program funds on hand. Effect of Potential Effect: Non-transfers of program funds to the program checking account can result in non-compliant use of program funds. Recommendation: We recommend that management immediately transfer program funds to program restricted accounts and retain any unspent funds in the restricted accounts. Views of Responsible Officials: Management agrees with the finding, see Corrective Action Plan. Corrective Action Planned: June 27, 2023. NEFWC entered into a repayment agreement with the Commonwealth of MA on June 27, 2023. Anticipated Completion Date: September 30, 2023.

2022-001 Condition: Cash receipts for the LIHEAP program are not adequately segregated from NEFWC's general operating accounts. Cause: NEFWC has a centralized deposit account to receive all Commonwealth of Massachusetts electronic program payments, including LIHEAP. Electronic payments received for LIHEAP are then transferred to the respective LIHEAP checking accounts to be available for the programs' disbursements. We noted that transfers to the LIHEAP account are made, but not in the exact amount when the cash is received. Some LIHEAP cash receipts remain in the centralized deposit account and are transferred when program disbursements are made. Criteria: The LIHEAP program grant receipts should be immediately deposited directly into the respective program checking accounts upon receipt. Effect or Possible Effect: Cash from the LIHEAP program could be utilized for NEFWC's other programs because it is not transferred from the centralized deposit account upon initial receipt. Recommendation: We recommend that management transfer the LIHEAP deposits immediately into the program's checking account or investigate the ability to have LIHEAP electronic payments made directly into the program checking account. Views of Responsible Officials: Management agrees with the finding, see Corrective Action Plan. Corrective Action Planned: Program contract not renewed, effective end date September 30, 2022. Anticipated Completion Date: Due to Program termination no further action required.

Planned Corrective Action: Management continues to follow the approved Excess Fund Balance Elimination Plan. It is expected the equipment investment will be made in the upcoming fiscal year. Quarterly reviews of the Cafeteria fund balance are planned. Anticipated completion date: June 2023. Responsible contact person: Angela Gleason, Finance Director.

ALN No. 97.036, Disaster Grants ? Public Assistance (Presidentially Declared Disasters); Award Number: 033-UECF5-00; Award Year: January 1, 2020 to July 1, 2022; Pass-Through Entity: State of Washington Military Department Emergency Medicine Division; Award Number: D20-368 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that purchase orders issued for capital purchases were fully fulfilled and paid prior to submission for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that costs are incurred prior to submission for program reimbursement. Instead of tracking purchase orders issued we will utilize general ledger details ensuring only purchase orders with receipts and subsequent invoices are included in reimbursement requests. The accounting team will pull invoice and payment support which will be reviewed by the Director of Finance prior to submission to ensure all expenditures have been paid prior to submitting a request for reimbursement. Person(s) Responsible for Implementing: Jenna Bevilacqua, Director of Finance and Lindsey Soboloski, Controller Implementation Date: March 20, 2023

ALN No. 93.498, Provider Relief Fund; Award Year: Periods 2 and 3: July 1, 2020 to June 30, 2021 Finding: Activities Allowed or Unallowed ? The controls were not sufficient to ensure that depreciation expense for capital purchases were excluded when the capital expense was also submitted for program reimbursement. Status: Corrective action in progress. Corrective Action: Internal controls will be strengthened in future periods to ensure that ledger details are appropriately filtered to exclude depreciation expense for costs already considered during the review of capital expenditures. The Director of Finance will review ledger details prior to submission to ensure only appropriate ledger accounts are included in requests for reimbursement. Person(s) Responsible for Implementing: Jenna Bevilacqua, Director of Finance and Lindsey Soboloski, Controller Implementation Date: March 20, 2023