Corrective Action Plans

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024

Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeeping account or as a separate bank account. The Hospital had excess cash available to cover the required reserve amount. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will establish a separate bookkeeping account in the general ledger to establish the correct reserve amount of cash within its general operating bank account. The reserve account will be part of total cash in the bank to maximize interest earned on the reserve balance. Anticipated Completion Date: June 30, 2024

2023-001 GRANT REPORTING Recommendation: The City should review and revise, as needed, its current control structure over grant reporting to ensure that all required reports are independently reviewed prior to being submitted to the grantor. This should include review of reports prepared by any third party consultants. Management’s Response: The City will update its control process to incorporate procedures to ensure that reviews of reports prepared by third party consultants are subject to independent review by City personnel prior to the reports being remitted to the grantor and that such reviews will be documented. Responsible Parties: Natalia Eckroth, CFO and Christine Aiken, Assistance Finance Director Anticipated Completion Date: December 31, 2024

Valle del Sol, Inc. is in the process of ensuring the proper reimbursement rates for the Mercy Care program will be utilized to invoice accurately. Val del Sol, Inc. will discuss with Mercy Care obtaining the most current formal fee schedule instead of a listing of allowable CPT codes. We will also implement a training for all front and back office staff to include a better understanding of the Mercy Care City program. Scripts for frequently asked questions from patients, and worksheets for staff to complete to ensure all required documents are received, will be available to staff to ensure proper application of eligibility of the Mercy Care program.

Upon discovering issues related to eligibility requirements, Valle del Sol, Inc. addressed and fixed the issues to ensure all patients who are eligible to be covered under the Mercy Care City of Phoenix ARPA award are appropriately charged for services. We implemented a training for all front office staff to include a better understanding of the Mercy Care City of Phoenix ARPA program, scripts for frequently asked questions from patients, and worksheets for staff to complete to ensure all required documents are received, to ensure proper application of eligibility of the Mercy Care City of Phoenix ARPA program. Our staff were fully retrained on the Mercy Care City of Phoenix ARPA program. We feel confident that the re-training to the front office staff and managers will ensure the the accurate application of the policy and accurate discounts are given to our patients. Valle del Sol, Inc. will track and monitor compliance through our QA/QI Committee on a regular basis.

Finding number: 2023-005 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: As found, the College has policies and procedures in place to report the disbursement records to the Department of Education through the COD system within the required fifteen calendar days. This singular Pell update was caught by the College while performing the year end Pell closeout. The record was corrected prior to the audit, but past the required timeframe. The College's corrective plan for this is to perform monthly Pell reconciliation at the same time as the required monthly Direct Loan reconciliation. By doing monthly reconciliation, we will catch potential corrections within the required timeframe. We enacted this practice in advance of the FY24 year. Timeline for Implementation of Corrective Action Plan: This was corrected in advance of the start of FY24. We will continue to review as noted. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

Finding number: 2023-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2023 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Bursar’s scope of work is to work with Financial Aid to ensure that ledgers are correct. Reconciliation reports are also reviewed monthly to ensure accuracy and resolve discrepancies timely. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

The Housing Authority understands that our prior procedure was incorrect and inadequate for capital fund drawdowns. The Finance Director has been instructed on the proper procedure of capital fund drawdowns to first reconcile LOCCS requests to vendor billing to properly request and expend funds with the three-day period

Management has established and implemented written procedures to ensure future compliance. Management will increase the detail of the review process over the tracking of meals, including both the financial function and those with direct knowledge and supervision of the services being performed. Management will also offer additional training for program staff.

Response and Corrective Action Plan: The District (Kevin Baccam) will implement a process to review and retain meal claim reporting documentation as outlined by the Iowa Department of Education and Office of Management and Budget.

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

Finding Number: 2023-002 Condition: The County did not track WIC interest income earned throughout the fiscal year, resulting in the County not refunding the Department of Health and Human Services the excess of $500 earned during the year. Planned Corrective Action: The financial analyst assigned to the grant will review interest income earned throughout the fiscal year and ensure any amount exceeding $500 is returned to the Department of Health and Human Services. Contact person responsible for corrective action: Vanessa Barker Anticipated Completion Date: 06/30/2024

Audit Finding Reference: 2023-003 Internal Controls Over Cash Management and Reporting Planned Corrective Action: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. a. Cash Drawdowns: i. Currently, all cash drawdowns are prepared by our grant accountant; and reviewed and approved verbally by our grant manager. In addition, all cash drawdowns are reviewed and approved by the national office of the grantor. Going forward, prior to the submission to the national office for approval, the cash drawdowns will be reviewed and approved via email or signature by upper management. b. Financial Reporting: i. Currently, all financial reports (FFR; SF-425; etc.) are prepared by our grant manager, with the assistance of information obtained from our grant accountant from the general ledger. These reports are reviewed and approved verbally by our Vice President of Finance, Development and Administration. In addition, all financial reports are reviewed and approved by the national office of the grantor. Going forward, prior to submitting the reports to the national office for approval, the reports will be reviewed and approved via email or signature by upper management. c. Performance Reporting: i. Performance reports are prepared by the grant lead, and verbally approved by their manager. Managers are copied on the emails to the Federal Office, verifying their approval of the report. Going forward, prior to submitting to the national office for approval, the reports will be reviewed and approved via email or signature by upper management. Planned Implementation Date of Corrective Action: 06/01/2024 Person Responsible for Corrective Action: Vice President – Finance, Development & Administration

Audit Finding Reference: 2023-002 Internal Controls Over Disbursements Planned Corrective Action: No documented review of employee reimbursements charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. All employee reimbursement expenses are reviewed and approved by the employee’s direct manager, within the payroll system (Paylocity) prior to processing payment (with bi-weekly payroll). In addition, the grant accountant and grant manager will review the timesheets and allocation of employee expenses to confirm that they agree. The approval is submitted via email to the payroll administrator for processing of the payroll. The payroll administrator will create the journal entry in the general ledger from the approval worksheet. In addition, with the implementation of our new general ledger system, the entries are reviewed and approved within the general ledger system by upper management. No documented review of payroll charged to grants: Our systems have required review and approvals procedures as described below but the notation of review and approval were not evident. Going forward either through email or sign-off, it will show approval. Payroll has multiple levels of approval. In FY23, the payroll folder, that includes timesheets, grant allocations, and payroll register, would be submitted for approval to the accounting manager. The accounting manager would review and approve payroll and return the folder to the payroll administrator for payroll submission to the payroll company. Starting in FY24, payroll would be submitted via email to the grant accountant, grant manager, and the assistant controller for multiple levels of review and approval. Corrections and approvals are done via email. In addition to the email approvals, upper management approves payroll by initialing the last page of the payroll register after a complete review. Furthermore, with the implementation of our new general ledger system, the entries are reviewed and approved within the general ledger system by upper management. Planned Implementation Date of Corrective Action: 02/01/2024 Person Responsible for Corrective Action: Vice President – Finance, Development & Administration

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will reconcile federal programs to the passthrough agencies 9 months into the fiscal year at a minimum as part of the preparation of the SEFA report.

Auditor Description of Condition and Effect. We selected a sample of disbursements that were charged to the grant. Of this sample, 5 out of 40 disbursements had questioned costs. Two disbursements had amounts submitted for reimbursement but no actual costs were incurred by the Organization. Another two disbursements included expenses for other clubs outside the grant agreement that was charged to the grant. The last disbursement was missing supporting documentation for the costs charged to the grant. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that the Organization verify that costs submitted for reimbursement are valid and allowable expenses. Additionally, the Organization needs to properly allocate costs in accordance with the grant agreements. Corrective Action. Management concurs with the finding. The Organization will ensure valid and allowable expenses, including proper allocation of costs, are remitted through enhancement of the current review processes. Responsible Person. Stacy Holman, Chief Financial Officer. Anticipated Completion Date. December 31, 2024.

Finding 2023-002: Overdrawn Federal Funding Condition The auditors identified duplicated federal award expenditures amounting to $380,644, resulting in overdrawn federal funds by $380,644. The excess cash on hand was not returned to the funding source in a timely manner. Correction action: NACDD has experienced drastic change in size over the past 3-4 years. Current policies and procedures have not been adequate for the size and volume of the transactions experienced in FY 23. In addition, there has been significant finance/accounting staff turnover including leadership of the Finance team. +The impact of this deficiency was isolated to one cooperative agreement which closed out as of 9.30.23. NACDD performed efficient and effective subsequent disbursement procedures after year end to ensure that expenses for this grant and others were recorded in the appropriate fiscal year. In the process of preparing the FFR and researching further additional expenditures related to this grant, expenses included in the initial subsequent disbursement adjustments, related to this grant were duplicated. +The Correction action plan includes previously implemented augmentation of the Finance staff. Since the end of the FY 23 fiscal year, the finance department has been fully staffed with knowledgeable accounting professionals, many who have financial federal grant experience. There is now a financial analyst on staff whose main responsibility is to reconcile and record federal grant expenditures and receivables. This process is done monthly. We believe that this additional procedure will eliminate the recurrence of this and any other like issues. Procedures related to the weekly PMS drawdown have been expanded to include reconciling the accounts receivable by grant with the PMS accounts to allow only amounts listed in PMS which are supported with appropriate expenditures to be drawn. +Implementation of corrective measures: The above expanded procedures and oversight have been in effect for most of the FY 24 fiscal year. PMS drawdowns are now done weekly with worksheets that tie in detail to the weekly expenditures. In addition, a control checklist will be created and utilized by the Finance staff leadership to monitor and document the successful implementation of corrective measures. + Additional over-arching controls – The Finance team will execute an interim audit process inhouse as of 6.30.24 and every year going forward to further identify errors and irregularities that may exist. If necessary, additional policies and procedures will be implemented to provide greater scope and assurance in preventing financial reporting errors. Responsible Person Trish H. Strong, CFO Anticipated completion date June 30, 2024

Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2024 claim.

Management agrees with the recommendations. We are revising the Financial Management policies and procedures to ensure that the separation of duties is clear, and the report preparation and review process complies with this recommendation.

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.

FINDING 2023-001 – Significant Deficiency in Internal Control over Compliance – Reporting Description of Finding: Controls should be in place to ensure the accuracy of reporting submitted for federal awards programs with proper supporting documentation to agree to the reports being submitted to the Department of Education. As part of the recordkeeping process, each month’s claim for reimbursement and all data used in the claims review process must be maintained on file. Of the eleven monthly claims reports reviewed during the audit, the supporting documentation for one of the claims (April 2023) could not be located. Statement of Concurrence or Nonconcurrence: The Town agrees with this finding. Corrective Action: The Town agrees with the finding and has implemented internal controls to ensure the supporting documentation for each monthly claim are filed and maintained. Each month the monthly claims reports and supporting documentation will be filed away in a designated secure location with a checklist by month to confirm processing. Name of Contact Person: Cynthia Varricchio, MBA, Director of Finance and School Business Operations. Projected Completion Date: June 30, 2024

Finding Reference Number: 2023-02 Description of Finding: Transportation reports were not submitted timely to the DOT per the grant agreement. Statement of Concurrence or Nonconcurrence: The agency does not concur with this Finding Corrective Action: Quarterly reporting and financial reporting are not joined under the same reporting deadlines. All Quarterly reports were submitted within the required timeframe; that is, 10 days after the quarter ends. There is no deadline for submitting invoices to DOT for reimbursement. In summary, NHCOG is of the opinion that the Finding does not accurately reflect the material detail and reporting of our programs, funding streams and administrative difficulties between the state and our providers. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2024

CORRECTIVE ACTION PLAN June 25, 2024 Appalachia Service Project, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 636 Shelby Street, Suite 400 Bristol, TN 37620 Audit period: December 31, 2023 The findings from the December 31, 2023, Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS AND QUESTIONED COSTS- MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-001: Community Development Block Grant-AL# 14.218, Controls over Reporting Condition: ASP included an amount for reimbursement to the City of Johnson City, TN that had not been paid and was not paid promptly, resulting in ASP receiving funds in advance from the City, which is in violation of the grant agreement ASP has with the City. Criteria: The grant agreerr.e nt with the City states that in no event shall the City provide advance funding to their sub-recipient. Cause: ASP failed to pay an invoice that was submitted for reimbursement prior to the receipt of the reimbursement from the City. ASP's controls over the process of reconciling reimbursement requests and payables from their general ledger to the request were not sufficient to prevent this issue from occurring, resulting in the error. Effect: ASP violated their agreement with the City and received funds in advance. Questioned Costs: NIA Perspective Information: An invoice recorded in their purchasing tracking software was not subsequently recorded in their financial software allowing for request for reimbursement to happen for an invoice that was not promptly paid. Controls were not sufficient to prevent this from occurring. Repeat Finding: No Recommendation: ASP should pay all invoices submitted for reimbursement prior to receipt of the reimbursement from the City in order to stay in compliance with their agreement with the City. ASP should also reconcile between the purchase tracking software and the general ledger to ensure that all purchases are promptly recorded in accounts payable to be paid promptly. ASP should ensure that controls are implemented to help prevent reoccurrence of this issue in the future. Corrective Action: ASP has policies and procedures in place to ensure all reimbursable expenditures are allowable, paid and clear the bank before submitting for reimbursement. However, on one occasion, ASP inadvertently submitted an allowable and paid expenditure of $32.78 that had not cleared the bank. ASP has since repaid this amount and the replacement check has been cashed by the vendor. In the future, ASP will ensure that all expenditures are allowable, paid, and clear the bank before submitting the reimbursement. ASP has re-emphasized the importance of following established procedures when submitting for grant reimbursements and believes proper controls and corrective actions are currently in place to prevent future issues. 2023-002: Community Development Block Grant - AL# 14.218, Reporting Condition: ASP, a sub-recipient, did not submit their Quarter 3 report in a timely manner, which is in violation of the grant agreement ASP has with the pass-through entity, City of Johnson City, TN. Criteria: The grant agreement with the City requires an annual report, a projected expenditures report, and four quarterly reports be submitted by ASP in a timely manner. Cause: ASP failed to submit their Quarter 3 report before it was due. Effect: ASP violated their agreement with the City and submitted their report late. Questioned Costs: NIA Perspective Information: The Quarter 3 report required by the grant agreement between ASP and the City of Johnson City was not submitted timely. Repeat Finding: No Recommendation: ASP should submit all required reports in a timely manner per the grant agreement. Additionally, ASP should review controls and procedures in place to ensure that there are policies to help aid with timely report completion. Corrective Action: ASP is currently engaged in home rehabilitation projects under an agreement with Johnson City CDBG. This agreement stipulates that quarterly reports must be submitted by the 15th of the month following the quarter. Despite completing the required work and accurately tracking expenses, the report due on I 0/16/2023 was submitted a little over 2 weeks late on I 1/2/2023 due to an omission by staff. However, ASP has maintained communication with the grant administrator at Johnson City and has remained compliant with all other aspects of the contract. The delayed submission of the quarterly report has not impacted ASP's favorable standing with the city, and we have promptly rectified the situation, ensuring full compliance with the agreement. ASP believes the proper corrective action has taken place to ensure future reports are submitted in a timely manner. If the Federal Audit Clearinghouse has questions regarding this plan, please call Greg DeGennaro, CFO at 423- 854-8800. Sincerely yours, Greg DeGennaro Chief Financial Officer

Grantee Response: The Association took immediate action to notify the grant administrators when the condition was discovered, performed an investigation, and submitted a report to the grant administrators detailing their findings. As a result of these circumstances, the Association has made several updates to their policies including 1) regularly reviewing cell phone records to detect out of state calls within one month of their occurrence; 2) developing an approval form for out of state travel that must include proof of the grant administrators approval and a detailed agenda of the trip; 3) requiring that expense reimbursement forms include travel dates and times as well as the event that the travel is related to; 4) crosschecking the shared office Outlook calendar each payroll period to personal leave requested in the payroll system; and 5) attending monthly grant administrator meetings to facilitate communication and ensure that the Association is made aware of travel requests.