Corrective Action Plans

The Organization agrees with the recommendation. An internal review is currently in process to evaluate and update policies as needed to address the use of federal funds.

2022-001 Sliding Fee Discount Determination Name of Contact Person: Kathy Martinez, CFO Correction Action: ? Redesign of FACT sheet for ease of use when entering data into electronic health records. ? Immediately retrain staff involved in Sliding Fee Discount Program on proper documentation requirements and implementation of sliding fee determination and billing including scanning of documentation into our OCHIN Epic electronic health records system. ? Work with OCHIN to create documentation storage at guarantor level and patient linking options to easily access sliding fee documentation within the system. ? In collaboration with OCHIN develop a charge review workque in which the billing team will manually audit the slide for accounts in which documentation adjustments were made after patient check in. ? Perform monthly internal audits of sliding fee documentation and transactions and provide continual training to ensure compliance. Proposed Completion Date: June 30, 2023

CORRECTIVE ACTION PLAN Audit Finding Reference: 2022-001 Planned Corrective Action: The Finance Department will work with a consultant to update the Policies and Procedures manual to be in line with best practices. We have implemented additional software modules to improve accuracy and efficiency in financial reporting. Finance added new hires towards the latter part of 2022 and management will provide training and professional development for the team. We are planning on completing a hard close for the period ending June 2023 and will consult with Cohn Reznick upon completion in Fall 2023. Our long-term goals are to conduct monthly and quarterly closes on all properties going forward. Name of Contact Person: Arlene Lawrence, CFO, arlene@nwnh.net, 203-562-4514 Anticipated completion date: November 2023 Audit Finding Reference: 2022-002 Planned Corrective Action: Our Property Management team worked with the tenant to bring the recertifications up to date. The recertification is now in compliance with the HOME Investment Partnerships Program. Name of Contact Person: Tom Cruess, President/CEO, tom@nwnh.net, 203-562-4514 Anticipated completion date: July 12, 2023

Finding Number: 2022-003. Corrective Action Required by Board: The district should maintain the completed valid New Jersey Household Information Survey Form or documentation of direct certification for all students reported as low income. Method of Implementation: The Food Service manager will produce and properly file all required reports and forms for direct certification for all students. Person Responsible for Implementation: Food Service Manager. Planned Completion Date of Implementation: May 1, 2023

In 2022 management hired additional oversight staff at the corporate level and changed the procedure for reviewing and approving annual certifications. The new Directors of Operations (along with the Compliance Specialists) are responsible for reviewing the certification process to ensure that certifications are completed timely. In addition, any property that has late certifications consistently are required to submit an Action Plan to the Regional Manager and update weekly on the progress to address the outstanding certifications. Management?s regional team and director of operations are focused on timely completion of certifications and review reports daily to make sure this is on task.

Finding: 2022-006 Verification Federal agency: U.S. Department of Agriculture Federal program Title: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555 and 10.559 Federal Award Identification Number and Year: 212MN061N1199- 2022 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-213-000 Award Period: June 30, 2022 Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend that District designate a second person to review applications. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The District will designate a second person to review applications. Name of the Contact Person Responsible for Corrective Action Plan: Randy Bergquist, Superintendent Planned Completion Date for Corrective Action Plan: June 30, 2023

2022-001 Student Financial Assistance ? Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures surrounding updating the ECAR to ensure reporting is accurate and completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Hamline has started a Corrective Action Plan by more clearly communicating the requirements of the timely reporting to the partnering departments or Finance, Provost, President?s Office and Student Accounts. The Corrective Action Plan will require the Student Accounts area to report to Institutional Effectiveness Office and Financial Aid Office any updates to third party servicers. The Provost Office will responsible for reporting to Institutional Effectiveness Office and Financial Aid Office any additions or changes regarding academic program or educational locations. The President?s Office will be responsible for reporting to Institutional Effectiveness Office and Financial Aid Office any changes in leadership or board members. All changes need to be reported immediately to Institutional Effectiveness Office and Financial Aid Office to ensure the ECAR is updated within the 10-reporting requirement. Additionally, IE and Financial Aid will annually review the ECAR at the end of June to correspond to the new fiscal year board of trustees that is effective on July 1 every year. Names of the contact persons responsible for corrective action: Sally Gerlach, Assistant Director of Institutional Effectiveness and Lynette Wahl, Senior Director of Financial Aid and Enrollment Planned completion date for corrective action plan: October 11, 2022

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Austin Fruits Contact Phone Number: 317-535-7579 Views of Responsible Official: We concur with the finding that there was not an effective control system in place to ensure the correct information entered in the Eligible Schools Summary section in the Title I application for Nonpublic schools was accurate. Description of Corrective Action Plan: The school corporation will work with the non-public schools within our district to implement a set of procedures to ensure the accuracy in reporting poverty counts in the Title I application. Anticipated Completion Date: 4/30/23

November 2022 PLANNED CORRECTIVE ACTION FOR CURRENT YEAR FINDINGS FINANCIAL STATEMENT FINDING There were no financial statement findings. FEDERAL AWARD FINDING OR QUESTIONNED COSTS For the year ended June 30, 2022, there was one federal award finding as summarized below. Finding 2022-001: The Office of Management and Budget Compliance Supplement requires that health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. In a sample of 40 sliding scale patients, one patient?s sliding scale category was incorrectly entered into the system. Views of Responsible Officials and Corrective Action Plan: Community Treatment, Inc has in place a policy regarding sliding fee discount program that includes review and random audits of individual sliding fee applications. The error found during the course of the financial audit was the result of incorrect data entry into the EMR for the specific patient. The application itself was correct. Corrective action to reduce the risk of this happening in the future includes, training to all staff of the policy and procedures and the importance of accurate data entry. Additional audit steps will include verification of the data entered and actual calculation on the patient ledger. The audit sample selected by the billing department will be increased for each clinic location and additional reporting of any findings to the appropriate management staff will be shared on a weekly basis. Contact: Amy Rhodes Anticipated Completion Date: December 2022

Management?s Response The UPR concurs with this finding. To address the situation and take corrective actions, a meeting was held at the Vice Presidency for Academic Affairs and Research on March 15, 2023 with registrars of the eleven (11) units of the UPR System. The following actions were proposed as corrective actions: ? Registrars were instructed to attend a Federal Student Aid workshop on March 28, 2023, on Loan Servicing, Enrollment Reporting, and the National Student Loan System. ? Professors will be oriented on the importance of taking and reporting attendance timely. ? All campuses must use the NEXT System (student data platform developed internally) to report partial and total withdrawals, as well as the attendance report. (We noted that the units that are using NEXT System did not have findings). For the five students of RUM and RCM the UPR was unable to provide information from NSLDS; the search on the website displayed ?Search returned 0 students. No matching students records found?. On December 9, 2022 RUM contacted NSLDS Customer Service Center by e-mail. They later received an e-mail informing the case was closed without further explanations. Also, NSLDS issued electronic announcements confirming problems with the implementation of their new website. On the other hand, RUM was able to provide evidence to auditors that they reported the status change of all students to the Clearing House on time. Responsible Person or Office: Executive Vice President for Academic Affairs and Research. Timeline: June 2024

Statement of Condition: The Organization's files did not consistently contain all of the required documentation, including documentation determining eligibility. Recommendation: The Organization should create a checklist of the items required in their files that they can use to identify that all required documents have been obtained and included in their files. They should also organize their files uniformly among the staff in charge of these files. Response: See Corrective Action Plan included herein. Comment on Findings and Recommendations We concur with the auditors' finding that the Organization's files did not contain all necessary information required. We addressed the concerns upon discovery. Actions Taken or Planned We have implemented procedures to ensure that our files contain all necessary documentation, however the items identified in the prior year Single Audit were not implemented until June, 2022.

Need Analysis Planned Corrective Action: The Pillar College financial aid office and third-party servicer utilizes the upgraded automated student information system to assess each student?s remaining need based on the Cost of Attendance Budget minus the total funding received from federal, state, and institutional scholarships. Triggers within the system are generated to the financial aid department when a student?s financial eligibility for packaging changes. Changes occur when the student?s enrollment status is reassessed and modified, or when their credits have increased after transfer credits have been entered into the system. Periodic reports will be set up in the student information system to check for over or under awarding of need based federal aid. Person Responsible for Corrective Action Plan: Betzi Schroeder, Financial Aid Officer Anticipated Date of Completion: current

Satisfactory Academic Progress Planned Corrective Action: To receive financial aid students must maintain a cumulative grade point average (GPA) of 2.0 (?C?) or better, or be in a SAP-Probation program to recover their GPA. Pillar College academic standards require a student to have a minimum of a 2.0 cumulative Grade Point Average (GPA) to graduate. Degree seeking students will be evaluated for Satisfactory Academic Progress (SAP) on an annual basis. Pillar College is dedicated to helping students succeed academically and progress to graduation and is therefore committed to identifying students who may be struggling. Satisfactory Academic Progress is measured by three components: 1) The student?s cumulative grade point average (CGPA), 2) The student?s rate of progress toward completion (ROP), and 3) The maximum time frame (MTF) allowed to complete the academic program. (150% for all programs.) All students who receive financial aid at Pillar College are required to meet qualifying Academic standards. The student must maintain Satisfactory Academic Progress (SAP). If a student?s cumulative GPA falls below a 2.0, the student will be placed in Suspension Pending and must appeal to remain in school. Upon review of the appeal, the student will be placed on SAP Probation for the following semester/year and directed to the Academic Resource Center (ARC) for mandatory tutoring sessions through registration into ARC-090 SAP Remediation, a pass/fail course for SAP students. For the LEAD Program, the GPA benchmark is 2.5 to remain in the program. The probationary status permits the student to continue in college while working with the Academic Resource Center (ARC) to address deficiencies and take corrective action for improvement. The student may continue to receive Title IV and State Financial Aid so long as they are adhering to their SAP Remediation Plan. The student must use the SAP Remediation Form while on SAP Probation (available from the ARC). An assessment of current enrolled students? degree progress will occur mid-July. If the SAP standard is not being met, the student will be placed on SAP-Probation. It is possible to continue to receive Financial Aid while on SAP-Probation if the student?s ?Academic Plan? is being followed, and grades are improving. If a student does not adhere to the ?Academic Plan?, they may be moved to SAP-Suspension, and removed from the financial aid program. Aid will also be suspended for the semester if credit hours attempted fall below the credit hour criteria. Pillar College financial aid office, the Academic Resource Center (ARC) and the registrar?s office met to discuss and update the Satisfactory Academic Policy (SAP policy), implementing the changes in the current fiscal year. These changes are reflected in the Pillar College Catalog. Due to upgraded student services systems the process is functioning more effectively and efficiently. As stated before, an assessment of current enrolled students? degree progress will occur mid-July. The registrar, financial aid, and the Academic Resource Center (ARC) will meet together as a team two days after the report is published to discuss the results. Students will be notified individually through phone calls and emails to make an appointment with the Academic Resource Center to create a self-evaluative plan to increase their GPA. The ARC will upload the plan into the student services system and monitor the student?s progress by direct contact with the student. It will be noted in the student services system under the individual student?s account if a student does not respond to the notices, phone calls or emails that are sent. The student will be put on academic hold and will not be able to enroll in the new semester. Person Responsible for Corrective Action Plan: Betzi Schroeder, Financial Aid Office Anticipated Date of Completion: current

Enrollment Reporting to NSLDS Planned Corrective Action: The college will continue to process the semi-monthly NSLDS reporting through the SIS and undertake spot checking 10% of the reported students after each enrollment reporting submission is completed to ensure accurate enrollment reporting. The errors will be fixed, and the type of errors will be tracked to modify the SIS as needed. Person Responsible for Corrective Action Plan: Brian Schroeder, Registrar Anticipated Date of Completion: current

Internal Control Over Compliance Personnel Responsible for Corrective Action: Venita Dye, Anticipated Completion Date: December 31, 2023 Corrective Action Plan Broomfield agrees with the auditors? recommendation to establish and follow a documented internal control process over the review of eligibility determinations. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document, in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

Finding: 2022-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2023

FINDINGS AND QUESTIONED COSTS - FEDERAL AWARDS PROGRAM 2022-001 Higher Education Emergency Relief Fund (HEERF) Institutional Portion Assistance Listing Number: 84.425F Criteria According to the Department of Education Higher Education Emergency Relief Fund III Frequently Asked Questions (FAQs) question 26, institutions may discharge student debt or unpaid balances by discharging the complete balance of the debt as lost revenue and reimbursing themselves through their HEERF institutional grants or by providing additional emergency financial grants to students (with their permission). This is available for the institutions for students who were enrolled in an institution at any point on or after March 13, 2020. Condition There was a lack of review procedures that led to not adhering to the HEERF requirements. Context A portion of HEERF institutional grant funds was improperly used to discharge student debt and/or unpaid balances, including debt and/or unpaid balances of students that were enrolled prior to March 13, 2020. Cause Insufficient monitoring of grant rules and regulations. Effect Lost revenue was calculated using an alternative method that fit within the regulations. Questioned Cost There were no questioned costs related to this finding. Recommendation We recommend that the University closely monitor all grant requirements and ensure that there are proper review processes in place to catch any potential noncompliance. Planned Corrective Action The Fiscal Staff will review and recommend to reduce / inactivate the number of accounting classifications that are no longer used, and therefore the chart of accounts will be more streamlined. The new chart of accounts will then be deployed without the same unnecessary legacy monthly closing protocols. Existing fiscal staff will now have more bandwidth to help with monthly analysis and accounting close protocols. Implementation Date Effective date: 7/1/23 for fiscal year 2024. Responsible Personnel Arlene Cash Interim Vice President for Enrollment Management awcash@ndnu.edu

Finding 2022-008 Name of contact person: Goldie Davis, IM Program Manager Corrective Action: "Second Party Reviews will continue to be completed monthly to ensure accurate information is entered. " Proposed Completion Date: Management will continue to monitor the progress of this issue and modify the controls as needed.

Finding 2022-007 Name of contact person: Goldie Davis, IM Program Manager Corrective Action: SSI Plan was amended July 1, 2022. Time standards implemented to initiate exparte review within three workdays and complete the exparte review by the State?s deadline. Proposed Completion Date: Management will continue to monitor the progress of this issue and modify the controls as needed.

Finding 2022-006 Name of contact person: Goldie Davis, IM Program Manager Corrective Action: "Resource refresher training will be completed. The training will include appropriate verification methods for countable and non-countable resources. Second Party reviews will continue to be completed. Management will continue to monitor the progress of this issue and modify the controls as needed." Proposed Completion Date: November 30, 2022.

Finding 2022-005 Name of contact person: Goldie Davis, IM Program Manager Corrective Action: "Documentation Checklist Template will be revised to include the date property, vehicles, Register of Deeds, and the Work Number are run/verified. Medicaid caseworkers will receive additional training on the revised Documentation Checklist template. Supervisors will continue to complete second party reviews to determine accuracy of evidence entered into NCFAST and to ensure new Documentation Checklist is being utilized correctly. Management will continue to monitor the progress of this issue and modify controls as needed. " Proposed Completion Date: November 30, 2022.

Finding 2022-004 Name of contact person: Goldie Davis, IM Program Manager Corrective Action: Refresher training for staff will be conducted on when a IV-D referral is required. Documentation Template revised to indicate the reason a IV-D referral was not sent. Proposed Completion Date: Training will be completed by 12/31/2022.

Oversight Agency for Audit, Edward M. Marx Apartments, Inc., respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: July 1, 2021, through June 30, 2022 The findings from the June 30, 2022, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III ? FINDINGS AND QUESTIONED COSTS ? MAJOR FEDERAL AWARD PROGRAMS AUDITFINDING No. 2022-002: Section 202 Supportive Housing for the Elderly, CFDA No. 14.157 Recommendation: Management should implement procedures to ensure that the Project verifies tenant income through the EIV system in a timely manner and maintain all required documentation and perform background checks prior to tenant acceptance. Action Taken: Training classes are planned and will be conducted on running EIV reports and performing tenant background checks. In addition, tenant files will be selected for review, at random, to ensure these items are completed in a timely manner. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

CORRECTIVE ACTION PLAN June 22, 2023 Department of the Treasury - CDFI Fund Grant River City Federal Credit Union respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew 305 West Big Beaver Rd., Ste. 200 Troy, MI 48084 Audit period: January 1, 2022- December 31, 2022 The findings from the December 31, 2022, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF TREASURY CDFI Program - CFDA No. 21.024 Significant Deficiency: See Finding 2022-001. Recommendation: Complete established procedures to identify and track eligible loans deployed during the RRP grant performance period and reconcile the totals to the underlying loan data. Action Taken: Management already has an established process to internally track eligible loans deployed during the RRP grant performance, some of the data compilation is automated and some require manual updating. Management has already replaced manual processes with excel functions like vlookup to reduce errors identified by Doeren. However, management has used this conservative process year after year and is confident with the method based on third party verification from Inclusiv, who reports annual data to the CDFI Fund, and acceptance by the CDFI Fund on an annual basis and by an additional independent 3rd party who reports annual grant requirements to the CDFI fund. Management is also confident that this current process appropriately tracks deployed loans required under the RRP Grant performance based on the sheer volume of loans granted annually. With under $2M in loans needed to satisfy the grant requirement in 2022, the credit union has identified a minimum of $20 million in eligible loans in eligible markets, well above the grant performance requirements. The current process would require a significant error rate of over 80% to fail in meeting grant performance requirement. Management does not agree with Doeren auditors' assessment of noncompliance based on the auditors performing a lin1ited scope, only reviewing 40 of the 3,676 loans funded in 2022. The 1.1% of loan evaluated is in1material and gives a false impression of the true effectiveness of the overall internal control process. With 2 errors identified in the sample of 40, Doreen auditors use this as a basis to recognize a significant deficiency- an evaluation management does not concur with. Doreen's evaluation was based on guidance for control-based auditing that is standard in the industry. Doreen's evaluation was also based on an assessment of the credit union's specific target markets, not in accordance with the grant agreement, which allows financial products in any eligible CDFI market and/or the credit union's approved target market. This generic industry standard assessment fails to consider household size in income evaluations and fails to consider underserved racial groups prevalent in Bexar County and identified as eligible CDFI targeted populations. Management is confident in its internal controls and welcomes the Department of Treasury to review its 2022 loan data and internal process by doing an in-depth analysis on a significant percentage of its total loans to verify internal controls are valid and acceptable to meet the grant performance in any eligible CDFI markets and the credit union's approved target market. If the Department of Treasury has questions regarding this plan, please call Michael Quintanilla, Chief Financial Officer at (210) 225-6866.

State Agency: Department of Labor Single Audit Contact: Samantha Doran Title: Auditor 3 Telephone: 518-457-9475 E-mail Address: Samantha.Doran@labor.ny.gov Federal Program(s) (ALN # [s]): Unemployment Insurance (ALN 17.225) Audit Report Reference: 2022-006 Anticipated Completion Date: 12/1/2023 Corrective Action Planned: Corrective action is in progress. NYSDOL is currently engaged in a multi-year project to update the Unemployment Insurance system. The modernized system will assist in future implementation of temporary federal programs and strengthen internal controls over the payment process.