Corrective Action Plans

Information of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Uninsured Program) Ascension Ministry Market: Various Pass-Through Award Numbers: Various Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials: The Uninsured Program administered by HHS stopped accepting claims due to lack of funding. All claims for testing or treatment had a deadline of March 22, 2022; thus, no further action plan is needed. Any patient accounts billed in error have been refunded to HRSA. Responsible Official: Andrew Gwin, Senior Director, Regional Lead, Revenue Cycle Anticipated completion date: N/A

CORRECTIVE ACTION PLAN March 29, 2023 Montgomery County, VA respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, VA 24018 Audit period: June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs (the ?Schedule?) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT 2022-001: Segregation of Duties (Material Weakness) Condition: A proper segregation of duties has not been established in functions related to payroll, accounts payable, accounts receivable, cash disbursements, and financial reporting. Criteria: A fundamental concept of internal controls is the separation of duties. No one employee should have access to both physical assets and the related accounting records, or to all phases of a transaction. Cause: The size of the County?s account staff and cost/benefit to minimize conflicting duties prohibits complete adherence to segregation of duties. Effect: A lack of segregation of duties exposes the County and School Board to a heightened risk of misappropriation. Recommendation: Steps should be taken to eliminate performance of conflicting duties, where possible, or to implement effective compensating controls. Corrective Action: The County and School Board have taken all steps deemed practical and cost beneficial to minimize conflicting duties. FINDINGS AND QUESTIONED COSTS ? MAJOR FEDERAL AWARD PROGRAM AUDIT 2022-002: SNAP Cluster ? State Administrative Matching Grants for the Supplemental Nutrition Assistant Program ? ALN #10.561, Eligibility Compliance Requirement impacted ? Eligibility Condition: Social Services did not verify the social security number for a household member in one out of twenty five applications selected for testing which were used to determine eligibility and benefit levels. Criteria: Under the requirements in the Uniform Guidance, social security numbers for all household members are required to be verified when applying for SNAP benefits. Cause: Social Services typically verifies all social security numbers for all household members included in the application for benefits, however, one household member was overlooked during the verification process. Effect: The lack of proper social security number verification could result in improper use of on an ineligible individual. Questioned Costs: None Perspective Information: One individual was not verified on one application out of twenty-five household applications selected. Repeat Finding: No Recommendation: Management should implement a procedure to ensure that social security numbers for all household members are properly verified. Corrective Action: Social Services will put into place a procedure to ensure that all social security numbers are verified during the eligibility determination process. If the Federal Audit Clearinghouse has questions regarding this plan, please call Lisa Rayne, Finance Director at (540) 382-6960 for finding 2022-001 and Kelly Edmonson, Social Services Director at (540) 382-6990 for finding 2022-002. Sincerely yours, Lisa Rayne Finance Director Kelly Edmonson Social Services Director

Upon review, this error occurred during the semester that the university experienced a cyber-attack whose impact resulted in "breaking" portions of the National Student Clearing House reporting "link". As a result, though these students were accurately entered by WAU as graduates- this info was not transmitted to NSCH. As a result, the default NSLDS "withdrawal" status was posted.

2022-002 Planned Corrective Action: Every year the Organization complies with an in-depth compliance review for LSC in which at least 75 cases that were closed in the previous grant year are randomly selected using an LSC designated randomization process. Those cases are then individually reviewed for 13 LSC designated errors, in a process called Self Inspection. The resulting information is collected and reported to LSC as part of Ongoing Compliance Oversight. Finally, the Organization must submit a Self-Inspection Certification and Summary Form which lists the number of cases where errors were identified. This process allows the organization to identify trends and make adjustments to protocols and training on an annual basis . The Organization has put in place all necessary protocols to ensure compliance with LSC regulations regarding assessing and documenting client eligibility. Ongoing training and oversight will be provided to intake staff and caseworkers throughout the year to ensure compliance. Responsible Person: Emma Sisti Date of Completion: December 31, 2023

CORRECTIVE ACTION PLAN May 16, 2023 United States Department of Housing and Urban Development Elk County Housing Authority respectfully submits the following corrective action plan for the year ending September 30, 2022. Name and address of independent public accounting firm: Maher Duessel, CPA?s 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit Period: October 1, 2021 ? September 30, 2022 FINDINGS ? FINANCIAL STATEMENT AUDIT No matters were reported FINDINGS ? FEDERAL AWARD PROGRAMS AUDITS Finding 2022-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster/Section 8 Housing Choice Vouchers ALN 14.871 Eligibility Recommendation: We recommend that the Authority implement procedures to ensure appropriate support is obtained and used. Authority Management Response: ECHA staff has already made changes to the internal controls by performing a file check upon completion, which should bring to light any mathematical errors. Self-certification was the highest form of verification during COVID-19, which ended on January 1, 2022. The files with the discrepancy were prepared prior to that date. Since January 1, 2022, ECHA only uses Self-certification as a last resort. If the Department of Housing and Urban Development has questions regarding this plan, please call Amy Auman at 814-965-2532. Sincerely yours, Amy Auman, Executive Director

6. Deficiency 2022-006 ? Material Weakness ? Eligibility Verification Review a. A material weakness in controls over compliance was identified for controls over compliance requirement N.1 from the 2022 Office of Management and Budget (OMB) Compliance Supplement. Controls over eligibility verification were found not to be implemented. The District should develop and implement policies and procedures to ensure that all eligibility verifications are review in a timely manner and documented appropriately. b. Plan of Action: The District will develop procedures to ensure all eligibility verifications are reviewed timely by an administrator and documented appropriately. c. Timeframe: August 2023

4. Deficiency 2022-004 ? Material Weakness ? Federal Vendor Status Check a. A material weakness in controls over compliance was identified for controls over compliance requirement I(b) from the 2022 Office of Management and Budget (OMB) Compliance Supplement. Controls over suspension and debarment determinations were found not to be implemented. The District should develop and implement policies and procedures to ensure that all suspension and debarment determinations are reviewed in a timely manner and documented appropriately. b. Plan of Action: The District is implementing new protocols to ensure vendors receiving federal dollars are appropriately vetted for suspension or debarment, using SAM.gov. c. Timeframe: New protocols are underway to be established for school year 2023-24.

3. Deficiency 2022-003 ? Material Weakness ? Eligibility Determination a. A material weakness in controls over compliance was identified for controls over compliance requirement E from the 2022 Office of Management and Budget (OMB) Compliance Supplement. Controls over eligibility determinations were found not to be implemented. The District should develop and implement policies and procedures to ensure that all eligibility determinations are reviewed in a timely manner and documented appropriately. b. Plan of Action: The District will develop procedures to ensure all eligibility determinations are reviewed timely and documented appropriately by an administrator. c. Timeframe: Beginning August 2023

Finding 2022-001 Significant deficiency on internal controls over the Eligibility Requirement for the Youth Homeless Demonstration Program Grant CFDA #14.276 2022-001 Recommendation: The Center should put in place controls to include oversight of eligibility procedures. Action Taken: We concur with the recommendation and will establish procedures to ensure controls are in place for determining eligibility requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Kim Reese, Chief Financial Officer, at 615-983-6857.

2022-006 Recommendation: We recommend that the District review the requirements of 2 CFR Section 200.213 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursement funds to the vendor. Views of the Responsible Officials and Planned Corrective Actions: The District has created a sams.gov account to verify any company that is paid with Federal money. Implementation Plan: The Interim Business Administrator will work closely with the new Food Service Director to verify and record any company/vendor that is paid with Federal money. Implementation Date: November 2022. Person Responsible for Implementation: Interim Business Administrator - Brenda Leitt.

All staff will be retrained in February 2023 on Consumer Information Records and the required documents and signatures, including the eligibility requirement. Staff are taking a pause from opening new cases for the month of February 2023 and confirming all documentation of current consumers is up to date and in the electronic file on CIL Suites. During this time staff will also close inactive cases. Going forward all electronic files will be reviewed by the Deputy Director before services can begin. This will allow the Deputy Director to verify all required documentation is in place before services begin. The Independent Living Staff also all agreed that our intake sessions for new consumers will occur in person only unless there are very extenuating circumstances. An in-person intake will ensure all documents are copied and signed by the consumer for uploading to the electronic files.

Corrective Action Plan: The Director of Business Services and Budget Analyst will work closely with grant managers across the district to conduct a review of grant compliance terms, including reporting and documentation requirements, for all state and federal grants awarded to the District. Reporting requirements will be clearly defined, and all grant managers will be required to maintain complete and comprehensive supporting documentation for all reports submitted to state and federal entities.

Oversight Agency for Audit, Piazza Apartments respectfully submits the following corrective action plan for the year ended September 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: October 1, 2021 through September 30, 2022 The findings from the September 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 AUDIT FINDING No. 2022-002: Section 202 Supportive Housing for Elderly, CFDA 14.157 Recommendation: The Project should verify initial income through the EIV system in a timely manner. Action Taken: Last month automatic alerts were activated in One Site, based on individual tenant move in dates to remind the manager it is time to pull the 90-day EIV Income Report. All managers have been trained that the 90-day EIV Income reports are required and must be pulled, reviewed, and placed in the tenant file. If the Oversight Agency for Audit has questions regarding these plans, please call Christine Harris at 954- 835-9200. Sincerely yours, Christine Harris Accounting Manager

Planned Corrective Actions: We will re-enforce the use of the move in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semi-annual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file audits on annual recertifications.

Single Audit Finding 2022-003 Material Weakness and Nonmaterial Noncompliance ? Allowable Costs and Eligibility See Corrective Action Plan for chart / table.

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

Finding: 2022-004 Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management?s Response: Audit Finding Review Training is held with Family and Children's Medicaid to review Audit results and errors found. Verification sheet for F&C Medicaid are reviewed. This form is to be used for every application and recertification. Additional trainings/unit meetings are also held throughout the year. Areas covered are review of: Child Support referrals, income, verification of Social Security Number, tax household, household relationship, reacting to changes, addresses, and OVS. Ongoing trainings continue. Individual conferences are held with each worker with an error. During the conference, the case record is reviewed along with policy, error explanations and steps to take to prevent error from reoccurring. Each quarter Pender County is required to submit to the State a Quarterly Report of cases 2nd party reviewed along with verification of trainings held, agendas and attendance sheets. Pender is required to review over 120 cases per quarter. There are 4 Medicaid Supervisors. Each month supervisors pull cases from each worker to 2nd party review. Supervisors meet with each worker that they have an error or internal control issue. Errors and internal control issues are discussed monthly at Unit meetings. Policy, manual changes, Admin letters, job aids and other information are also discussed and reviewed monthly during Unit meetings. Proposed Completion Date: Immediately and ongoing. Finding: 2022-005 Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management?s Response: The County has corrected and resubmitted the impacted report and continues to pay close attention to detail when compiling all of the data for payroll calculations. Once resubmitted, there were no monies owed, just minor adjustments in allocations between programming. Additionally, the Business Officer has worked with the Internal Audit Compliance Officer in the Finance Department to strengthen the excel formulas and lessen the inherent opportunity for errors. Finance also implemented additional checks during the 1571 monthly review process to ensure elimination of any such errors prior to submission. Proposed Completion Date: Immediately and ongoing. Finding: 2022-006 Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management?s Response: The County, much like other local governments around the State and Country, has experienced turnover from employee resignation and longterm employee retirements. The County met requirements for 2nd party reviews when program supervisor positions were filled, and in the future will ensure that there is a back up or at least a look back period for 2nd party reviews for periods of SNAP program supervisor vacancies. Proposed Completion Date: Immediately and ongoing. Finding: 2022-007 Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management?s Response: The County, much like other local governments around the State and Country, has experienced turnover from employee resignation and long-term employee retirements. The County met requirements for 2nd party reviews when program supervisor positions were filled, and in the future will ensure that there is a back up or at least a look back period for 2nd party reviews for periods of LIHEAP program supervisor vacancies. Proposed Completion Date: Immediately and ongoing.

Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management?s Response: The County, much like other local governments around the State and Country, has experienced turnover from employee resignation and long-term employee retirements. The County met requirements for 2nd party reviews when program supervisor positions were filled, and in the future will ensure that there is a back up or at least a look back period for 2nd party reviews for periods of LIHEAP program supervisor vacancies. Proposed Completion Date: Immediately and ongoing.

Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management?s Response: The County, much like other local governments around the State and Country, has experienced turnover from employee resignation and long-term employee retirements. The County met requirements for 2nd party reviews when program supervisor positions were filled, and in the future will ensure that there is a back up or at least a look back period for 2nd party reviews for periods of SNAP program supervisor vacancies. Proposed Completion Date: Immediately and ongoing.

The McAllen Chamber of Commerce will develop and adopt a written policy that clearly defines the procedures and requirements for suspension and debarment verification, in alignment with 2 CFR 200, for current and future programs that are directly and indirectly funded through federal grants. In addition, the McAllen Chamber of Commerce has retroactively verified suspension and debarment verification, in alignment with 2 CFR 200, of recipients that have received funding. No recipients, who received federal grants, were found to be In suspension and debarment.

A. Current Findings on the Schedule of Findings and Questioned Costs 1. Finding 2022-001 a. Comments on the Finding and Each Recommendation We agree with the finding and the auditor's recommendation has been adopted. b. Action(s) Taken or Planned on the Finding Management agrees with the finding. In addition to hiring a new Director of Compliance and rebuilding the compliance team in 2021 to review and approve certifications, we have increased our corporate operations team and they are now responsible for reviewing all certification due dates weekly with the site teams to ensure timely completion of certifications.

CORRECTIVE ACTION PLAN July 27, 2023 United Stated Department of Health and Human Services Northern Oswego County Health Services, Inc. d/b/a ConnextCare respectfully submits the following corrective action plan for the year ended December 31, 2022. Cohn Reznick LLP 350 Church Street Hartford, CT 06103 Audit Period: 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. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2022-001 - Sliding Fee Scale Discount Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Action Taken ConnextCare as established the following system of internal controls, effective immediately: 1) Monthly internal audits of new patient records being entered into our practice management system. This review will ensure the proper character (U) is entered into the Sliding Fee Scale tab. 2) Review of accounts when new Income Verification forms are received from the patients to ensure that reported income aligns with the practice management system. In addition, perform monthly audits of 25 active Sliding Fee Scale patients for proper Slide percentage and calculation. 3) Additional training provided to all Patient Access Representatives, Medical and Dental Billing Staff on proper calculation of a self-pay eligible sliding fee scale patient. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 298-6569, ext. 2020. Tracy Wimmer Sr. VP/Chief Financial Officer

The Authority has attempted to segregate accounting duties by having a person who does not initiate, prepare or post disbursements review the bank statements and co-sign all checks. The Authority will continue to monitor its policies and procedures in an effort to improve control efficiencies, however, at this time, the Authority has determined that the cost of eliminating the deficiency would exceed its benefit.

U.S. Department of Housing and Urban Development 2022-001 HOME Investment Partnerships Program ? Assistance Listing No. 14.239 Recommendation: We recommend that policies and procedures are implemented to ensure required certifications are completed and reviewed in a timely manner as required by HOME regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has hired additional staff in the Compliance Department for internal audits of files. Certification status is checked on a weekly basis for all funding program. Training of compliance requirements takes place during the onboarding process for all employees. Name(s) of the contact person(s) responsible for corrective action: Flo Beaumon Planned completion date for corrective action plan: January 1st, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Kasey Clark Contact Phone Number: 574-772-1604 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: The income guidelines will be uploaded into the food service system after printing off the government site and two people will have eyes on them and this has started for 2022/2023. Anticipated Completion Date: March 2023