Corrective Action Plans

Finding 2022-001 Condition There was not an adequate system of controls in place that would have prevented or detected potential material noncompliance matters within the Activities Allowed or Unallowed, Eligibility and Special Tests and Provisions (related to Return of Title IV Funds, Enrollment Reporting and Federal Direct Loan Disbursements) compliance requirement areas. Corrective Action Plan Corrective Action Planned: We agree with this finding and are rectifying the issue. United Lutheran Seminary has retained a new Financial Aid Specialist who possesses the required knowledge and suitable skills for the position. Name(s) of Contact Person(s) Responsible for Corrective Action: Susie Kowalski, Director of Financial Aid. Anticipated Completion Date: Ms. Kowalski started with United Lutheran Seminary July 1, 2022.

The City?s Housing department will review the current filing system in place, and by using a checklist, will make sure to implement procedures that will ensure all proper documentation is filed and available for review.

CHRISTUS Health Corrective Action Plan Year Ended June 30, 2022 Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. We plan to review our processes related to the retention of expense documentation to improve audit evidence. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: September 2023 with the filing of the 5th portal filing.

Condition: During testing of CFDA 93.461 HRSA COVID-19 Uninsured Program the auditor identified one eligibility finding related to a patient selected for testing who was uninsured at the time of service, but the patient subsequently applied for and received coverage under Medicaid with a retroactive coverage effective date prior to the date of service. UCHealth should have controls and processes in place to identify retroactive insurance coverage for patients treated under the program to ensure HRSA reimbursement is not received for patients with insurance coverage. Planned Corrective Action: This account was reviewed. Emergency Medicaid was found and attached to the account and a full refund to HRSA COVID-19 was processed on 2/1/2023 in the amount of $50,808.16 on check #431627. Review of the account demonstrated that system actions identified the correct Medicaid coverage and flagged for manual review. User error was made on consecutive days where Medicaid was not properly added to the account. Financial Counseling and Business Services leadership have reinforced coverage attachment protocols with staff 2/24/2023. Contact person responsible for corrective action: Michael Bishop Anticipated Completion Date: 2/1/2023

Finding: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, two patients did not have a valid application in effect for the date of service tested, resulting in the ineligible patients receiving discounts of approximately $275 and $168. Individual(s) Responsible for Corrective Action: Primary: Nicole Townsend Treber, Front Desk Supervisor Support: Brendan Johnson, Director of Quality Support: Lora Ressler, Executive Administrative Assistant Planned Corrective Action: ? Front Desk Supervisor will provide on-going training to individuals involved in the patient intake and billing processes specific to the patient income and family size entry process; ? Monthly: Director of Quality will provide reports that show SFS adjustments vs completed SFS applications; ? Monthly: Designated employee will be responsible for audit sampling; ? Monthly: Results of audit sampling will be forwarded to Front Desk Supervisor and if needed, will provide additional training. Anticipated Completion Date: January 1, 2024

Finding 2022-002 Internal Controls Condition: During testing of compliance requirements such as eligibility and verification testing, there was not documentation of a level of review to ensure the requirements were met and accurate. Views of Responsible Officials: The Academy does not disagree with this audit finding. Corrective Action Plan: The Academy's Financial Aid Counselor will complete a checklist for eligibility and verification and the Director of Financial Aid will provide documented signoff once the checklist is reviewed for completeness and accuracy. Responsible Party: Frances Hutchinson, Director of Financial Aid Anticipated Completion Date: This process was implemented in November 2021 once Clifton Larson Allen started assisting the Academy.

Planned Corrective Action: Annual Income Verification ? MMHA staff will work diligently to ensure the correct information is used for all verification purposes. The information is verified and entered by MMHA?s Occupancy Specialist. Moving forward, the Executive Director will review documents before they are entered into the system and will conduct random monthly spot checks to ensure all tenant files contain the appropriate documentation to meet the requirements for income verification and housing assistance reporting. Anticipated Completion Date: 3/8/2023 Responsible Contact Person: Angie Finley, Executive Director

Corrective Action For the year Ended June 30, 2022 Section II - Financial Statement Findings Significant Deficiency Finding 2022-001 Reporting Name of Contact Person: Tyrone Lindsey, Executive Director Corrective Action: The Authority will prepare and file all delinquent reports. Proposed Completion Date: Management will implement the above procedure immediately. Section III - Federal Award Findings and Questioned Costs Significant Deficiency Finding 2022-002 Internal Control Over Compliance - N/C S/R Section 8 Program Name of Contact Person: Tyrone Lindsey, Executive Director Corrective Action: We will review our intake and recertification procedures. We will also review our tenant file monitoring procedures. Proposed Completion Date: Management will implement the above procedure immediately.

Finding 2022-002 Federal Agency Name: US Department of Housing and Urban Development Program Name: Section 8 Moderate Rehabilitation CFDA # 14.856 Significant Deficiency in Internal Control over Compliance and Noncompliance Finding Summary: Aurora Housing Authority?s controls in place for completing reexaminations were not in place during 2022. Responsible Individuals: Tania Morris, Director of Assisted Housing Corrective Action Plan: Effective December 31, 2022 the Aurora Housing Authority?s administration of all Section 8 Moderate Rehabilitation (MR) programs ended. Closing out the last MR program will allow the Assisted Housing Department the opportunity to focus on improving quality control and enhancing services for the remaining vital Section 8 programs. Anticipated Completion Date: December 31, 2022

Corrective Action Plan January 9, 2023 Health Resources and Services Administration The Family Health Centers of Georgia, Inc. respectfully submit the following corrective action plan for the year ended May 31, 2022: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: May 31, 2022 The findings from the May 31, 2022, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number in the schedule. FINDING- FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Cluster Programs (Assistance Listing Number 93.224/93.527/COVID-19 93.224) MATERIAL WEAKNESS Finding 2022-001 - Special Tests and Provisions Recommendation: We recommend that proper training be given to employees and that sliding fee discounts be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. We recommend that the Center improve the implementation of their policy regarding keeping and maintaining the patient's proof of income or self-attestation regarding their income. Action Taken: The organization revised its policy and procedures, trained its employees, and restmctured the processes for the sliding fee program including strengthening monitoring, and hired a new coordinator. Completion Date: These changes were implemented in January 2022. No non-compliance issues were detected by the auditors during the period subsequent to the implementation of these changes. If the Health Resources and Services Administration has questions regarding this plan, please call William Bledsoe, CFO at 404-756-8743.

2022-003 Department of Veteran Affairs Federal Financial Assistance Listing 64.033, 20-SD-136-21, 20-SD-136-22, 10/1/2021-9/30/2022, 10/1/2022 ? 9/30/2023 VA Supportive Services for Veteran Families Program Eligibility Material Weakness in Internal Control over Compliance Finding Summary: Six instances were identified in which the participant was not recertified within three months. Responsible Individuals: Teena Conrad, SSVF Program Coordinator Corrective Action Plan: Management has implemented a process for all recertifications to be calculated 90 days from the last recertification date, instead of at 90-day increments from the enrollment date. This will ensure recertification is done within three months. Anticipated Completion Date: April 17, 2023

FINDING 2022-002 ? Verification Condition Found: The information on the verification worksheet and tax transcript for Parents? AGI, Parents? Taxes Paid, Parent 1 and 2 Earned Income, and Parents? Military/Clergy Housing Allowance did not agree to the amounts reported on the ISIR for one of the twenty-five students sampled. Corrective Action Plan: The Financial Aid Office updated the income items and recalculated the EFC for the students in question. The amount of Pell the student was eligible to receive was calculated based on the new EFC. $300 was returned to the Department of Education in August 2022. Anticipated Completion Date: The corrective action was completed in August 2022. Contact Person: Samuel Tschetter, Director Student Affairs/Title IX Coordinator 816-322-0110 Ext. 1384

Finding 2022-002: Verification Type of finding: Significant Deficiency in Internal Controls over Compliance and Compliance Major Program: Student Financial Aid Cluster Recommendation We recommend the financial aid and registrar?s offices review documents of students selected for verification ensure that all documents required for verification are obtained. Views of Responsible Officials and Planned Corrective Actions Student Financial Aid Services has revised our V4 Federal Verification procedures to require a second authorized staff member to review and approve any V4 Federal Verification documents directly from our imaging system. While it was an option to have the V4 documents reviewed by a second authorized staff member it was not required and often during the peak season campuses would accept, review, and approve V4 documents all at the same time. This change will require one authorized staff member to review documents when they are received from the student and again in our imaging system by a second authorized staff member. We have provided copies of our revised procedures and scheduled staff training. The person responsible for implementing these revised procedures will be the District Director of Student Financial Aid Services.

Enrollment Reporting to National Student Loan Data System (NSLDS) Explanation: It was found that some students enrollment data were being reported incorrectly. It is not known if the error is coming from PowerCampus or NCS as majority of student records are correctly submitted. Planned Corrective Action: The Office of Financial Aid will be working more closely with Registrar?s Office on the enrollment reporting submitted to the National Student Clearinghouse (NCS) each reporting cycle. Errors will be reviewed to determine why the error happened and how to correct the issue to prevent future errors. Comparisons will be done between our report and NSC and then with NSLDS. Person Responsible for Corrective Action Plan: Karen LaQuey and Dr. Wendy McNeeley Anticipated Date of Completion: Ongoing. Will do review for success December 2022 and then again in May 2023

Housing Choice Vouchers ? CFDA 14.871 Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to eligibility. Action Taken: New management has taken over the Commission subsequent to the period under audit and will ensure all staff members involved in the annual recertification and interim examinations are properly trained with respect to the rules and regulations pertaining to this process. Management will also implement stronger internal controls and policies regarding rent certifications. Anticipated Completion Date of Action: June 15, 2023

Recommendation: The Commission should consider reviewing its current policy regarding rent certifications. The Commission should ensure all persons involved in the certification process are properly trained and understand regulations in order to accurately identify errors. The Commission should adopt policies and procedures that would require a second person to be involved in the certification process to ensure the accountability of tenant files. The reviewer should sign and date the verification form, evidencing the control is being performed.Action Taken: New management has taken over the Commission subsequent to the period under audit and will ensure all staff members involved in the annual recertification and interim examinations are properly trained with respect to the rules and regulations pertaining to this process. Management will also implement stronger internal controls and policies regarding rent certifications. Anticipated Completion Date of Action: June 15, 2023.

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Stonington respectfully submits the following corrective action plan for the year ended December 31, 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: January 1, 2022 through December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING No. 2022-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that tenant income utilized at move-in is accurate in determining the tenant?s monthly rent, and verification through the EIV system is completed in a timely manner. The Project should have made an immediate correction to form HUD-50059 upon receiving the correct income from the EIV system. Action Taken: Training on income calculations and including the double checking of calculations more than once for accuracy will be conducted with managers. In addition, compliance has created an income calculation worksheet with formulas where managers can enter data and the worksheet will complete the calculations. If the audit Oversight Agency has questions regarding these plans, please call Christine Harris at 954-835-9200. Sincerely yours, Christine Harris Accounting Manager

2022-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Gurjeet Sandhu Cause: COVID made it challenging to collect the information from patients as vast majority of the visits were telephonic and not all the patients have the ability to provide the information electronically. In addition, there was constant turnover in staff and their knowledge may have been limited. Corrective Action: Golden Valley Health Centers will: - Immediately retrain staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. - Train all new staff at new hire orientations, conduct an internal audit, and retrain current staff based on outcome as needed. - Perform periodic audits of sliding fee transactions Proposed Completion Date: October 31, 2022

Identifying Number: 2022-001: Accuracy of Reporting Criteria: Management was responsible for reporting accurate lost revenues based on the terms of the grant agreement. Condition: During compliance testing, it was identified that certain lost revenues included in the final report were not accurate based on the definitions of the grant agreement. Context: The lost revenue amount reported for the period was not accurate. Cause: The supporting documentation retained that calculated lost revenues had certain inaccuracies in the revenues reported for January 2020. Effect: As a result of the condition, the Hospital's required reporting for this grant was misstated, however the Hospital was able to recalculate the appropriate lost revenues and, in conclusion, report that there were enough losses to charge to this federal award to support the propriety of all funds received. Recommendation: In the future, the Hospital should ensure it implements appropriate processes and controls to ensure a review is performed prior to submission to the awarding agency. Contact: Richard Scheinblum, Chief Financial Officer Corrective Actions Taken or Planned: Management acknowledges the finding and will ensure appropriate review of supporting calculations and COVID-related expenditures utilized within the report. An amended report will be filed with the awarding agency, as applicable. On December 27, 2022, management received a confirmation letter from HRSA, Division of Financial Integrity, acknowledging that the procedural finding has been satisfactorily resolved. The Corrective Action is subject to review during the next audit.

Finding #2022-001- Segregation of Duties (Prior Year Finding #2021-001) Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. This includes systems that are designed to limit access or control of any one individual to your government?s assets, and to achieve a higher likelihood that errors or irregularities in your processes would be discovered by your staff. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. At this time, the District does not have the following controls in place: -Persons processing accounts payable are not always separate from those ordering or receiving goods or services. -Persons initiating electronic fund transfers are not separate from those authorizing, confirming, or reconciling the transactions. -There are no procedures in place for review and approval of new vendors. -Persons preparing the payroll also maintain employee records, change employee rates, and change data in the payroll system. -The person reviewing free and reduced food service eligibility can also modify information entered into the system to determine eligibility. -Account reconciliations are not performed by someone independent of the processing of transactions in the account. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities as a result of the lack of segregation of duties. Cause: Limited number of personnel. Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or has the ability to both make and conceal an error, whether such error is intentional or unintentional. Recommendation: We recommend that the District consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase the office staff in an attempt to bring about a more effective segregation of duties. The Building Principals and the Business Manager approve purchase orders and the Business Manager approves monthly accounts payable checks. Also, the Building Principals or department supervisors approve payroll timesheets prior to processing payroll. The payroll along with the time sheets are then approved by the Business Manager. The Business Manager, Building Principals, and department supervisors will continue to monitor transactions of the District. Contact Person: Greg Benz Anticipated Completion: Not applicable

Finding #2022-001 ? Significant Deficiency and Other Noncompliance Applicable federal program: U. S. Department of Agriculture Food Distribution Cluster: Emergency Food Assistance Program (Food Commodities) Assistance Listing #10.569 Passed through The Houston Food Bank, Montgomery County Food Bank, and Galveston County Food Bank Contract Year: 10/01/21 ? 09/30/22 Recommendation: Communicate and emphasize adherence to contractual requirements for determining and documenting eligibility and retaining documentation and provide training to volunteers as needed to ensure compliance. Planned corrective action: We will implement action plans of retraining of Vincentian food pantry volunteers at the two food pantries that were missing application forms by March 31, 2023. The single audit requirements will be emphasized to ensure volunteers have a complete understanding of the policy and procedures. From April 1, 2023 through June 30, 2023, The Council will conduct internal audits to determine whether the deficiencies have been addressed. Responsible officer: Kirk Vogeley, Director of Finance Estimated completion date: June 30, 2023

Section III: Finding 2022-002 Internal Control Structure Material Weakness ? Eligibility, Reporting and Special Tests and Provisions, Repeat Finding 2022-001 Agree with finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

Views of responsible officials and planned corrective actions: The accounting department, under the direction of the chief financial officer, will conduct monthly audits of random patients? accounts for whom the sliding fee schedule has been applied, as well as training for receptionists to minimize errors. Receptionists have been mandated, along with assistance from internal billing staff, to review all patients? accounts (including income verification) at least annually.

Finding 2022-002: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster - Section 8 Housing Choice Vouchers - Mainstream Vouchers Federal Catalog Numbers: 14.871, 14.879 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,313 units. Of a sample size of forty-five (45) tenant files, the following was noted: - HUD 9886 Form was missing in 1 file - Verification of income was missing in 2 files - Verification of assets was missing in 1 file - HUD 50058 annual recertification was missing in 4 files - Original Application was missing in 5 files Our sample size is statistically valid. Known Questioned Costs: $215,596 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained, and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Finding 2022-002 (continued): Authority Response: MHA agrees with the findings that some tenant file documents were essentially unavailable for examination at the time of the audit and that a system of consistent document filing, and regular file reviews are necessary. The ?missing? documents were subsequently found but in various electronic locations, thereby making them not easily accessible to the auditors. There were also timing issues, in that a recertification was begun in 2022 but not completed or made effective until 2023 once all documents had been received. ? The tenant documents will now be filed in one place, in Yardi as attachments to the Family Detail Info (FDI) screen in the proper subfolder depending upon subject (e.g. Assets, Income, Member). MHA is working to create and label the subfolders needed for this purpose. ? The contractor and internal staff will receive detailed instructions on how to file all documents, from the receipt of documents from the tenant to the commemoration of the transaction in a HUD Form 50058. All will be required to sign a confirmation they received such instructions. ? All new staff responsible for collecting documents, processing transactions and creating 50058s will obtain training in the correct system of filing such documents as part of their on-boarding packet of trainings. ? MHA will institute a quality control procedure for the regular review of random sample files at least quarterly to ensure that the filing system is being followed and the documents are complete and readily found. Views of responsible officials and planned corrective action: Susanne Joyce, HCV Program Manager, is responsible for implementing this corrective action by December 31, 2023.

Finding 2022-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Federal Catalog Numbers: 14.850 Noncompliance ? E. Eligibility ? Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority?s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 456 units. Of a sample size of seventeen (17) tenant files, the following was noted: - HUD 50058 annual recertification was missing in 1 file - Original Application was missing in 2 files - Citizenship Declaration was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $27,341 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Public and Indian Housing Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: MHA agrees with the findings that some tenant file documents were essentially unavailable for examination at the time of the audit and that a system of consistent document filing, and regular file reviews are necessary. The ?missing? documents were subsequently found but in various electronic locations, thereby making them not easily accessible to the auditors. There were also timing issues, in that a recertification was begun in 2022 but not completed or made effective until 2023 once all documents had been received. ? The tenant documents will now be filed in one place, in Yardi as attachments to the Family Detail Info (FDI) screen in the proper subfolder depending upon subject (e.g. Assets, Income, Member). MHA is working to create and label the subfolders needed for this purpose. ? The contractor and internal staff will receive detailed instructions on how to file all documents, from the receipt of documents from the tenant to the commemoration of the transaction in a HUD Form 50058. All will be required to sign a confirmation they received such instructions. ? All new staff responsible for collecting documents, processing transactions and creating 50058s will obtain training in the correct system of filing such documents as part of their on-boarding packet of trainings. ? MHA will institute a quality control procedure for the regular review of random sample files at least quarterly to ensure that the filing system is being followed and the documents are complete and readily found. Views of responsible officials and planned corrective action: Nick Zhou, Chief Financial Officer, is responsible for implementing this corrective action by December 31, 2023.