Corrective Action Plans

Corrective Action Plan PURPOSE: This Plan describes Internal Control Audit findings; documents responsibility for addressing the findings; and describes progress towards addressing the findings. Provide enough information to enable the reader to understand the nature of the finding, the impacts, and the planned remedy. Audit Name: New River Valley Agency on Aging - September 30, 2022 Audit Finding No. & SS Concurrence Short Title Summary Anticipated Completion Date Responsible Person(s) and Due Date * Status Status Date Concurs: Planned Action & Status Does Not Concur: Mitigating Controls & Risk Acceptance 2022-001 Updating and offsetting future Vehicle Sales Correction implemented immediately Completed and ongoing Senior Services Program Director C 9/30/2022 Concur 2022-002 UAI Forms Properly Completed Correction implemented immediately Completed and ongoing Aging and Disability Services Supervisor C 9/30/2022 Concur * Status Legend: NS = Not Started; U = Underway; C = Completed

CORRECTIVE ACTION PLAN September 5, 2023 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 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 number assigned in the schedule. FINDINGS- FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (CFDA 93.224/93.527) Finding 2022-01 - Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken This finding was also reported in the calendar year 2021 audit. As part of our corrective action plan, we instituted monthly audits to capture any issues early. Unfortunately, the same finding was noted by the auditors in this 2022 audit. There were several factors that impeded us from resolving the sliding fee scale finding. We continue to have high staff turnover in the front desk position. In addition, the population generated from the system to select our sample on a monthly basis included both self-pay and insured patients, even though self-pay was the only criteria selected. It made a proper audit -inefficient. We are committed to putting in place a process that will prevent the reoccurrence of this finding. We have hired a consulting firm, "Health Efficient", to do a comprehensive review of our EMR systems to ensure that the system setup is correct and proper reports are being generated. In addition, we have retained them to train all front desk staff, including the director and supervisor. The consulting firm will also conduct bi- weekly audits for six months to ensure the issue is resolved. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext. 226. Sincerely yours, Daniel Desire

The District Federal Programs Coordinator will: 1. Attend professional development activities provided by our Federal Programs Consultant, Dr. Cheryl Sattler with Ethica, LLC. These activities include monthly technical calls, annual Title 1 Bootcamp, and Spring Coordinator's Workshop. 2. Seek help and advice from Dr. Sattler as needed. 3. Attend FASFEPA Conferences, twice per year, to learn about updates and changes to federal laws regarding Title 1 funds. 4. Review the budget entered into the district's accounting system to ensure there are no discrepancies.

Finding 2022-005, Non-Material Non-Compliance - Eligibility Corrective Action Plan: Goal: To ensure timely completion, review, and all required signatures are obtained on the Family Services Agreements and retained on file. Plan: The County will require F&C Supervisors to log the most recent PPR/CFT meetings on the monthly spreadsheet to track when the next FSA will be due for review. Performance Improvement Strategies: 1. All PPR/CFT meetings will be held for each child in FC DSS custody every three months. 2. The meeting includes but is not limited to completion of FSAs and any other review tools necessary. All completed forms will have two-level review and signature and be maintained in the record. 3. The F&C Division already has a monthly spreadsheet to track monthly contact with youth in care. Two additional columns will be added to track the most recent meeting/form and the second column will target when the next id due to be reviewed. 4. All Supervisors will be expected to complete the two additional columns monthly recording the date of the last FSA review and projecting the next FSA review due date. 5. The Program Manager and Division Director will review the spreadsheet monthly to ensure that all FSAs have been completed timely. 6. In the event that an FSA is found to be untimely, the Supervisor/Program Manager/Division Director will ensure that the assigned caseworker completes the FSA review within 5 business days and routes any untimely forms for Program Manager review. Responsible Parties: Family & Children?s Services Division Director, Foster Care/Adoptions Program Manager, All Foster Care Supervisors, and Social Workers Timeframes: Policy will be communicated to responsible parties no later than April 1, 2023 and implemented effective immediately.

Finding Number: 2022-002 Condition: We examined $1,746,599 of federal funds reimbursed to the City from the State Revolving Fund award during the year. Management informed us and we verified that $134,102 of reimbursements were for ineligible construction costs as these amounts were bid alternates that were not allowed uses of the federal award. Further, management informed us and we verified that $17,253 of federal reimbursements were received for a duplicate construction invoice. Further, as a result of reviewing the ineligible costs, management found that in fiscal year 2021, ALN 66.458 included $5,768 in ineligible expenditures, and the overall total expenditures was understated by $184,073. In addition, ALN 14.228 had expenditures of $229,554 that were understated in fiscal year 2021, and ALN 10.760 had expenditures totaling $81,228 that were understated in fiscal year 2021. Planned Corrective Action: The City adopted an allowable cost policy on 04/17/23. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 04/17/23

2022-002 CFDA#14.871 ? Housing Voucher Cluster ? Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. The agency has begun implementing the Yardi software system that will include a landlord portal that will streamline W-9 and direct deposit documentation, while also creating a digital, cloud-based file for each landlord. This will enable the agency to better serve the needs of our landlords while also improving our records retention and filing systems. This function will also improve redundancy for continuity of operations and disaster planning. The new management team also created two (2) Fraud Specialist positions within the Housing Choice Voucher ? Assisted Housing department that will audit landlord documentation to mitigate fraud risk. Person Responsible for Correction of Finding: Mr. Justin Brooks, Executive Director Projected Completion Date: December 31, 2023

Staff will update policies and procedures to ensure compliance specifically with Section 105(a)(8) of the HCDA and 24 CFR 570.201(e) of the CDBG entitlement regulations.

There is no disagreement with the finding. Management will review procedures to implement mitigating controls to reduce the risk of error.

Action Taken: The Health Center is committed to serving patients that are underserved and under- or un-insured. Staff will be re-trained on how to implement annual updates of the sliding fee discount schedule for Department of Health and Human Services annual poverty guidelines changes, across all types of visits, on a timely basis, to ensure that self-pay and patients with third-party health insurance are assessed and charged a discounted fee based on their income and family size according to CBWCHC?s sliding fee discount schedule. In addition, they will periodically self-check patient records to see if the training was effective. This training will begin in the 2nd quarter of 2023 and will be on going as new staff are added. Person responsible: Kaushal Challa, CEO

Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and provide additional training as deemed necessary.

Management agrees with the summarized findings. Management has discussed the findings with the third-party vendor administering the application process. The vendor has provided additional training in the affected areas to ensure a thorough application review is completed and proper documentation is included in the file prior to disbursement.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Dan Durrwachter Contact Phone Number: 765-473-3081 Views of Responsible Official: We agree with these findings. Description of Corrective Action Plan: Our Food Service Director will receive the poverty status application and review them as they are inputted into skyward. Our Food Service Treasurer will review to make sure the application was completed correctly and calculated accurately. Additionally, the food service treasurer will review and approve the uploaded direct certification and income guidelines. Anticipated Completion Date: 6/01/2023

During the COVID-19 pandemic, DCH Health System (DCH) developed a methodology to identify eligible costs in accordance with the Health and Human Services (HHS) produced COVID-19 Provider Relief Fund (PRF) Reporting Requirements and FAQ guidance. DCH's methodology identified costs used to prevent, prepare for, and respond to coronavirus that fell into the following categories: COVID-19 specific costs, direct and indirect incremental costs due to COVID-19, and calculated lost revenue. To calculate direct and indirect incremental costs due to COVlD-19 for DCH Regional Medical Center, DCH leveraged HHS FAQ guidance from October 28, 2020, that introduced examples demonstrating how providers could calculate marginally increased expenses related to coronavirus using a reasonable methodology comparing pre-pandemic to post-pandemic average expenses for an office visit. OCH utilized this methodology to calculate direct and indirect incremental costs due to COVID-19 on a per-patient discharge basis, which is akin to an office visit for a hospital, per the HHS FAQ guidance. Though this specific example was removed in subsequent versions of the FAQ, HHS never communicated that the guidance that DCH relied upon to calculate incremental expenses was incorrect. DCH's view is that the total cost of patient discharge includes direct patient care and indirect costs (overhead and general administrative (G&A) costs). Indirect costs (e.g., facilities, maintenance, utilities, and management salaries) were incurred by DCH to prepare, prevent, and respond to COVID-19, consistent with the intention of the purpose of the PRF to 'provide financial support to providers who experienced lost revenues and increased expenses during the pandemic in order to maintain national health system capacity.' For instance, the ability to serve COVID-19 patients relied on incurring utility expenses to keep ventilators and other equipment functioning, of which the organization utilized well more than the norm which resulted in higher utility costs. These costs were vital for accommodating COVID-19 patients during the pandemic, just as they were necessary for serving other patient types before the onset of COVID-19. These incremental indirect costs were also not reimbursed through other sources. DCH allocated indirect costs in accordance with other accepted government rules as defined in various government regulations such as 2 CFR and the Federal Acquisition Regulation. The indirect costs allocated to patient care costs were considered part of the total cost of patient discharge. In addition, though DCH calculated lost revenue, DCH did not report on lost revenue as part of the system's use of funds (please note that there was one reporting period where Fayette had to report separate from DCH because of targeted funds received. Fayette did report lost revenue in that period based on a budget to actual calculation). DCH believes that the funds identified and reported are consistent with HHS guidance and the spirit of the law to maintain national health system capacity It is DCH's understanding that Single Audit Finding 2022-001 is particularly focused on DCH's approach to identifying indirect incremental costs due to COVID-19, citing these expenses as ineligible costs that were included in the HHS PRF portal submission. Similarly, DCH did not report lost revenues, resulting in 'inaccurate lost revenues reported.' Both FORVIS and DCH acknowledge that DCH incurred eligible expenses and lost revenue sufficient to cover the PRF funds received. Therefore, based on the FORVIS finding, and assuming the finding is sustained, DCH will implement processes to submit future PRF reports as suggested in Single Audit Finding 2022- 001, which includes identifying specific individual expenses incurred during the reporting period to prevent, prepare for, and respond to COVID-19, rather than utilizing the initial HHS guidance for calculating incremental costs due to COVID-19. In addition, OCH will include lost revenue in the PRF portal submission.

Finding Number: 2022-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding ? Financial Assistance Supervisor Ashley VanOverbeke ? Financial Assistance Supervisor Corey Remiger ? Financial Assistance Supervisor Corrective Action Planned: ? Review and remind staff to utilize checklist with all applications and renewals to ensure all documentation was obtained and/or retained in the file. ? Discuss all verification of asset requirements and the importance of supporting documentation. ? Discuss all income verification requirements and the importance of supporting documentation. ? Discuss case transfer process to ensure all verifications and documentation is obtained and included in case files and in MAXIS. ? Discuss findings at unit meetings. Anticipated Completion Date: September 30, 2023

Persons responsible for corrective action plan: Resty Rios, Staff Accountant Resty.rios@crihb.org Adrianna Davisson, Grants Manager Adrianna.davisson@crihb.org The Clinic will review all patient files to ensure all applicable documentation is located within each file. Any applicable documentation that is missing from the file will be requested from the patient to verify continued eligibility or services will be terminated. The Clinic will also implement an approval process for new patients to ensure patient eligibility is reviewed and approved prior to providing services. The anticipated completion date is 6/30/2023.

Finding 2022-001; Federal Assistance Listing Number 14.181 Statement of Condition: In connection with our lease file review, we noted that: 1. One out of two tenants recertification was not performed timely; and 2. One out of two tenants recertification was not signed by the agent. Corrective Action: We will issue continuous communication to tenants to seek compliance. REACH continues to employ a compliance team to review files and provide support and training to property management staff on income verification and signing and filing of documents. This is an area of continuous improvement. When errors or missing items are identified, they are being corrected and impact of non-compliance communicated to tenant. Contact Person: Daniel Valliere Completion Date: 4/11/2023

2022-1 Condition: Deficit in COCC Steps to resolve: The Authority's continued conversion to private based ownership via tax credits and Rental Assistance Demonstration will ease the burden of capital need. Once all our properties are converted this issue will not exist. Individual responsible for correction: Ms. Denise Brooks-Jones, Acting Executive Director Timeframe: As of March 31, 2023

The County does check Sam.gov for suspension and debarment transactions. We will be more diligent in documenting our reviews. The three companies referred to in this finding have been doing business with the County for years and are local.

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has implemented policies to ensure all meal and attendance reports are accrate. Anita Moreau is also encouraging centers to utilize the computer claiming software. These policies have been provided to all centers. On February 3, 2023, TDA reviewed the Corrective Action Plan provided by Anita Moreau and has concluded its review.

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has implemented policies to ensure all information is captured on the Meal Benefit Income Eligibility Forms. These policies have been provided to all centers. On February 3, 2023, TDA reviewed the Corrective Action Plan provided by Anita Moreau and has concluded its review.

In October of 2022 there was no waiting list in the Housing Management Software, there was not a handwritten waitlist that could be located. Staff entered all applications that were located into the software by date and time and with preferences that are in the out-of-date Admissions and Occupancy Policy and Administrative Plan. Documentation was submitted to the San Antonio Field Office in September of 2023 to show the waitlist and the families that have been selected in order of the waitlist or removed at the request of the family.

In November of 2022 the Housing Authority started using a Rent Reasonableness form that compares the unit in question to two other units of the same type with similar amenities and age. If the unit in question is a Tax Credit property the Housing Authority uses the unit?s most currently rented, listed on the back of The Request for Tenancy Approval form, provided by the landlord to ensure the rent paid for assisted units is not more than unassisted units.

2022-002 Enrollment Reporting to NSLDS Planned Corrective Action: Admissions department and registrar department will provide a list of all non-true freshman to the financial aid department. The financial aid department will run NSLDS reports to determine if students have utilized financial aid in the past. Each student that has received aid in the past will be reported to NSLDS whether they utilize any federal aid at ABU or not. Person Responsible for Corrective Action Plan: Laurel Bartlett- Admissions Director, John Rocha- Financial Aid Director, Janie Taylor- VP of Academic Affairs / Registrar Anticipated Date of Completion: Spring 2023

Identifying Number: 2022-001 Finding: Three student?s enrollment changes were not reported to the National Student Loan Data System (NSLDS) within the 60 day timeframe for the School?s reporting on the roster file submissions. Corrective Actions Taken or Planned: MHSL has hired an outside consultant through Agilyx to create a new enrollment report that will more accurately track and report the enrollment statuses for all students. MHSL will be using this report starting Fall 2022. The Director of Financial Aid now completes enrollment reporting. For each report, students will be selected by Director at random to manually review. Assistant Director of Financial Aid will also select a group at random to review for accuracy. This way both the person who runs the report and a person who does not will review a random sample of students. Also, additional scheduled date for enrollment reporting have been added to the school transmission schedule including j Term and summer. This will prevent late reporting over the summer. Contact Person: Lynn LeMoine ? Dean of Students; Katie Kuehl ? Registrar; and Nick Anderson ? Financial Aid Director. Anticipated Completion Date: Fall 2022

LAKE LAND COLLEGE COMMUNITY COLLEGE DISTRICT NO. 517 MATTOON, ILLINOIS CORRECTIVE ACTION PLAN FOR CURRENT-YEAR AUDIT FINDINGS FOR THE YEAR ENDED JUNE 30, 2022 CORRECTIVE ACTION PLAN Finding No. 2022-001 ? Internal Controls over Student Financial Assistance Special Test and Provisions Condition: A. During compliance testing of ?Special Tests and Provisions ? Return of Funds? we noted that for eight (8) out of twenty five (25) students tested the College utilized the incorrect semester end date for the Spring 2022 semester. B. During the compliance testing of ?Special Tests and Provisions ? Eligibility? we noted that one (1) student out of forty (40) students tested the College utilized the 2020-2021 Pell payment schedule versus the 2021-2022 Pell payment schedule. Plan: A. The College will develop internal controls to ensure that the correct semester dates are utilized for the return of funds calculation to determine the amount of the Title IV assistance earned by the student. B. The College will establish procedures to ensure their software is utilizing the current Pell payment schedule. Anticipated Date of Completion: Immediately upon learning of the deficiency. Contact Person Responsible for Corrective Action: Jennifer Hedges, Director of Financial Aid and Veteran Services 98