Corrective Action Plans

Enrollment Reporting to NSLDS Planned Corrective Action: Errors may have occurred due to transition in staff and insufficient processes related to identifying student non-attendance. Error reports from the National Student Clearinghouse are reviewed after every submission and errors are corrected. Second, processes related to identifying students who have stopped attending classes were strengthened during the Fall 2022 semester. Person Responsible for Corrective Action Plan: Chris Vetter - Interim Provost Anticipated Date of Completion: December 30, 2022

2022-005 Head Start Cluster, Federal Assistance Listing No. 93.600 Special Tests and Provisions Recommendation: The auditors recommend that the Organization should establish policies and procedures to ensure all applicable special tests and provisions are completed accurately and timely. Actions Taken or Planned: The Organization has created a written plan to provide appropriate training and technical assistance on the Head Start performance standards that is sufficient to ensure that the governing body and policy council can fulfill their responsibilities under the Head Start Act. Training is to take place within 180 days of the beginning of the term of a new governing body or policy council. The training: i) includes methods on how to collect complete and accurate eligibility information from families and third party sources; ii) explains program policies and procedures that describe actions taken against staff, families, or participants who attempt to provide or intentionally provide false information; and, iii) incorporates strategies for treating families with dignity and respect and dealing with possible issues of domestic violence, stigma, and privacy. Person Responsible: The Howard Area Community Center Executive Director, Jason Kaiser, Early Childhood Education Director Nancy Salvador, and ERSEA Tech Maria Hernandez. Estimated Date of Completion: The Organization?s Board of Directors received training for FY23 on July 28, 2022. The next training for the policy council will be completed on March 16, 2023 and the HACC Board Training for FY24 is scheduled to be completed by March 30, 2024.

2022-001 Sliding Fee Discount Determination Name of Contact Person: Cheryl Petersen Pine, CFO Corrective Action: Bay Area Community Health 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: January 31, 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Real time reporting will be compiled by the Data Management Specialist (currently Stephanie Jackson) and will be reviewed by the Title I Grant Coordinator (currently Tim Rayle). Annual Financial reports will be compiled by the Director of Business Affairs (currently John Szabo), and prior to submission those reports will be reviewed by the Title I Grant Coordinator. Anticipated Completion Date: July 2023

Oversight Agency: U.S. Department of Aging Community Crisis Center, Inc. respectfully submits the following corrective action plans for the year ended June 30, 2022 Auditor: Dugan & Lopatka, CPAs 4320 Winfield Road Suite 450 Warrenville, IL 60555 Audit Period: For the year ended June 30, 2022. The finding from the schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the numbers assigned in the schedule. Findings- Federal Award Programs Audit Department of Justice 2022-001 Crime Victim Assistance Program Auditor's Recommendation: We recommend Community Crisis Center, Inc. review its client files to ensure that all client files contain the required confidentiality forms. Action Taken: The Center's midnight Case Manager staff will work through all the intake paperwork for the day to ensure all forms are present, including the confidentiality form for clients. If the funding agency has questions regarding this plan, please call me at 847-742-4088

Finding No. 2022-001 ? Activities Allowed or Unallowed; Allowable Costs; and Reporting Identification of the federal programs: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials and planned corrective actions: Although not in place the entire period of performance, effective March 31, 2022, the Financial and Data Analytics Director began conducting spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting and retains evidence of this testing.

Finding No. 2022-002 ? Activities Allowed or Unallowed; Allowable Costs and Eligibility ? Significant Deficiency in Internal Control Over Compliance Identification 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, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Program) Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials: December 31, 2022, the Company completed its evaluation of additional EPIC automated processes and opportunities to add documentation to evidence HRSA claim reviews. Additional opportunities to add documentation in EPIC were not identified. Testing and treatment claims under the above federal program are no longer accepted after March 22, 2022 and vaccine claims are no longer accepted after April 5, 2022. Should the program return, the Company would support either internal claim compliance spot testing, with evidence of this testing retained, or an EPIC system software audit of the automated processes.

Recommendation: We recommend that DCF have internal controls in place to mitigate this from happening in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The first case is from Feb. 2008 and the other one is from May 2014. While there were several documents provided from those two cases, missing from that, was nonrecurring expense documentation. The staff persons identified with both cases were from the SN County (NE Region). Neither staff member identified is still currently employed with DCF. KDCF has a policy that all casefiles contain documentation to support any state expenditure, as well as documentation to support all payments, (reference Policy #0430 Contents of Foster Care, Adoption and Independent Living Services Case Records). Internally, we have quarterly meetings with adoption staff and specialists, as well as monthly meetings with Regional Foster Care Administrators. We will discuss the audit findings and the importance of properly maintaining all the adoption and subsidy related paperwork. It is vital all of documents can be accounted for in the adoption files. We will stress that files be double-checked to make sure they have all items in place before being filed. Name(s) of the contact person(s) responsible for corrective action: Corey Lada, Adoption Program Manager Planned completion date for corrective action plan: March/April 2023

Recommendation: We recommend that KDHE reviews the process of redeterminations being sent to the household and identify any problem areas in the process which could undermine the redetermination frequency. We also recommend that KDHE reviews the training materials to ensure that all staff who make eligibility determinations are aware of the required supporting documentation to be saved for both initial eligibility determinations and redeterminations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Due to the current COVID-19 Public Health Emergency (PHE) and the continuous enrollment requirement mandated by CMS, no action has been taken on cases to correct the issue of annual redeterminations as it would cause adverse action with active recipients of Medicaid. At the conclusion of the continuous enrollment requirement, all active recipients will receive a redetermination and updated information based on changes in circumstances will be addressed to determine on-going eligibility. As redeterminations have not been conducted for the past three years, the State of Kansas has utilized the ?downtime? to enhance both KEES and training in preparation for the resumption of redeterminations. From a KEES perspective, numerous updates have been made to redetermination functionality/logic to ensure households receive the required redeterminations appropriately. Throughout the course of day-to-day activities, tickets can be submitted to Helpdesk when a potential problem area is identified in KEES. These tickets are then tracked, prioritized, and analyzed to determine the root cause. The State of Kansas has continued to utilize this information to fix on-going defects that prevent undermining the redetermination frequency. Additionally, validations have been implemented within KEES and visuals added to assist eligibility staff in how redeterminations are completed as part of the review process. A complete redesign has also been completed regarding the Transitional Medical program to ensure KEES is following policy. As mentioned in previous Corrective Action Plans, to prevent untimely redetermination processing in the future, enhancements have been made to the reviews batch and the reviews data available. This will be utilized as redeterminations resume in the State of Kansas. KDHE enhanced the reviews batch process to ensure beneficiaries are sent their review earlier. This allows more time to determine ongoing eligibility prior to the beneficiary losing coverage. Reporting enhancements were made that provide previously unavailable data. The enhanced data allows for greater analysis of mailed and return volumes, which is then used to allocate staff for reviews processing in a more effective manner. From a training perspective, all redetermination training materials were updated and sent through the approval process based on current policies and procedures. These materials are now housed on a document repository (KanShare) that is accessible by all eligibility staff. In February and March 2023, all eligibility staff who will be tasked with processing redeterminations when they resume in April 2023 attended redeterminations training to ensure their comprehension of policies and procedures. This training was divided into three (3) sections: Part 1 is the policy and procedures of determinations; Part 2 is the application of policy and procedures and Part 3 was a post-assessment to gauge the understanding of redeterminations. Lastly, due to the already made enhancements in KEES surrounding redeterminations, all eligibility staff completed `KEES Reviews Update? training in March 2023. This allows eligibility staff to put together redeterminations from beginning to end and ensure all required documentation is maintained with KEES. All active recipients will receive at minimum one annual redetermination by April 2024.This will allow the State of Kansas to gauge recent efforts to mitigate errors identified during the FY22 SSA. Name(s) of the contact person(s) responsible for corrective action: Donna Wills Planned completion date for corrective action plan: April 2024

Finding 2022-002 ? Budget to Actual Analysis Cluster: Research and Development Supporting Agency: Department of Health and Human Services and Department of Energy Award Names: Development and Testing a Field-based Hazard/Near-Miss Sharing System for Commercial Fishing Vessels and Aerodynamic Turbines, Lighter and Afloat, with Nautical Technologies and Integrated Servo-control (ATLANTIS) Award Numbers: U01OH012288 and DE-AR0001188 Assistance Listing Title: Occupational Safety and Health Program and Advanced Research Projects Agency - Energy Assistance Listing Number: 93.262 and 81.135 Award Year: FY 2022 To ensure that ABS is in compliance with 2 CFR 200.303, ABS is updating its Contracted Research and Development Process Instruction to outline appropriate communication and coordination for budget to actual analysis of all research and development projects and to ensure appropriate documentation is maintained. The updated process instruction will articulate the designation of project managers to formally document a consistent review of budgets to actuals cost analysis on a quarterly basis. The process instruction will further ensure the documentation accounts for the review of cost allowability, and the project manager will sign and date as verification of a completed review. The anticipated completion date is the first quarter of 2024.

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-006 Unemployment Insurance, COVID-19 ? Unemployment Insurance ? Assistance Listing No. 17.225 Action taken in response to the finding: The Department of Unemployment Assistance (DUA) will review and enhance procedures and controls to ensure that it sends a monetary determination letter to all claimants upon completion of eligibility determination. DUA is in the process of replacing the unemployment insurance application with a new system, which will strengthen procedures and controls and not lead to these types of issues. The current UI system does not save all monetary determination letters for all claimant and is unable to regenerate a letter that may not be saved in the existing system. The DUA modernization project will eliminate this current flaw in the system. Name of the contact person responsible for corrective action: John Saulnier, Director of Benefits Performance, DUA Planned completion date for corrective action plan: February 2025 is the implementation date of the new system.

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-002 Child Nutrition Cluster ? Assistance Listing No. 10.555, 10.559, 10.582 Action taken in response to the finding: The Office for Food and Nutrition Programs (FNP) has moved from a paper based permanent agreement to a web form that exists on the DESE Security Portal. All existing and new Child Nutrition Sponsors will continue to sign off on the document via the web-based portal allowing for a more efficient collection and document retention process. The identified sponsors with missing permanent agreements for the time period selected now have signed permanent agreements via the web-based form. Name of the contact person responsible for corrective action: Robert Leshin, Director of Nutrition Planned completion date for corrective action plan: Action Completed

Clinic agrees with the finding. Management and staff have reviewed the policy. It has been decided that the sliding fee application needs restructured. This new application will be approved in the Clinic Board Meeting on September 28, 2022. In conjunction with this new application, staff with be trained on employment verification and several new patients? sliding fee documentation and slide calculation will be audited each quarter.

Finding - Eligibility Condition Out of forty students selected for testing, one student was under awarded subsidized and unsubsidized loans based on their grade level. Views of Responsible Officials and Planned Corrective Actions During our annual audit, one student was identified as receiving less than the maximum eligibility in Federal Direct Student Loans for her grade level. This issue was the result of human error. While processes were in place to identify and resolve any students who are potentially awarded federal student loan amounts which exceed their eligibility, isolating students who are under-awarded is more complex. ? A student's eligible loan amount can be less than the maximum associated with their grade level for several legitimate reasons: ? A student elects to reject or reduce their loan amount. ? A student reaches or approaches the maximum lifetime limit in federal student loan programs for an undergraduate program. ? A student is enrolled in their final semester which may require loan amount proration. ? A student earns more credits or is granted additional transfer credits after the loan is initially awarded. To ensure all students are receiving the maximum Federal Direct Student Loan eligibility, the Office of Student Financial Services has put the following steps in place: ? Additional training has been provided to undergraduate financial aid counselors to remind them of the need for accuracy when determining eligibility based on grade level. ? To ensure the most up to date information on transfer credit evaluation is available to financial aid counselors at the time of awarding, staff in Undergraduate Admission have received additional training on the importance of recording the total number of transfer credits awarded at the time of acceptance. ? A thorough review of all 2022-2023 Federal Direct Student Loan amounts for undergraduate students was conducted that included an examination of all registered undergraduate students who were awarded. Any students who did not appear to receive the maximum amount for their grade level were reviewed prior to disbursement by the assigned counselor to determine if an increase was appropriate. If a student had additional eligibility, the award amount was revised and an updated award offer was sent to the student. ? The staff in Student Financial Services will continue this monitoring process on a monthly basis to ensure any future awards are also offered at the student's maximum eligibility. Responsible Official: Jennifer Ricciardi Completion Date: August 31, 2022

2022-1 Condition: Deficiencies Noted in Maintenance of Resident Files Steps to resolve: Management agrees with the audit finding and has a plan in place to correct the condition. We will continue to review the recertification process to determine areas of weakness. We also are in process of having more standardization in file organization of information. Individual responsible for correction: Mr. Rod Trahan, Executive Director Timeframe: As of March 31, 2023

Organization's Response: In the future, if any grants contain payroll element, we will ensure that time sheets are properly reviewed for allowable costs when preparing payroll amounts to be reimbursed/ requested under the grant.

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.

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. James Williams, Executive Director, will be responsible to implement this corrective action by June 30, 2023.

CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS For the Year Ended August 31, 2022 FINDING NO. 2022-001: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance ?Special Tests and Provisions ? Sliding Fee Applications? requirements, we noted the following exceptions: ? For three (3) out of forty (40) sliding fee applications the annual income calculated was incorrect. Plan: Rural Health, Inc.?s (RHI) Director of Revenue Cycle and Chief Financial Officer will implement an additional step in the sliding fee application review process. Once RHI?s billing staff review the application for completeness, RHI?s Accountant will review and recalculate the patient?s household annual income to ensure patient is being placed in the correct discount level. This additional step in the review process will ensure that the sliding fee process is operating effectively and that the sliding fee policies and procedures are working properly. Anticipated Date of Completion: March 1, 2023 Name of Contact Person: Robert Odum, CFO

VCI?s Action Plan will include the following: 1) We will deduct the amount of the stipend paid to the former volunteer from the federal expenses charged to the grant. This will remove the funds allocated to the grant by AmeriCorps. 2) VCI will not credit these funds to the non-federal line item, thereby ensuring that these monies are not allocated towards the required non-federal match. 3) To ensure that this does not occur again, VCI has implemented the following changes to our income verification process: a. FGP staff have been instructed to ensure that medical deductions do not exceed AmeriCorps guidelines. b. The FGP manager has been instructed to review Income Verifications as they arrive and not set them aside until they have all been collected. Holding all verification forms until they are all completed causes a bottleneck that slows down catching volunteers who may be over income. c. Once the FGP manager has reviewed the forms, they are then turned over to the Office Assistant for another review. Once the Office Assistant completes her review, they are given to the Executive Director for a final audit. d. The Executive Director will then conduct his/her audit in more timely manner than he did in 2022. 4) VCI is confident this issue will not occur in the future as our staff are much more cognizant of the importance of this process. If you have any further questions, please contact me at 407.298.4180 ext. 104

Finding Number: 2022-002 Condition: As part of the Period 1 portal submission, the Hospital included $5,268,942 of eligible expenses. Within its listing of eligible expenses for reimbursement, the Hospital submitted a purchase order for $4,810 which included items that were also submitted to reimbursement from other sources and items that were ineligible for reimbursement under the grant, as the expense was not tied to COVID-19. Planned Corrective Action: The Hospital will review its processes surrounding the methodologies used to complete portal submissions and will implement additional levels of review to ensure that the proper reporting is followed in future portal periods. This additional level of review included verifying there is an actual paid invoice used as verification of the expense versus accrued value. Contact person responsible for corrective action: Brenda Winn and Alex Roehling Anticipated Completion Date: 12/14/2022

U.S. DEPARTMENT OF TREASURY: Emergency Rental Assistance Program (21.023) 2022-028 Compliance with Subrecipient Monitoring See Compliance Finding 2022-023. 2022-023 Compliance with Subrecipient Monitoring Recommendation: We recommend the Government develop a formal policy in relation to subrecipient monitoring including the review procedures to be performed, the timing, frequency of the monitoring(s) and follow-up procedures. The Government should formally document their risk assessment of the subrecipient to support the nature, timing, and extent of testing of the subrecipient. Corrective Action Plan: The Government originally received this finding in 2021 to which the response was it would monitor subrecipients no less than once per fiscal year in which the awardee received funding or otherwise as required by Federal regulation for individual grants. The Government has met that requirement. In order to further improve upon monitoring practices, the Government will perform follow-up monitoring reviews within 3 months, as applicable by program type, of finding deficiencies in the subrecipients? programs to ensure corrective active has taken place. The Government will also consider the subaward amount as part of the risk assessment when contracting with each subrecipient; higher risk subrecipient programs will be monitored at a more frequent interval. This project is expected to be completed within six months and will be overseen by the Community Development & Planning Director Mary Sliman.

U.S. DEPARTMENT OF TREASURY: Emergency Rental Assistance Program (21.023) 2022-023 Compliance with Subrecipient Monitoring Recommendation: We recommend the Government develop a formal policy in relation to subrecipient monitoring including the review procedures to be performed, the timing, frequency of the monitoring(s) and follow-up procedures. The Government should formally document their risk assessment of the subrecipient to support the nature, timing, and extent of testing of the subrecipient. Corrective Action Plan: The Government originally received this finding in 2021 to which the response was it would monitor subrecipients no less than once per fiscal year in which the awardee received funding or otherwise as required by Federal regulation for individual grants. The Government has met that requirement. In order to further improve upon monitoring practices, the Government will perform follow-up monitoring reviews within 3 months, as applicable by program type, of finding deficiencies in the subrecipients? programs to ensure corrective active has taken place. The Government will also consider the subaward amount as part of the risk assessment when contracting with each subrecipient; higher risk subrecipient programs will be monitored at a more frequent interval. This project is expected to be completed within six months and will be overseen by the Community Development & Planning Director Mary Sliman.

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT: CDBG ? Entitlement Grants Cluster (14.218) Material weakness- 2022-027 Compliance with Allowable Activity and Allowable Cost See Compliance Finding 2022-022. 2022-022 Compliance with Allowable Activity and Allowable Cost Recommendation: The Government should review its internal control policies and procedures over allowable costs and activities to ensure payments meet both requirements before being approved as a charge to the grant Corrective Action Plan: The home identified in this finding received major rehabilitation work under the HOME grant in 2012. This included flooring installation but the Government failed to install a moisture barrier. As such, the external moisture caused the wooden sub-floor to deteriorate slowly over a 10 year period which posed a serious threat to the health and safety of the homeowner. Although per the contract the homeowner had one year to identify issues, it was determined that the homeowner has no reasonable way of identifying the error made by the Government which caused this issue. In order to circumvent the eminent danger to the homeowner as a result of the Government?s error, it was decided that the original warranty would be honored. As per HUD regulations, CDBG may be used for minor rehabilitation (which the replacement of the floor qualifies as), and was used in this instance. In order to ensure the one year contractual language does not preclude the Government from correcting errors made, the policy and procedures of the Housing Rehabilitation Program have been updated. The following language has been added ? All work done under the auspices of the Housing Rehab Program (RHP) is guaranteed against faulty installation and/or material for one year after the home is confirmed to meet or exceed the standards of the International Property Maintenance Code (IPMC). Following the one year guarantee, should LCG have substantially failed to meet the standards of the IPMC, resulting in extreme Health and Safety issues for the homeowner, the Housing Rehabilitation Program staff, at its discretion, may review homeowner eligibility for additional repair of the faulty work in order to meet Health and Safety requirements and to fulfill its good-faith obligation to the homeowner. The homeowner must continue to meet HUD income and eligibility requirements. This finding is not expected to reoccur.

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT: CDBG ? Entitlement Grants Cluster (14.218) 2022-022 Compliance with Allowable Activity and Allowable Cost Recommendation: The Government should review its internal control policies and procedures over allowable costs and activities to ensure payments meet both requirements before being approved as a charge to the grant Corrective Action Plan: The home identified in this finding received major rehabilitation work under the HOME grant in 2012. This included flooring installation but the Government failed to install a moisture barrier. As such, the external moisture caused the wooden sub-floor to deteriorate slowly over a 10 year period which posed a serious threat to the health and safety of the homeowner. Although per the contract the homeowner had one year to identify issues, it was determined that the homeowner has no reasonable way of identifying the error made by the Government which caused this issue. In order to circumvent the eminent danger to the homeowner as a result of the Government?s error, it was decided that the original warranty would be honored. As per HUD regulations, CDBG may be used for minor rehabilitation (which the replacement of the floor qualifies as), and was used in this instance. In order to ensure the one year contractual language does not preclude the Government from correcting errors made, the policy and procedures of the Housing Rehabilitation Program have been updated. The following language has been added ? All work done under the auspices of the Housing Rehab Program (RHP) is guaranteed against faulty installation and/or material for one year after the home is confirmed to meet or exceed the standards of the International Property Maintenance Code (IPMC). Following the one year guarantee, should LCG have substantially failed to meet the standards of the IPMC, resulting in extreme Health and Safety issues for the homeowner, the Housing Rehabilitation Program staff, at its discretion, may review homeowner eligibility for additional repair of the faulty work in order to meet Health and Safety requirements and to fulfill its good-faith obligation to the homeowner. The homeowner must continue to meet HUD income and eligibility requirements. This finding is not expected to reoccur.