Corrective Action Plans

Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300 Estimated completion date: June 30, 2024 Corrective Action: The Executive Director of Family, Parish and Community Outreach department and Senior Program Manager will create and implement the following for FPCO awardees: a required document checklist for each of the EFSP jurisdictions; develop and provide a training for all staff assigned to Emergency Food and Shelter Program case work, to be given out with each new award and periodically as needed; and monitor use of funds throughout the implementation of the funding period. All required eligibility support documents will be stored in a secured Caseworthy case management database system.

2023-004 ALLOWABLE COSTS/ACTIVITIES ALLOWED - INTERNAL CONTROLS Contact Person - Superintendent Kirk Thorstenson Corrective Action Plan - The district will implement policies and procedures to ensure all employee's wages are approved, timecards submitted are approved, and transactions that are charged to grants are reviewed and approved before being charged to the grant. The District will also implement a quarterly review of general ledger expenditures related to grants. Completion Date - January 1, 2024

To Whom it May Concern, NEF has reviewed the identified weaknesses and has made appropriate corrections in its financials to ensure that its positions are accurately reflected. To rectify these identified weaknesses, NEF will implement appropriate corrective steps to improve. The following action plan is identified: NEF will implement additional year-end closing procedures and review of GAAP adjustments to include a management review of year-end accounting and internal control procedures. This will allow for practical improvemeents and timely submission of Audited Financial Statements. Immediate actions include: • Adjust Journal Entries to ensure assets, depreciation, previous legal expenses, grants receivable, sources of funds, timing of grant awards, Loan provisioning, and payables are properly reflected in adjustments. • Reclassify Journal Entries to reclassify current maturities of longterm obligatons, office expenses, net assets with donor restrictions. We will reclassify journal entries to our year end closing procedures to ensure proper reflection of these categories. Additional actions steps include: • Confirmation of all PY adjustments are entered upon completion of final audit by January 2024. • Our procedures will be reviewed and executed to include all transactions in appropriate accounts to accurately reflect incomes, expenses, assets and liabilities in monthly financial reporting to be reviewed by management monthly. Any adjustments will be reviewed at periodically. • In addition to monthly management review, quarterly finance committee review and annual review will take place. This will ensure these items are included, and additional adjustments will not need to be made in order to present the financial statements in accordance with accounting principles, generally accepted in the United States of America. • Prepare end of quarter and semi-annual proposed adjustments and reclassifications for confirmation. • Quarterly meeting with NEF’s contracted accounting specialist to review areas for improvement and enhancements of efficiency. • Institute a plan to document the retention of quarterly reports. Party Responsible for Implementation: Jane Olson, Program Manager Implementation Start date: January 1, 2024 Signed: James A. Reiff Executive Director

Audit for the 2022-2023 academic year. Enrollment Reporting Finding Compliance Requirement: Special Test and Provisions - Enrollment Reporting Criteria: The College is required to send changes in attendance levels, graduated, withdrew, dropped out, or enrolled changes to the NSLDS within 60 days of the change. Cause: The College had not reported changes for graduated students to the NSLDS as required with the time period to be in compliance with enrollment reporting requirements. Context: Of the nine students selected for testing in the annual audit, the college did not send changes related to four students whose status changed after graduation on May 8th, 2023 to the NSLDS system. Later the status was updated however, was outside of the 60 day requirement. Corrective Action Plan from College: Documentation of Graduation enrollment dates missing. This is submitted to Derrick Everhart, Director of Financial Aid by the College Registrar Brooke Millsaps. Update regarding processing of NSC Grad Only file for May 2023 Warren Wilson College has made multiple efforts to submit a May 2023 Grad Only file to the National Stud Clearinghouse but has been unable to due to our software not recognizing or pulling the files of the students who are documented as May 2023 graduates. We submitted an end-of-term file to the NSC which was certified on June 6, 2023. As of August 17, 2023, we have taken the following steps to try and remedy this: • Applied a script/patch provided by our software company (Jenzabar). This script failed to resolve the issue. • Manually edited all graduating student records for the NSC grad only file report. This manual input of information did not result in our ability to process a grad only file. • Consultation with IT Department and software consultants to determine what we can do to process and report this grad only file. Action Steps: Moving forward, if an enrollment file cannot be uploaded to National Student Clearing House for any reason by the College Registrar within the 60-day requirement, the Registrar will communicate with the Director of Financial Aid. A file with updated enrollment reporting of student records will be created from the Colleges reporting system. Those records will then be manually entered into the NSLDS system by the Director of Financial Aid to main­tain compliance with enrollment reporting requirements. Management Response: The Director of Financial Aid concurs with this finding and noted while the College out of compliance with the reporting timeframe, the College did make a substantial effort to complete the requirements and follow up with NSLDS and NSC to correct the students enrollment. Contact College personnel for corrective action. Derrick Everhart, Director of Financial Aid deverhart@warren-wilson.edu Brooke Milsaps, College Registrar bmillsaps@warren-wilson.edu

Federal Program Name: • Coronavirus State and Local Fiscal Recovery Funds – ALN 21.027 • Block Grants for Prevention and Treatment of Substance Abuse – ALN 93.959 Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on the incurred date, rather than paid date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the audit finding. The previous process for grant salary, fringe, and indirect billings was based on salary paid date and therefore on a cash basis rather than accrual. The policy and process were immediately updated when the issue was identified during the fiscal year 2022 audit to bill based on period incurred rather than paid date, but the issue was identified after the invoices in question were sent. Revised invoices were not sent as total costs incurred during the period of the award, excluding the amounts noted in the finding, were still well over and above the award amount. All questioned costs were allowable but were outside the grant period and there are other eligible expenses during the period of performance which could have been billed to fully draw down on the award. Name(s) of the contact person(s) responsible for corrective action: CFO, Controller, and Grants Manager Planned completion date for corrective action plan: Will implement in fiscal year 2024

Management Response: Management agrees with this finding. To prevent this situation from occurring in the future, staff members will create a new academic record in our Student Information System (Jenzabar) for a student who graduates and enrolls in a subsequent semester. The new academic record will reflect the student’s non-degree status. A new academic record will prevent reporting conflicts between the student’s graduation status and subsequent non-degree enrollment status and therefore, will assist the college in reporting within the 60-day timeline. When a student changes enrollment statuses between regular monthly reports, staff members will continue to exercise the option to use the National Student Clearinghouse ad-hoc enrollment reporting so that the National Student Loan Database System receives timely enrollment updates. Contact Person: Betsy Henkel, Director of Financial Aid (henkelb@beloit.edu) Anticipated Completion Date: December 1, 2023

Responsible Official’s Plan: • The District will establish a policy and implement internal control procedures regarding the review of all grant award letters to ensure that the District is aware of all requirements that are imposed on the District with accepting the funds. • Timeline for completion of corrective action plan: December 2023 • Employee position(s) responsible for meeting the timeline: Mr. Felix Garcia, Federal Programs Director and Patricia Cordova , Federal Programs Clerk

Internal Controls over inventory management (Material Weakness) Response and Corrective Action Plan: The impact of COVID on the Mercy Brown Bag program's execution and associated inventory documentation was significant. It necessitated the restructuring of historical food distribution practices with recipients and the increase in food provided through the TEFAP program. Priority was given to distributing food to recipients, despite limited staffing caused by the increased operational workload and social distancing requirements. Starting in FY23, the program management initiated semi-annual inventory counts, which will continue into FY24 and beyond. Additionally, an Inventory Management System was implemented at the end of FY23 and will be used throughout FY24, starting on July 1, 2023. Responsible Person: Janice Roberts, Program Director, under the oversight of the Mercy Executive Director. Estimated Completion Date: July 1, 2023

Procedures will be updated to include verification that a vendor has not been suspended or debarred. A record of this verification will be retained.

Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through MDE; All project numbers. Auditor Description of Condition and Effect: The one contract selected for testing that was subject to the Wage Rate Requirements did not include the required provision and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: District officials will ensure that construction contracts contain these requirements during the bid process. Responsible Person: Maria Gistinger, Interim Business Manager Anticipated Completion Date: June 30, 2024

j) Corrective Action Plan While appropriate controls exist relative to invoice review and allocation of invoices, opportunities exist to retrain staff to further enhance these controls. k) Anticipated Completion Date June 28, 2023 l) Name of Contract Person for Corrective Action Heather Landry, Director Accounting

Statement of Condition 2023-001 (Assistance Listing 14.157): During the year ended September 30, 2023, the Corporation paid an expense totaling $920 on behalf of an affiliated entity without HUD approval. Recommendation: The affiliated entity should repay $920 to the Corporation. Management Response: Agree. The affiliated entity repaid the Corporation $920 on November 17, 2023.

Effective with the 2023-2024 fiscal period, the District created an Audit Specialist position within the Business Office. The Audit Specialist will assume responsibility for all grant reporting. The Audit Specialist will receive training on the reporting requirements for each grant. All reporting deadlines will be entered on the master department calendar that is maintained in Microsoft Outlook. The Audit Specialist will create the master calendar and the Assistant Superintendent of Business and Operations will verify and approve the calendar. Reminders for each report will be calendared with reminders sent one month prior to the due date, two weeks prior to the due date, one week prior to the due date, and one day prior to the due date. Electronic reports will be printed and physically signed by the person completing the reimbursement or report and the Assistant Superintendent of Business and Operations. The paper copy will be maintained in Grant Files. When available, security access will require one employee to submit the report and the Assistant Superintendent of Business and Operations to approve the report within the grant portal. Estimated Completion Date: August 2024 Management Contact: Margaret Lee

FINDING 2023-009: Wage Rate Compliance Response: We are implementing robust measures to ensure adherence to prevailing wage standards in all future construction contracts. This includes the inclusion of prevailing wage clauses and the requirement of weekly certified payrolls as part of our standard contracting process. Additionally, it's important to note that for the projects referenced in this finding, we did obtain certified payrolls, it just wasn’t done weekly. These additional safeguards will ensure compliance with wage rate regulations and reinforce our commitment to fair labor practices.

The Financial Aid Office and the Registrar's Office will work closely together to resolve the NSLDS reporting discrepancies. Based on the review information from last year's similar finding (2022), it was determined after the fact that Webster University had both repeated the enrollment information correctly and in a timely manner to the Clearinghouse, however, the Clearinghouse frequently reported glitches and outages that prevented reporting to NSLDS in a timely manner. The Clearinghouse continues to have system issues that delay reporting. Because the Clearinghouse is not able to consistently report accurate enrollment until their system challenges are resolved, the Financial Aid Registrar's Offices, with the assistance of IT and Enrollment Technology, will develop a mechanism going forward to establish more internal checks to compare against NSLDS data. One of these measures would include a monthly enrollment reporting audit to ensure timely and accurate enrollment information is provided to NSLDS.

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Foster Care Federal Assistance Listing Number: 93.658 Significant Deficiency and Non-Material Non-Compliance – Allowability and Eligibility Finding 2023-005 Criteria or specific requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: For one (1) of the 40 participants selected, an amount of $1,004 was requested for reimbursement that was not paid to the third party facility. Questioned Costs: $1,004 and likely questioned costs of 90,594. Effect: By not having the required documentation in the files to support payment for costs recorded, the County may request reimbursement for costs not incurred. Cause: County oversight when performing reviews over payment reimbursements. Recommendation: We recommend the County implement a procedure to ensure all costs being requested within reimbursements have been incurred by the County prior to requesting reimbursement. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. The Data Integrity unit within the Finance Department will continue to review invoices, child by child, to verify correct placement information. The Supervisor will review sample of invoices to ensure each Facility is paid the correct amount depending on child placement. Responsible Individual(s): Annette Madden, Management Analyst, Data Integrity Unit, Finance Date of Implementation: 12/31/2023

Department of Housing and Urban Development Program Name: Continuum of Care Program Federal Assistance Listing Number: 14.267 Material Weakness, Non-Material Non-Compliance – Special Test – Reasonable Rental Rates Finding 2023-004 Criteria: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: There were 37 instances out of 40 program participants tested where evidence of a secondary reviewer of the eligibility determination was not retained. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could provide funding to individuals who are not eligible. Additionally, without retaining evidence a person other than the prepared reviewed the eligibility determination, the County will not be able to evidence such control to a third party. Questioned Costs: None. Cause: The County did not have a formal policy to document the review process for eligibility determinations and a process to ensure they were being completed and retained. Recommendation: We recommend the County document and follow its policies regarding eligibility determinations and ensure all documentation is included in the file prior to final approval. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. Corrective Action Plan: It was noted during the review, 3 documents evidencing rent comparisons were not provided; those 3 documents have been obtained, showing evidence that rent comparisons were made. In relation to the absence of evidence supporting a secondary reviewer in determining eligibility, the following has been implemented to ensure compliance: Program policy: “The Initial Leasing Activities policy #SPC ADM-02” has been updated to reflect changes in the File Review Process. The new policies will be reviewed for final approval during the next PIC (Performance Improvement Committee) on 1/24/24 at 1p. All case coordinators and administrative staff will receive training on the new file review process no later than 02/29/2024. All program checklists have been updated with required signature lines to substantiate review of eligibility determination. Effective January 2, 2024, all files are being reviewed and approved by the clinical supervisor or designated staff to demonstrate confirmation of all required eligibility documentation. This will be evidenced by a signature and date on the respective review checklist. Upon completion of review, the signed checklist, will be included in participant file and transferred to the administrative staff for placement on the Electronic Database System (OnBase). Person Responsible: Adia Robinson, Clinical Supervisor

U.S. Department of Treasury Program Name: Coronavirus state and local fiscal recovery fund Federal Assistance Listing Number: 21.027 Significant Deficiency, Nonmaterial Noncompliance - Procurement Finding 2023-003 Criteria or specific requirement: Per Section 200.318 of the Uniform Grant Guidance, a non-federal entity must use documented procurement procedures for the acquisition of services required under a Federal or State award. Condition: There was one instance out of 11 contracts tested where the County did not properly follow the Uniform Grant Guidance procurement standards for contracted services. Questioned Costs: None. Effect: By not having the required documentation in the files, the County could have improperly contracted with a vendor that was not considered eligible to be paid with grant proceeds. Cause: The County utilized an existing vendor contract that had not been previously procured in accordance with the Uniform Grant Guidance procurement standards. Recommendation: The County should consider utilizing the Uniform Grant Guidance procurement standards for all County contracts or at least ensure that when utilizing a previously issued contract, the necessary procurement standards are met or completed prior to utilizing the vendors contract for a Federal or State grant. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: Procurement will incorporate the completion of a checklist entitled “Subaward versus Contractor Checklist” created by UNC School of Government to determine a vendor’s status as Contractor or Subrecipient. The form, its use and requirements will be included in Procurement’s Process and Procedure manual and all staff training. This checklist will be required as a supporting document for each appropriate procurement/contract record upon approval by a Procurement Manager. Person responsible: David Boyd, Chief Financial Officer Estimated date of completion: February 28, 2024 David Boyd Chief Financial Officer 1/10/2024

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Medical Assistance Federal Assistance Listing Number: 93.778 Material Weakness and Non-Material Non-Compliance – Eligibility Finding 2023-002 Criteria or specific requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NCFAST. We noted several errors related to the following compliance criteria: a) The caseworker should prepare and submit a DMA-5097 form in the case of noncooperation as described in the Eligibility Review Document. b) When the Social Security Administration (SSA) terminates social security income (SSI) eligibility, the county is required to make an ex-parte determination for eligibility. This determination is required to be made within 120 days after the termination of the SSI payment. c) An OVS inquiry must be completed and agreed to information reported in NC FAST. d) An AVS inquiry must be completed and agreed to information reported in NC FAST. e) When forcing eligibility, documentation explaining the reasoning for the forced eligibility is required to be maintained on file. Condition: The following are the results of non-material non-compliance noted for each criteria listed above out of the 122 program participants selected for testing: a) There were two instances where the non-cooperation with IV-D was identified but no DMA-5097 was sent. (93 and 105) b) There were two instances where the County did not complete the ex-parte review for a participant whose SSI benefits were terminated during the year. The County should have forced eligibility, due to the COVID-19 exemption, but did not force eligibility for these instances. (63 and 121) There was one other instance where the County did force eligibility, but they forced it to the wrong program. (47) c) There was one instance where the resources found through the register of deeds did not agree to the resources in NC FAST which affected the countable resource calculation. (68) d) There were two instances where the OVS query was not ran at the time of the determination. (92 and 93) e) There were two instances where eligibility was forced but no documentation explaining the reasoning for was documented at the time of the determination. (114 and 122) Lastly, there were 31 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely. Context: There were 9 out of 122 unique participants tested with the errors noted above, in which one was determined to have been improperly determined eligible. Questioned Costs: We noted a total of $59,534 in benefit payment claims paid by the State of North Carolina based on an improper eligibility determination made by the County for which the State relied on; see item “c” above. As the County did not make the payment directly, it is not considered questioned cost for the County under Uniform Grant Guidance §200.516(a)(3); however, in accordance with NC general statutes §108A-25.1A, the County is financially responsible for the $59,534 of erroneous issuance of Medicaid benefits for an ineligible individual. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could provide funding to individuals who are not eligible. Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis. Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: The County will take a multi-faceted approach to mitigating such errors in the future. Training: The Quality and Training unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified including completing ex-parte determinations for eligibility when SSA terminates SSI eligibility, properly documenting and reacting to IV-D non-cooperation, correct and appropriate usage of forced eligibility, and performing the required electronic verifications to complete an application or review. This training will be delivered by the end of the third quarter of fiscal year 2024. Responsible Individual(s): Ellese Massey, ESD Quality & Training Manager Anticipated Completion Date: March 31, 2024 Process Improvement: The Economic Services Division (ESD) has begun training new hires in one function of the Medicaid program, for example, processing applications or recertifications/changes. This is to build a stronger foundation before they learn the second function of their assigned program. Our Quality and Training Team is adding additional time for training, as needed, to ensure our trainees receive the support they need while learning a new program. ESD has specific protocol for managing the recertification process for SSI terminations and will ensure this policy is followed moving forward. Responsible Individual(s): Kim Konior, Medicaid Program Manager and Ellese Massey, ESD Quality & Training Manager Anticipated Completion Date: March 31, 2024 Quality Sampling and Accountability: The Quality and Training Unit will complete monthly quality sampling for Medicaid. Error trends will be shared with the managers and their supervisors, who will work collaboratively with Quality and Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward. Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process. Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. The Quality Assurance team in OSI/CFAS will conduct an independent evaluation and review the second party review process at the divisional level to ensure review was accurate and errors were corrected timely. This team will report out to ESD Leadership quarterly on findings. Responsible Individual(s): Kim Konior, Medicaid Program Manager & Sonya English, Quality Assurance Supervisor Anticipated Completion Date: Currently Ongoing

Recommendation: We recommend management ensure that the data collection forms are submitted electronically to Sam.gov each fiscal year going forward. Action Taken: Management acknowledges that the submission of the data collection form and required reporting package to the Federal Audit Clearinghouse (FAC) was not completed for the year ended June 30, 2021 and was submitted late for the year ended June 30, 2022. Management will provide additional oversight to ensure that the submission of the data collection form and reporting package is completed by the required due date.

FINDINGS – FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Education Passed Through Kansas State Department of Education Program Name: Education Stabilization Fund Cluster Federal Assistance Listing Numbers: 84.425W, 84.425U, 84.425D Finding 2023-001 Recommendations: The District should have an employee compare the Board Clerk’s supporting documentation and the Education Stabilization Fund spreadsheet report before its submission to the State of Kansas for its accuracy. After the approval by the secondary review employee, the report submitted should be printed, initialed by the secondary reviewer, stapled with the information used to compile the report and combined with all financial records for the fiscal year. Action Taken: We agree with the recommendation. Our targeted implementation date is March 2024. If the Kansas State Department of Education and/or Kansas State Department of Administration has questions regarding this plan, please call Rex Richardson at 620-675-2277.

As noted within the portal filing summary for the general reporting period 5, the Corporation’s consolidated cumulative lost revenues totaled $141,363,926. Through the period 5 report, $99,467,570 cumulatively, had been applied to lost revenues to date, leaving $41,896,356 in unreimbursed lost revenues. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the “Finding” section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions, if required. As of the date of this letter, PeaceHealth Networks has reported on all PRF funds received and has no future portal reporting obligations. Corrective Action Plan Completion Date: October 15, 2023

2023-001 – Cost of Attendance Calculation. Auditor Description of Condition and Effect. Two students out of the 40 tested had an incorrect COA recorded in PowerFAIDS. The error was isolated to the population of students enrolled half-time at the College. The College determined that they did not properly update COA for the year. Subsequent to initial testing, the College adjusted the COA for the half-time students whose COA was not updated for the year. This condition did not result in any students being awarded an incorrect amount of Pell. As a result of this condition, the College was exposed to an increased risk that incorrect information would be used to determine students' Pell Grant award amounts. Auditor Recommendation. We recommend the College implement procedures to ensure the COA used to calculate each student's Pell Grant is updated for each academic year and reviewed by an independent official. Corrective Action. The College will evaluate and implement controls that will ensure Pell Grant Budget Cost of Attendance requirements are met. The Financial Aid Office will determine Cost of Attendance budget component amounts and School Administration will approve these amounts prior to the financial aid system and school website being updated accordingly each academic year. Responsible Party. Financial Aid Office and School Administration. Anticipated Completion Date. September 27, 2023

This is no disagreement with the finding. Management immediately began to review policies and procedures.

CORRECTIVE ACTION PLAN October 23, 2023 Health Resources and Services Administration Care Resource Community Health Centers, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2023 The findings from the June 30, 2023 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, Opioid STR (Assistance Listing Number 93.788) Finding 2023-001 – Reporting SIGNIFICANT DEFICIENCY We recommend that the Center strengthen their system of internal controls to ensure that all reporting requirements are monitored and met on a timely basis. Action Taken Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency. This deficiency has been corrected as of the current date. During the fiscal year, there was a data element change in the Carisk portal that required an “evaluation score” to be added to the performance outcome measures. This was not previously required. Although data was uploaded on a monthly basis to the Carisk portal, the change caused the data to be rejected as an “error” resulting in measures not being uploaded. This was discovered in the BBHC February 2023 desk review of July - December 2022 data. A corrective action plan was recommended, prepared, and accepted by BBHC. The “evaluation score” was not part of the template in the electronic medical record (NextGen) therefore data could not be uploaded and was rejected. Once discovered, the data element was added to the template within the electronic medical record and data uploads of performance outcome measures were able to be extracted and successfully uploaded to the Carisk portal. The screening tool to produce the “evaluation score” is being added to the electronic health record and will be included in the workflow of the Behavioral Health Providers so that it may be captured for performance outcomes and discharges. This process requires the Care Resource Data Analytics team and external data consultants and service providers to create the templates. During the fiscal year, invoices are due on the 10th of the month unless the tenth falls on a weekend or a holiday in which case the invoices are due the following business day. There are times where extensions are necessary due to portal uploads or data corrections. Approval is given by the contract manager of BBHC. Approvals have been granted verbally and in writing (email). In the case of the invoice for the month of May 2023, verbal approval was provided, however not documented. In the future, all requests if approved verbally, will be confirmed in writing (email) to ensure proper supporting documentation of the approval. If the Health Resources and Services Administration has questions regarding this plan, please call Keenan Karwan, Chief Financial Officer at 305 - 576-1234 x203. Sincerely yours, Keenan Karwan