Corrective Action Plans

The District will implement internal controls to monitor and ensure that the appropriate time and effort documentation of those employees paid in whole or in part with federal funds is on file to support the amount of time an employee works on a federal program. Compliance will be achieved by: 1)Develop a set of internal controls for time and effort documentation which provides reasonable assurance that charges are accurate, allowable, and allocable. (CFO/Treasurer) 2)Require time and effort documentation be filed in a timely manner with the CFO/Treasurer and maintained for records. (CFO/Treasurer ? Superintendent ? Direct Supervisor) 3)Require Direct Supervisor of employees to maintain time and effort documentation in accordance with District policies and procedures, as well as federal laws and guidelines. (Direct Supervisor) 4)Periodically monitor time and effort documentation in relationship to the percentage of time the employee spends on a federal program vs. non-federal. (CFO/Treasurer ? Superintendent - Direct Supervisor)

RANDOM MOMENT STUDY (RMS) EMPLOYEE LISTING Federal Agency: U.S. Department of Health and Human Services and U.S. Department of Agriculture Federal Program Title: Medical Assistance Program (Medicaid Cluster), Temporary Assistance for Needy Families (TANF) and State Administrative Matching Grants for Supplemental Nutrition Assistance Program (SNAP Cluster) Assistance Listing Number: 93.778, 93.558, and 10.561 Pass-Through Agency: Minnesota Department of Human Services and Minnesota Department of Agriculture Pass-Through Numbers: 2205MN5ADM, 2201MNTANF, and 222MN101S2520 Award Period: Year-Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the County review the RMS listings and employees within the department and account codes to ensure the proper employees are included on the listing and general ledger accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will conduct a training session for applicable health and human services staff regarding accurate reporting of the random moment studies. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

ELIGIBILITY DETERMINATION INCOME AND ASSET VERIFICATION Federal Agency: U.S. Department of Health and Human Services and U.S. Department of Agriculture Federal Program Title: Medical Assistance Program (Medicaid Cluster) and State Administrative Matching Grants for Supplemental Nutrition Assistance Program (SNAP Cluster) Assistance Listing Number: 93.778 and 10.561 Pass-Through Agency: Minnesota Department of Human Services and Minnesota Department of Agriculture Pass-Through Numbers: 2205MN5ADM and 222MN101S2520 Award Period: Year-Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the County implement procedures to ensure that asset and income documentation in the case files matches the information input into the METS eligibility system as required by federal standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will conduct a training and informational session to show staff proper documentation and entry into METS. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services and U.S. Department of Agriculture Federal Program Title: Medical Assistance Program (Medicaid Cluster), Temporary Assistance for Needy Families (TANF), Title IV-E Foster Care and State Administrative Matching Grants for Supplemental Nutrition Assistance Program (SNAP Cluster) Assistance Listing Number: 93.778, 93.558, 93.685 and 10.561 Pass-Through Agency: Minnesota Department of Human Services and Minnesota Department of Agriculture Pass-Through Numbers: 2205MN5ADM, 2201MNTANF, 2201MNFOS and 222MN101S2520 Award Period: Year-Ended December 31, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County perform case file reviews on a more representative sample of the total clients served and that adequate documentation be retained of those reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will conduct a training session for health and human services staff regarding procedures required for case file reviews. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2023

93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2022-025 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: DOM acknowledges OSA's concern regarding the initial review of case files and the prompt action to select and provide a new sample of cases. Historically, DOM has provided a hardcopy of the actual beneficiary case files to OSA. Since those cases were active, an inventory control process, which included a notation in the electronic beneficiary file of the request to send the physical folder to the central office, was implemented. Likewise, upon arrival in the central office, notation of receipt of the files are added to the system prior to providing said files to the auditor. Occasionally, there are multiple files depending on the office with whom a beneficiary communicates, and multiple individual files associated with a family case. Additionally, cases in the sample may also be undergoing redetermination. To ensure that OSA has all the documentation needed for their case review, DOM staff reviews the files prior to sending them to central office. If an adverse eligibility determination is discovered, DOM has an obligation to correct at the time of discovery. As such, changes to the files are noted in the case history, which is available to the auditors. DOM will be transitioning to a paperless environment, which should alleviate any concerns during future audits. Use of Tax Return Resources DOM Does Not Concur. OSA compared eligibility data to state income tax returns. DOM is prohibited from accessing state income tax records per Mississippi Code Annotated ?27-3-73 and currently, does not have access to federal income tax records. DOM maintains that for determining eligibility, it has complied with the CMS-approved state plan. Using the approved CMS MAGI Based Verification plan in effect during the audit time period, the state sought to verify the reported income to the standard of reasonable compatibility, as defined by CMS, through all available electronic data sources. Further, DOM is required to accept the information provided by the applicant and utilize the available verification methods as detailed in the CMS-approved state plan to evaluate the accuracy of the information provided. If an applicant does not report self-employment income, and the tools available to DOM do not reveal such, DOM has performed its due diligence in the eligibility process and complied with the requirements of CMS, DOM's federal regulatory and oversight agency. OSA questioning DOM's determinations based on information that DOM was not provided nor have access to is shortsighted and does not align with the federal regulations that are imposed on this agency. While DOM is only required to use tax return information in certain circumstances, the agency continues to pursue the authority to review state and/or federal tax return information. To date, DOM has not been provided statutory authority to access Mississippi Department of Revenue tax information and is still awaiting IRS approval of the Safeguard Security Risks document. DOM plans to continue to follow the approved federal/state plan for eligibility determinations and will utilize additional resources as they become available. One MAGI beneficiary - DOM did not use taxable unearned income reported on tax return DOM Concurs. The application on file states neither parent has earned income. Although, the unearned income was not included in the initial calculation, adding it did not result in the beneficiary being ineligible. One MAGI beneficiary - self-employment income was reported to MDOM, but MDOM did not request a tax return from the beneficiary. DOM Concurs. The tax return was not requested for this particular beneficiary. This was an oversight, and the issue has been corrected. Two of the 180 MAGI beneficiaries - income was not verified through Mississippi Department of Employment Security DOM Concurs. There were multiple transactions associated with each of the beneficiaries identified. As a result, DOM's eligibility vendor is investigating to determine the reason the MDES search was not performed. One of the 180 MAGI beneficiaries - the beneficiary's case file did not contain an application or verification of income. DOM Concurs. This file could not be located. One of the 300 beneficiaries - auditors were unable to verify that any eligibility redeterminations have been performed since 2018. DOM Does not Concurs. A redetermination was not completed prior to the PHE. During the PHE, DOM was not allowed to performed redeterminations, which would have allowed DOM to update this file. Nine instances - resources were not verified through AVS at the time of redetermination. DOM Does not Concur. This is a prior finding from OSA 2021-041. Please note that all redeterminations in question occurred prior to the OSA audit period (FY22) and were suspended due to the public health emergency from March 2020 to June 2023. The eligibility system was updated in June 2022, after finding 2021-041, to include automatic asset checks within the system processing workflow to eliminate the manual request process and facilitate asset verification through AVS. Again, each instance identified above occurred prior to this implementation. In addition, AVS was checked on the 9 instances OSA sited, which resulted in no change in the eligibility determination. One instance - the beneficiary's case file did not contain a current level of care decision. DOM Does not Concur. DOM disagrees with this finding as redeterminations for the category of eligibility in question were suspended due to the public health emergency from March 2020 to June 2023. The date in question is from July 2021, which falls within this timeframe, and the child would have been eligible regardless. Seventy-three beneficiaries were not included on all of the required quarterly Public Assistance Reporting Information System (PARIS) file transmissions for fiscal year 2022. Of the 73 beneficiaries, six beneficiaries were not included on any quarterly PARIS file transmissions during fiscal year 2022. DOM Does not Concur. Per an amendment to DOM's CMS-approved State Plan, DOM is only required to verify Title XIX applicants and individuals eligible for covered Title XIX services. The above members were covered in Family Planning, which is not considered Title XIX, and did not receive Title XIX services. Therefore, these members should not have been included on any of the PARIS file transmissions. DOM Corrective Action Plan: a. All issues identified will be reviewed with regional office staff. Further, examples of these issues will be included in annual training sessions performed by Eligibility. DOM will continue to work with the vendor to ensure that income is verified through MOES, as applicable, and to implement controls that will limit this issue in the future. Further, DOM is implementing an electronic storage system to house all documents associated with applicants/beneficiary files. b. Cindy Bradshaw c. December 31, 2024

ALN Number 17.225 ? Unemployment Insurance 2022-022 ? Strengthen Controls to Ensure Compliance with Reporting Requirements for Unemployment Insurance. Cat ? L, Finding Type, A, C2 (MW, IMNC) MDES Response: During the pandemic emergency, MDES relied upon the procedures encoded in ReEmployMS to generate the non-emergency tasks. Currently, the Policy and Compliance staff conduct random reviews and tests of both files and reports for accuracy validation using samples identified by the US DOL. The ReEmployMS system generates and stores flat files containing the specific individual records to create the ETA reports. When an error occurs in the generated reports, the staff receive alerts to review the data and reconcile the report. If the system does not generate an error, the information passes as accurate and verification occurs later upon the generation of test samples. Corrective Action Plan: After the relative subsidence of the COVID-19 crisis and review of our activities, MDES better appreciates the value of ensuring that appropriate staff review reports and of maintaining documentation for each examination. Moreover, MDES currently has procedures in place to ensure the review of all reports and to document such activities.

ALN Number 17.225 ? Unemployment Insurance 2022-021 ? Strengthen Controls to Ensure Compliance with Matching Requirements for Unemployment Insurance. Cat ? C, Finding Type, A, C1 (MW, MNC) MDES Response: MDES has begun evaluating both the requirements for and the analysis of the recommended system programming changes to implement the suggested controls. MDES has a goal date of October 31, 2023 to complete the recommended corrective action.

2022-005: Special Tests and Provisions Rural Rental Housing Loan-Assistance Listing 10.415 Noncompliance: AGREED RCHA agrees that it is in noncompliance with the Special Tests and Provisions, we are governed by for the Rural Development Properties. Corrective Action: RCHA Administration will keep working towards budget decisions that will assist with making regular deposit towards the Rural Development Reserve Account by April 1, 2023.

FEDERAL AWARD FINDINGS 2022-002 - ALLOWABILITY Recommendation: We recommend that the Council implement controls to ensure that expenditures are properly reviewed and approved before being charged to a federal award and that adequate supporting documentation is maintained. Action Taken: In February 2023, the current Fiscal Officer received formal training from the National Endowment for the Humanities' grants management staff on allowable costs and proper documentation procedures for federal grants and grant-making entities, under 2 CFR 200. The Fiscal Officer and all staff involved with federal grants subsequently reviewed the Council's internal procedures, to ensure that all expenditure paperwork is received, approved, and filed with the grant documentation.

FINDING 2022-004: Untimely Paid Credit Balance A. Comments on Findings and Recommendations: In response to the untimely paid credit balance, Brillare Beauty Institute agrees with the Single Audit Finding 2022-003. B. Actions Taken or Planned: Brillare Beauty Institute had resolved the student account credit balance issue but not in the required time. Brillare Beauty Institute hired an additional Financial Aid Officer in February 2022 to help with administering the Title IV program. The new position gave the institute the ability to have an additional set of eyes reviewing many of our processes to ensure compliance. At the time of this error, training of the new employee was still in process.

FINDING 2022-003: Under awarded Federal Direct Subsidized Loan A. Comments on Findings and Recommendations: In response to the under awarded Direct Subsidized Loan, Brillare Beauty Institution agrees with the Single Audit Finding 2022-002. B. Actions Taken or Planned: Brillare Beauty Institute has resolved the 2021-2022 award year regarding the under awarded Direct Subsidized loan. The 2021-2022 financial aid award year was re-opened and the under award loan amount was reallocated from Direct Unsubsidized to Direct Subsidized in Common Origination and Disbursement. Brillare Beauty Institute hired an additional Financial Aid Officer in February 2022 to help with administering the Title IV Direct Loan program. At the time of this error, training of the new employee was still in process. Also, Brillare Beauty Institute has contracted with a new 3rd Party Financial Aid Servicer as of December 2022 and as part of this transition, both reviewed and strengthened our Federal Direct Loan policies and procedures.

A. Comments on Findings and Recommendations: 2022-001 - Missing Proof of Loan Entrance Counseling. It seems that the student may not have completed entrance counseling. When this student started, MCU was contracted with Weber as its Third- Party Servicer who used to check entrance counseling before processing our students. Since 2020, MCU has been contracted with Campus Ivy whose platform now requires the Financial Aid Department to upload the entrance counseling proof before processing can occur. B. Actions Taken or Planned: 2022-001 - Missing Proof of Loan Entrance Counseling. The student in question has now performed the required Entrance Counseling. Since May 2020, MCU's updated entrance counseling process with Campus Ivy has helped mitigate a risk of gaps with regard to the completion of entrance counseling. MCU will perform an internal review on current students enrolled before May 2020 to ensure entrance counselings are complete.

A. Comments on Findings and Recommendations: 2022-003 - Untimely Enrollment Status Reporting. The Financial Aid Department has a consistent procedure surrounding NSLDS updates, but like many schools, encountered some technical issues over the summer when the NSLDS platform was updated. B. Actions Taken or Planned: 2022-003 - Untimely Enrollment Status Reporting. MCU switched over to Campus Ivy performing its NSLDS reporting in December 2022 which helps eliminate the duplication of efforts in updating CORE and NSLDS. This should also help to close any potential gaps in reporting.

Finding 2022-001: Segregation of Duties / Internal Control Industrial Development Authority Corrective Action Plan: The following procedures have been implemented to improve controls and segregation of duties. 1. Each Accountant has been assigned an authority for monitoring and invoicing. Invoices are sent on the first of the month. The Auditor or Sr. Finance Manger will monitor Quickbooks to ensure invoices are prepared timely and efforts are made for collection. 2. Loan receivable detail including amortization schedules and payment schedules will be maintained monthly and reconciled to Quickbooks each month. 3. Interfund activity will be recorded timely and reconciled monthly. The Sr. Manger or Auditor will review monthly. 4. Only the Auditor or Sr. Finance Manger will make journal entries. Finding 2022-002: Allowable Costs/Cost Principles and Reporting Industrial Development Authority Corrective Action Plan: 1. To prevent incorrect interest rates in the future, a loan process flow document [Exhibit C] has been created. The project and division manager will use this tool prior to drafting an offer letter, which serves as the first official offering of a fixed rate. Rates will be checked again prior to closing. If at this time, the rate is different then what was provided in the offer letter, the division manager will seek approval from EDA. Please see table included in the corrective action plan. 2. Business Development, Finance, and the Deputy Director have set up monthly loan monitoring meetings. Additionally, Business Development staff will send out annual specific requests for loan monitoring materials for all active loans, on top of the monthly reminders already sent with invoices. 3. ACED Business Development will work with ACED Finance to perform a monthly reconciliation to ensure cash balances are reported accurately and timely in all systems. 4. Federal reports are now being prepared by the Manager of Business Development and reviewed by the Sr. Finance Manager, the Assistant Director, and the Deputy Director before submission with an approval memo tracking their review. Reports are now current and were submitted on time for June 30, 2023. Please contact me with questions or concerns regarding the corrective action plans. Sincerely, Simone McMeans Authorized Designate

The procedure of maintaining appropriate evidence of approval prior to submitting quarterly reports and requests for reimbursement to the grantor will be implemented in fiscal year 2023.

Finding 2022-003 ? Late Refunds: During the audit, we noted two students who did not have refunds returned to the Department in a timely manner. The Institution agrees with the finding. The Institute acknowledges that the lag time between registration and financial aid did contribute to this issue. Similar to the resolution above, the director will continue to monitor these issues and work between the financial aid and business offices to ensure that refunds are made in a timely manner.

Finding 2022-002 ? Incorrect Refund Calculation: During the audit, one student had an incorrect refund calculation resulting in $1,592 that should be returned to the Department of Education. The Institution agrees with the finding. The erroneous action happened due to administrative oversight, the refunds to the Department have been completed in the amount of $211.00 Pell grant and $1,381 in Subsidized Direct loan funds. The school understands the importance of calculating the Title IV refund correctly, as a new financial aid administrator and director move into these roles, more oversight from the director position will be initiated.

Finding 2022-004-- Inaccurate Program Data to NSLDS Management Response: Beloit College?s IT and Registrar?s Office identified the issue in the software system causing the incorrect dates to populate and are working to correct it. Because the Registrar pulls the program information out of the software system, the correct information will be provided as soon as the software issue is remedied. After the software issue is fixed, the Financial Aid Office will audit program level data for accuracy no less than once per semester. Anticipated Completion Date March 1, 2023 Contact Person: Betsy Henkel, Director of Financial Aid henkelb@beloit.edu, 608-363-2662

Finding 2022-003 -- Incorrect Enrollment Reporting to NSLDS Management Response: Management agrees with this finding. The Registrar and Financial Aid Office share a report to process mid-semester withdrawals. An additional column was added to this shared report to more clearly display the date the Registrar should be reporting to the NSLDS when a student withdraws mid-semester. Furthermore, the Financial Aid Office will audit the effective dates reported for mid-semester withdrawals to verify the Registrar is reporting the correct dates. Anticipated Completion Date December 1, 2022 Contact Person: Betsy Henkel, Director of Financial Aid henkelb@beloit.edu, 608-363-2662

Finding 2022-002-- Late Enrollment Reporting to NSLDS Management Response: Management agrees with this finding. Beloit College?s Registrar will exercise the option to use the ad hoc NSC reporting tool to ensure that timely enrollment reporting updates are received by NSLDS. Anticipated Completion Date October 15, 2022 Contact Person: Betsy Henkel, Director of Financial Aid henkelb@beloit.edu, 608-363-2662

U. S. Environmental Protection Agency The Lancaster Farmland Trust respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent accounting firm: Brown Schultz Sheridan & Fritz 454 New Holland Avenue, Suite 101 Lancaster, PA 17602 Audit Period: January 01, 2022 to December 31, 2022 The findings from the schedule of questioned costs for the year ended December 31, 2022 are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS ? FEDERAL AWARD Finding reference: 2022-001 Federal Agency: U.S. Environmental Protection Agency Pass-through entity: National Fish and Wildlife Foundation Federal Program: 66.466 Chesapeake Bay Trust Program Requirement: Matching Type of Finding: Material weakness in internal control over compliance; Noncompliance Condition and criteria: Federal funds were used as matching contributions that are required to be nonfederal. Cause: The Trust did not realize the funds being applied as matching funds were federal when they indicated them as matching funds. This resulted in noncompliance. Effect: Ineligible matching funds were used. Recommendation: The Trust should verify the source of funds it will use as matching funds for federal grants. The Trust?s response: The Trust will secure other nonfederal funds before the grant period ends and will verify the source of matching funds going forward. If the U. S. Environmental Protection Agency has any questions regarding this response, please call Jeffery Swinehart, President and CEO at 717-687-8484.

Finding 2022-002 ? Reporting Information of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Provider Relief Fund Reporting Entity: Northwestern Memorial Healthcare Group Tax Identification Number (TIN): 364724966 Federal Award Period of Performance: 01/01/2020?06/30/2022 (Period 3) Views of responsible officials and planned corrective actions: Management will add additional peer review for the out of period adjustments to ensure reported amounts align with financial reporting for net patient service revenue. Responsible Official: Paal Braathen, Finance Director Completion date: May 17, 2023

Finding 2022-001 ? Activities Allowed or Unallowed and Eligibility Information of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured and the COVID-19 Coverage Assistance Fund Federal Award Numbers: Various Federal Award Period of Performance: 09/01/2021?04/05/2022 Views of responsible officials and planned corrective actions: Management made the adjustments to the report script to ensure all uninsured COVID-19 patient accounts eligible for reimbursement by HRSA are captured for management review and includes accounts with a zero balance and/or have a closed status. The corrective action plan was implemented and in place by December 31, 2021 shortly after the 8/31/2020 Uniform Guidance audit was completed on November 29, 2021. The adjustments will ensure that claims completed after December 31, 2021 are captured. Responsible Official: Michael Mullen, Vice President Revenue Cycle Completion date: December 31, 2021.

2022-004 Name of contact person: Brent Temple, Board Chair Corrective Action: Management concurs with this finding. Management will immediately implement an employee Payment Statement in each employee file (see attached Employee Payment Statement). Proposed Completion Date: The Board will implement the above procedure at their June 3, 2023 meeting.

2022-002 Name of contact person: Brent Temple, Board Chair Corrective Action: Management concurs with this finding. Management will immediately begin using paper checks and limit the use of the debit card to emergencies using dual approval for purchases. Debit card transactions will be reported to the Finance Committee for review and comment. Proposed Completion Date: The Board will implement the above procedure at their June 3, 2023 meeting.