Corrective Action Plans

Internal Controls over distribution of USDA Foods to recipients (Material Weakness) Response and Corrective Action Plan: In addition to strides made in FY23 towards correcting the documentation of recipients in Link2Feed, Brown Bag has continued to address it in FY24 by performing the following- 1) Build communication and relationships with the remaining sites still not documenting (16 of our current 77) 2) Issued emails and phone calls asking sites to update their records. 3) Making appointments and visiting all sites still not in compliance to make an in-person plea to comply. 4) As of November 1, issue written communications warning any remaining sites that food deliveries will cease at the end of the year for any remaining sites not in compliance. No exceptions. Participants will be invited to go to the closest open MBBP site in their area. 5) Management is actively trying to close the loop on the remaining MOU’s, including SAHA, which remains unsigned. Deliveries will cease to any sites not covered with an MOU at the end of calendar year. No exceptions. Responsible Person: Janice Roberts, Program Director, under the oversight of the Mercy Executive Director. Estimated Completion Date: July 1, 2023

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

2023-004 Material weakness in internal control over compliance and compliance for suspension and debarment Recommendation: We recommend the District ensure that this suspension and debarment verification occurs before entering covered transactions and that supporting documentation of this internal control is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work with their departments utilizing federal dollars to ensure the proper suspension and debarment verification is performed for all covered transactions and that the process is well documented. Name(s) of the contact person(s) responsible for corrective action: Paul Bourgeois, Executive Director of Finance and Operations. Planned completion date for corrective action plan: June 30, 2024.

Finding: 2023-001 Name of Contact Person: Angela Karchmer, Social Services Director Criteria: In order for costs to be allowable for purposes of reimbursement they must be allowable in accordance with 45 CFR section 1356.60 and the NC Division of Social Services Manual. All County Department of Social Services employees which provide direct services must maintain daysheets in accordance with the NC Department of Social Services Information System Policy. Recommendation: Require the County Program Directors to implement procedures to ensure that daysheets are properly supported by documentation of time charged to each program. Corrective Action/Management’s Response: Management concurs with this finding and will adhere to the Corrective Action Plan in this audit report. The County has implemented the following process: Daysheet/Documentation Reviews: • QA are conducting random checks bi-weekly to ensure daysheets and documentation are coded correctly. • QA maintains a log of all audits completed. • Audit results are sent to supervisors and social workers for review of the findings. If errors are found discussion takes place regarding how to correct errors. • Supervisors conduct random checks of daysheets and discuss finding during supervision. • All new staff are required within 30 days to watch the state webinar on daysheet entry and take a quiz to insure comprehension. • Daysheet trainings are conducted twice a year for all staff. • DSS Management will work with the Gaston County IT department to upgrade the current daysheet system to allow for better tracking of employee daysheets. • Children and Family Services supervisors will be required to conduct 1 intensive daysheet review per worker each month, attaching eligibility determination paperwork, narratives verifying the work, and ensuring the appropriate funding code is used in daysheets. This paperwork will be reviewed by the program coordinator and administer via an electronic system (Polimorphic). • Supervisors will ensure daysheets are current within 7 days, minimizing errors, and ensuring accuracy. Proposed Completion Date: Management and the Board will implement the above procedures immediately.

District is in the process of establishing procedures and controls by the Business Manager to oversee the retention of verification documentation and information obtained through the verification process.

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

October 25, 2023 School District No. 55-0145, Waverly, Nebraska, respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Period: September 1, 2022 through August 31, 2023 The findings from the October 25, 2023 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2023-001 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. FINDINGS – FEDERAL AWARD PROGRAM AUDIT Nebraska Department of Education 2023-002 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. If the Nebraska Department of Education has questions regarding this plan, please call Mikal Shalikow at (402) 786-2321.

October 25, 2023 School District No. 12-0056, David City, Nebraska, respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Period: September 1, 2022 through August 31, 2023 The findings from the October 25, 2023 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2023-001 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. FINDINGS – FEDERAL AWARD PROGRAM AUDIT Nebraska Department of Education 2023-002 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. If the Nebraska Department of Education has questions regarding this plan, please call Chad Denker at (402) 367-4590.

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 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

Finding: 2023-001: SEFA – Material Weakness The SEFA prepared by management included an incorrect Assistance Listing (AL) number for one grant. Federal grant AL NO. 20.513 Enhanced Mobility of Seniors and Individuals with Disabilities was incorrectly identified as AL No 20.507 Mobility Management. While both grants are from the Federal Transit Agency, they fall under different clusters in the Office of Management and Budget’s Compliance Supplement and thus have different audit requirements. Auditor Recommendation: We recommend management verify with the grantor the AL number of the grant. This can be done by obtaining the information from grant documents, or direct communication with the grantor. We further recommend the SEFA be reviewed for accuracy by an individual not included in the SEFA preparation process. Review should be notate with initials and date. Contact Person Responsible for the Corrective Action: Lisa Cappellari, Chief Financial Officer, LisaC@paratransit.org Management Response and Corrective Action Plan: After the end of Fiscal Year 23-24 on 6/30/2024, Jody Wadley, Finance and Grants Manager, will start the preparation of the FY24 SEFA and make sure all components are correct. Lisa Cappellari, Chief Financial Officer, will review the SEFA for accuracy, checking grant documents and directly contacting the granting agency if necessary. Once each component of the SEFA is thoroughly reviewed, Lisa Cappellari will initial and date.

Name of Contact Person: Jacob Weavil, Finance Director Corrective Action/Management's Reponse: Regarding payroll records, the City is converting to Tyler Time and Attendence which will be a cloud based time keeping software. This will provide the same additional layer of backup support as the cloud-based storage for internal files. All payrolls starting from the first pay period after the network event are being racked with phyiscal timecards submitted by Departments on a bi-weekly basis. Propsed Completion Date: Immediately and ongoing.

Name of Contact Person: Michael Ferris, City Manager Corrective Action/Management's Response: The City has filled the vacant Director position in Public Housing with a temporary consultant who specializes in Housing and Urban Development (HUD) programs. This individual is assisting with training Housing staff and reviewing current internal controls to make improvements to operations. Proposed Completion Date: Immediately and ongoing.

Date 09/22/2023 Finding 2023-001 Federal Agency Name: U.S. Department of Agriculture (USDA) Program Name: Child Nutrition Program Cluster Assistance Listing # (10.553,10.555,10.559) Finding Summary The procurement of Shamrock Foods during August of 2022 was not presented to and approved by the Board as required by the District’s procurement policies. Total purchases were $419,154 during fiscal year 2023. Response from Kuna School District The districts followed the RFP bid process as outlined in CRF 200 and the Idaho Code. Shamrock Foods was the only company that responded to the RFP, and they are known as the sole vendor in the area with this capability. The Kuna School District acknowledges that the final internal step, a second presentation to the board, did not occur. In reviewing the process, the district identified the cause as a change in personnel with authority over the program. In response, the School District has added a new layer of control. Now, when different departments engage in procurement, they will go through the business department. Afterward, they must submit all approved contracts to the business department, along with a detailed completed checklist of the entire procurement process. Additionally, it will be mandatory to include all supporting documents with the contract. Anticipated Completion Date: September -October 2023: additional procurement training. Effective November 2023, it will be mandatory to include all supporting documents with the contract. The contact person responsible for implementation of the corrective action plan: Elmira Feather, CFO.

Finding Reference Number: 2023-001 Initial Fiscal Year: 2023 Summary of Finding: Material Weakness: Gramm-Leach-Bliley Act (GLBA) (U.S. Department of Education, William D. Ford Direct Loan Program, ALN #84.268) Entity’s Corrective Action Plan Due to turnover within the IT Department, GLBA requirements were not communicated well to incoming staff or to the organization. Once GLBA requirements were discovered, a plan was developed to begin implementing GLBA controls and revise our security plan. The plan to bring the organization into GLBA compliance was developed for the 2023-2024 school year and was not in effect before this audit. The IT Department, and key stakeholders within the organization, are working to ensure GLBA compliance within the next year.. Anticipated Completion Date: September 21, 2023 Name and Title of Responsible Person: Luke Edwards, Director of IT.

Corrective Action to be Taken for Finding 2023-001 - Food Purchases o The practice of purchasing food will be to have the Caseworker for each case take the family shopping to Giant Foods, where there is a Catholic Charities account. The Caseworker should shop with the family and then after the purchase is completed the clients signs the required RF-35 documentation and the receipt is then given to the Program Director to pay within the accounting software. A copy of the signed RF-35 and receipt will be made available for the client case file and for the Fiscal department for billing purposes. o If the option of shopping at Giant Foods is not available due to dietary restrictions or culture requirements, gift cards to these specific grocery stores will be made using a Catholic Charities credit card. The gift card will be given to the family for them to sign the appropriate RF-35. The Caseworker will then take the family shopping to ensure clients spend funds on federally approved food items. A copy of the receipt for the gift card purchases and the signed RF-35 as well will be made available for the client case file and for the Fiscal department for billing purposes. - Rent Payments o The practice will be to have a lease from the Landlord to issue a check for security deposit and rent. On the day of move in, the lease will be signed by the client, the RF-35 will be signed, and then the check will be released to the Landlord. Once the lease is signed, a copy of the lease and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. o The practice when a client is going to be living with their US-tie is that a letter of agreement between the case’s primary applicant and the US-tie will be established explaining the amount the client is responsible for paying for rent and utilities. That agreement will then be signed by the client, the US-tie, and will be witnessed by a third party (Caseworker, Program Director, Operations Director). That agreement will then be utilized as the documentation for requesting rent payments on behalf of the client along with the signed RF-35. A copy of this agreement and signed RF-35s will be made available for the client case file and for the Fiscal department for billing purposes. o The practice when two unrelated clients are going to be living together is as follows: all appropriate required documentation establishing the responsibilities between the two clients will be established. The lease and all agreements will then be signed and will be witnessed by a third party (Caseworker, Program Director, Operations Director). The lease and signed agreement will then be utilized as the documentation for requesting rent payments on behalf of the clients along with the signed RF-35s for each case. A copy of the lease, this agreement, the signed RF-35s will be made available for each of the clients’ case files and for the Fiscal department for billing purposes. o Rent payments made after the initial payment will be made in the amount of the client’s rent according to the lease and will be accompanied by a signed RF-35. A copy of each signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. - Utilities o Educate the clients to turn utility bills into the Caseworker and have the client sign a RF-35 in the amount of the utility bill. The Caseworker then gives the utility bill to the Program Director to enter the invoice into the accounting software for payment. A copy of the utility bill and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. o If the Landlord pays the utilities and seeks reimbursement, the landlord will provide a copy of an invoice for the client to turn into the Caseworker and have the client sign a RF-35 for the amount of the utility bill. The Caseworker then gives the invoice to the Program Director to enter the invoice into the accounting software for payment. A copy of the invoice and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes.

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements (material weakness). Auditors’ Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the Authority should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements.Grantee Response: Transit Authority of Warren County has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, we acknowledge our responsibility for the financial statements and have the ability to make informed judgments on those financial statements. Management expects that it will continue to outsource the preparation of the annual financial statements to its audit firm as this is the most cost effective manner to produce this information.

Finding 2023-003 Department of Agriculture Federal Financial Assistance Listing #10.766 Communities Facilities Loans and Grants Cluster Finding Summary: The System does not have an internal control system designed to provide for the preparation of the schedule of expenditures of federal awards (the schedule. We requested our auditors to assist with the preparation of the schedule. Responsible Individuals: Teresa Mallett, Chief Financial Officer Corrective Action Plan: Due to cost considerations, we will continue to have Eide Bailly LLP prepare our draft schedule of expenditures of federal awards and accompanying notes to the schedule of expenditures of federal awards. Anticipated Completion Date: Ongoing

Auditor’s Recommendation: The auditor recommends the District implement controls to ensure student files are complete and accurate and conduct training to for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Views of Responsible Officials of Auditee: The district will continue to strengthen current controls and implementnew controls to ensure student files are complete and accurate. This will include training registrars to enhance documentation that is obtained to support the student records for all situations in which a student may be removed from designated cohort.

Responsible Official’s Response and Corrective Action Plan Management has added a more experience accountant and hired a BDO Field Accountant firm to expedite processes within the Organization. Management is creating new policies and procedures and tightening internal control to address issues related to timeliness of reporting. New procedures were implemented within the fiscal year 2023. Planned Implementation Date of Corrective Action Date: 04/01/2022 Person Responsible for Corrective Action Rosemarie Bizune Title: Director of Finance

Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System’s expense tracking spreadsheet, which identified the expenses claimed under the federal program as allowable costs included three expenses which were subsequent to December 31, 2022, and therefore, outside the period of performance. Although invoices were approved for payment, only one invoice included documentation relating to specific approval as allowable costs related to the grant. Likewise, the Health System’s expense tracking spreadsheet did not include a documented secondary review and approval by someone other than the preparer. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a control process which includes an independent review and approval of the expense tracking spreadsheet which identifies the expenses claimed under the federal program as allowable costs and retain documentation of the review process. The expenses referenced as being outside of the period of performance were costs to a vendor whom was contracted/engaged prior to the period of performance. Due to supply chain/vendor demand issues, the work was completed subsequent to the period of performance. It was our understanding that these are eligible expenses under the program, as the work and payment was delayed due to supply chain/vendor demand issues. However, if necessary, we have identified other qualifying expenditures incurred within the period of performance we can submit which will satisfy allowable costs claimed for the period of performance. Anticipated Completion Date: 01/31/2024

College Response: In November 2023, in conjunction with the College’s annual external audit, errors were identified in Cuyahoga Community College’s timely Return to Title IV funds. After careful internal review of the student records, all applicable corrections to student records were made to ensure compliance with federal regulations. All financial aid funds related to Return of Title IV funds had been returned to the U.S. Department of Education. In December 2023, the college completed a review of internal procedures and processes to mitigate untimely Return of Title IV funds in the future. Mitigation Strategy: The following process and procedural changes for the review of the Return of Title IV funds have been put in place to resolve the issue of late returns of funds as identified in the 2022-2023 external audit: 1. Retrained staff responsible for the Return of Title IV processing, including updates and revisions to the policies and procedure manual for this financial aid function to strengthen the internal quality check for manual review of the accuracy of returns 2. Identified and cross-train additional financial aid employees to support the high-volume financial aid process, including two team members to check and validate the timely processing and accuracy of the return of funds 3. Developed an enhanced report to compare completed calculations of the return of funds in Banner to the processed with the COD-generated report to verify the timely return of funds 4. Automated reports for Return of Title IV report to be delivered bi-weekly to the central mailbox, which will enable multiple employees to have access to the Return of Title IV reports and ensure more than one trained team member to timely process the return of funds to meet the 45-day federal requirement 5. Conduct a quality check of the Return of Title IV funds to assess the accuracy of the calculation and timely return of funds by conducting an internal Financial Aid Team review of 5-10% of the return of funds assessment every 60 days Anticipated Completion Date: 12/19/2023 Responsible Contact Person: Angela Johnson –VP of Enrollment Management

2023-01 Recommendation: The Organization review its transactions for repairs and maintenance and obtain the fixed assets depreciation schedule in order to properly record capital improvement and depreciation transactions. Corrective Action Planned: We acknowledge that there is currently not a sufficient process in place to ensure that capital expenditures and depreciation are properly recorded. A policy will be implemented to review the accounting records to ensure that capital expenditures and depreciation are properly recorded now that the Organizations has staff and an outsourced accounting firm with the knowledge and skills to fulfill this need. Implementation Date: This action plan is for the entity to adopt a policy to review repairs and maintenance activity on a regular basis to determine what amounts need to be capitalized as a fixed asset to ensure proper treatment of activity.. This will be implemented by the entity by December 31 2024.

Management concurs with the recommendation. Management has implemented policies and procedures in Accounting Procedure Manual to ensure revenue would be recorded properly.

Finding 2023-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the consolidated schedule of expenditures of federal awards (the schedule) and accompanying notes to the schedule. Responsible Individuals: Dalton Huber, Chief Financial Officer Corrective Action Plan: Lack of resources make this necessary. Anticipated Completion Date: Ongoing