Corrective Action Plans

The transitioning to the new Finance Director continued during year and additional account reviews were required. This has caused a delay in the timing of our filing. HealthHIV will continue to addressed our internal control on filing our audit report timely and by the FAC due date.

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s currently in place. Changes will be made if necessary. Additionally, TCA has hired a third-party consulting firm that can assist with grant best practices.

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. TCA will also assess the current staff to ensure the proper personnel is in in place.

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve efficiency. Each position in the Business Office other than HR has been crossed trained with one-to-two other team members. Cross training throughout the business office was implemented in 2016 and has continued to exist. Each position has the ability to have someone step in case of emergency, elongated vacations and when/if someone resigns or is terminated. The positions are not covered in entirety, but the important items that must be dealt with can be and are accomplished. Examples are as such: Accounts Payable is covered by our Special Ed Bookkeeper, and other staff have the ability to review manifest once generated. Payroll has been covered by the Assistant Business Administrator when vacations or vacancies have existed, Grants can be covered by the Business Administrator when vacations or vacancies have existed. The Assistant Business Administrator is covered by the Business Administrator during vacations and vacancies. Each position continues to do their own assigned job duties and takes on the other tasks as necessary. The work may not get completed in the same timely fashion as if the actual staff member holding the position was there because they are also completing their own tasks, but the work does get accomplished. When there are multiple turnovers and/illness occurring at the sometime it makes it challenging even when cross training exists. Every year the Business Administrator reviews workloads and reassesses if changes should occur to help create efficiencies and create equivalent workload between all staff members. While some positions have more deadlines than others it can appear that their plates are larger than others, but frequently tasks are divided out throughout the team to help alleviate this. These discussions are brought forth to COLT, the Senior Leadership team at the SAU, and restructuring is finalized at that time. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Already occurs

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of allowable costs. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

Responsible Official’s Response: Management agrees with the recommendation to establish and follow a documented internal control process over the review of reporting. Staff will work to develop an appropriate internal control process and once the process has been developed staff will document in writing, the process and review it with department leaders. Additionally, staff members working in areas concerning this process will be trained to ensure process adherence.

Finding 2022-001 Federal Program Funds Utilized for Non-Federal Programs Recommendation: The Authority should locate additional sources of non-federal funds or reduce costs sufficiently so that the program can have enough cash to cover ongoing operations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Taken: The Authority has reevaluated its cost allocation plan and restructured various departments to better align staffing. This process helps ensure the COCC and funds are being properly charged for actual costs incurred. The Authority is also redeveloping its entire portfolio. This process had been and will continue to bring in developer and management fees to the COCC. Name of Contact Person responsible for Corrective Action: Cia Cook, Deputy Executive Director & CFO Planned Date for Corrective Action plan: June 30, 2024

The Club has evaluated the cost vs. benefit of establishing internal controls over the preparation of financials statements in accordance with GAAP and determined that it is in the best interest of the Club to outsource this task to its external auditors, and to carefully review the draft financial statements and notes prior to approving them and accepting responsibility for their content and presentation.

A new employee prepared the final grant reporting to the grantor (State of NH) who had no knowledge or participation in the FY21 audit. In FY21 the auditors had tested the multi-year grant, and the Club did not clearly label the most up-to-date and final audited files, and incomplete information was used for preparation of the final report. The Club has engaged an IT consultant to improve its technology. Additionally, the finance team will also institute best practices for digital file management.

FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October 2022. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels. A Case Manager managed all aspects of an individual patient’s care. Once a patient’s care was complete, the case was closed by the Case Manager in the online portal. Completed cases were compiled by the Clinical Manager into a data sheet, which was then submitted to the Manager of Administration. The Manager of Administration based on the compiled data sheet prepared and submitted a reimbursement request to the State without an oversight, review, or approval process to ensure the reimbursement request was complete and accurate. Recommendation: We recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate.” Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: Option 2: “We disagree with part of the finding.” Explanation and Reason for Disagreement: The County already has an established process of review and evaluation. The Case Manager’s reports on work are reported to their superior, the Clinical Manager. The Clinical Manager reviews data, enters report data into the program portal as required. A spreadsheet with case start date, patient ID number, home address and payment is submitted to the Manager of Administration who acts as secondary review and completes the invoice and submits it to the State where an additional process of review is then executed before approval and federal funds are drawn. Once the invoice is submitted, the Manager of Administration makes two copies of the invoice and the spreadsheet, one copy is sent to the Clinical Manager and the other to the Auditors office. This is an excellent procedure for checking and balance. Description of Corrective Action Plan: The Elkhart County Health Department receives elevated blood lead levels from the State. The Lead Case Manager determines if criteria are met to initiate a case. They conduct a home visit and make appropriate referrals. The lead case manager enters case information into NBS. INDIANA STATE BOARD OF ACCOUNTS 38 Ongoing case management for children with elevated blood leads levels includes coordination of blood lead tests, education, and appropriate referrals. The Lead Case Manager submits a list of cases each month to the Clinical Manager that meet the criteria for submission for reimbursement. The criteria are a completed home visit, a completed nutrition assessment, a referral for developmental assessment and documentation in NBS. The Clinical Manager reviews the cases in NBS and compiles a list and submits the data sheet to the Fiscal Manager. The Fiscal Manager prepares the invoice and submits it along with documentation to the State and Timothy Conley for review and approval. The Elkhart County Health Department will continue to have collaborative compilation of data which will be reviewed by field specialists before being submitted to the Manager of Administration for invoice reimbursement. The data and records are reviewed by the Manager of Administration and the invoice total will be confirmed and documented with the Clinical Manager prior to being submitted to the State for review and approval. Confirmation emails of secondary review will be retained as documentation. The State must approve invoices with supporting documentation and is the external party requesting reimbursement with Federal funds once approved. A copy of supporting documentation is supplied to the Elkhart County Auditor’s Office to be retained on file and to be used for receipting records once reimbursement is received and deposited into its unique 8000 series fund. Anticipated Completion Date: August of 2023 (Note: Provide the projected date of completion of major tasks for the planned corrective actions.)

FINDING 2022-003􀯗 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting􀯗 Summary of Finding:􀯗􀯗 Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the Department of the Treasury (Treasury). The reporting periods, as well as the respective due dates, are based upon type of recipient and its population, as well as the recipient's allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The County was classified as a metropolitan county with a population below 250,000 residents that received an allocation of more than $10 million in Coronavirus State and Local Fiscal Recovery Funds (CSLFRF). Therefore, quarterly P&E Reports were due by January 31, 2022, and the last day of the month after the end of each quarter thereafter. The County submitted four quarterly P&E Reports during the audit period. The County’s process for the completion and submission of the P&E Reports was the Grant Administrator prepared the P&E Reports and the County Auditor reviewed them prior to submission; however, the control was not effective in detecting and preventing noncompliance. Two of the four quarterly reports submitted during the audit period were selected for testing. The County utilized the current period obligations field to document total obligations less current period expenditures. For the reports tested, the current period obligations, per the County’s interpretation of the field, were not supported by the County’s records. The following errors were noted: Quarter 2 P&E Report (April 1, 2022 - June 30, 2022) 􀄁 The Current Period Obligations for the Revenue Replacement project were overstated by $399,097. Quarter 3 P&E Report (July 1, 2022 - September 30, 2022) 􀄁 The Current Period Obligations for the Prairie Creek Water Run Water Line project were overstated by $67,773. 􀄁 The Current Period Obligations for the Parks Department - Latrine project were overstated by $25,758. 􀄁 The Current Period Obligations for the Foraker/Southwest project were overstated by $230,338. The lack of effective internal controls and noncompliance was a systemic issue during the audit period. Contact Person Responsible for Corrective Action: Patricia Pickens Contact Phone Number and Email Address: 574.535.6719 ppickens@elkhartcounty.com􀯗 􀯗 􀯗 INDIANA STATE BOARD OF ACCOUNTS 36 117 N. 2ND St Rm 203 Goshen, IN 46526 - 574-535-6719 􀀃 Views of Responsible Officials:􀯗􀯗 We disagree with the finding.􀯗􀯗 􀯗 Explanation and Reasons for Disagreement:􀯗􀯗 The finding does not accurately reflect the administration of the SLFRF program and fails to correctly identify key challenges that impacted the difference in data. There is a rigorous system of diligent records keeping, auditing expenditures, and internal controls including multiple points of review and approval for reporting ARPA funds. All expenditures are accounted for and maintained with supporting documentation. The auditing team can clearly demonstrate attention to detail in the tracking and reporting of all expenditures. They also have extensive record of on-going issues with the reporting portal including tickets and communications with Treasury support. They have identified issues with the portal that prevented the submission of reports or caused erroneous calculations/data.

Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024

Federal Agency Name: Department of Health and Human Services; Department of Agriculture Assistance Listing Number: #93.498; #10.766 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution; Community Facilities Loans and Grants Cluster Finding Summary: The Hospital does not have an internal control system designed to allow for a complete and accurate Schedule being audited. We were requested to draft the Schedule. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: We will continue to have our auditors assist with preparing the schedule of expenditures of federal awards (SEFA). Anticipated Completion Date: Ongoing

2022-005 Material Weakness: See finding 2022-005. Federal program: Public Housing Capital Fund CFDA 14.872 Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to better establish policies and procedures to ensure compliance with the grant requisition processes. Action taken: We concur with the recommendation. The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management is evaluating its processes and procedures related to grant requisitions and is planning on implementing procedures to ensure grants are requisitioned in the future.

2022-003 Material Weakness: See finding 2022-003. Federal program: Public Housing Capital Fund CFDA 14.872 Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Action taken: We concur with the recommendation. The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its submissions were not timely. Management engaged the services of a fee-accountant subsequent to year-end who will assist with these submissions going forward.

Finding 2022‐006 – Special Tests and Provisions Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not have adequate internal control policies in place to ensure review and approval over the reserve funds, monitoring of all required debt covenants, proper funding of the reserve accounts, or to ensure that proper procedures are followed for obtaining USDA approval for any withdrawals from the debt service reserve funds. Responsible Individuals: Kelly Johnston, CFO Status: The Hospital enhance internal control policies to ensure formal documentation of reviews for the reserve fund reconciliations is retained, monitoring that the required debt covenants are monitored and reviewed, reserve funds are properly funded, and that there are proper procedures in place for obtaining USDA approval for any future withdrawals from the debt service reserve funds. Anticipated Completion Date: 6/30/2024

Finding 2022‐005 – Reporting Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not submit the quarterly reports for 2022 to the United States Department of Agriculture and the interim financing lender and did not send the annual budget, financial statements, cost report, and debt service reserve calculation to the United States Department of Agriculture. Responsible Individuals: Kelly Johnston, CFO Status: Management will implement policies and procedures surrounding the reporting required under the United States Department of Agriculture loan program as well as provide the required reports on a timely basis to all respective parties. Anticipated Completion Date: 6/30/2024

Finding 2022‐004 – Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: United States Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: Proper controls over financial reporting include the ability to prepare the schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. We were requested to draft the Schedule. Responsible Individuals: Kelly Johnston, CFO Status: It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule and accompanying footnotes. We requested that our auditors, Eide Bailly LLP, prepare the Schedule and accompanying footnotes as a part of their annual audit. We have designated a member of management to review the drafted Schedule and accompanying footnotes. Anticipated Completion Date: Ongoing

Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this material weakness and has considered adding additional personnel to assist in the monthly reconciliations and financial statement preparation. Management reviews and approves the monthly interim financial statements.

Management's Corrective Actions: Community Action of East Central Indiana, Inc. management will implement auditor's recommendations through revisions of policies and procedures with annual target of June 1 for availability of all relevant information for completion of annual audit. The 2023 audit is expected to be timely filed.

Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to work with HUD and review staffing as well as work with the fee accountant to ensure the proper supporting documentation is retained. Planned Completion Date for CAP Immediately

Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to work with HUD and review staffing as well as work with the fee accountant to ensure the proper supporting documentation is retained. Planned Completion Date for CAP Immediately

Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to work with HUD and review staffing as well as work with the fee accountant to ensure the appropriate information is available. Planned Completion Date for CAP Immediately

Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to work with HUD and review staffing as well as work with the fee accountant to ensure the proper supporting documentation is retained. Planned Completion Date for CAP Immediately

Contact Person Tim Greene, Executive Director Corrective Action Plan The Authority will continue to work with HUD and review staffing as well as work with the fee accountant to ensure the proper personnel perform reconciliations within a timely manner of year end. Planned Completion Date for CAP Immediately