Corrective Action Plans

Finding reference number: 2022-001 Corrective action planned: We agree with the finding noted above. Prior to the issuance of these financials, we began a project to implement system based controls over changes to the vendor master file. Additionally, we are in the process of designing manual controls/review process which would further strengthen our control environment.

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review of wage rates for eight employees selected for testing. There was no formal documented review for the calculation of indirect costs submitted for reimbursement for four months selected for testing. There was no formal documented review for seven reimbursements requests selected for testing. Washburn Center has designed internal controls over these areas; however, the controls were not formally documented. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: Management will review the current active review process and implement a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: December 2023

Finding Number: 2022-003 Condition: The Organization did not submit audited financial statements to REAC within the required time frame after the fiscal year end for the year ended December 31, 2022. Planned Corrective Action: No further corrective action will be taken. The Section 232 HUD insured mortgage is in default. The Mortgage Servicer made claim on the HUD insurance and has been paid. HUD is working through the process to bring the note/mortgage to sale later in 2023 or early 2024. Contact person responsible for corrective action: Daren Lee, Chief Operating Officer Anticipated Completion Date: March 31, 2024

Finding Number: 2022-002 Condition: As of December 31, 2022, principal and interest payments on the mortgage are delinquent by $53,154. In addition, the various escrows are underfunded by $13,635. Planned Corrective Action: No further corrective action will be taken. The Section 232 HUD insured mortgage is in default. The Mortgage Servicer made claim on the HUD insurance and has been paid. HUD is working through the process to bring the note/mortgage to sale later in 2023 or early 2024. Contact person responsible for corrective action: Daren Lee, Chief Operating Officer Anticipated Completion Date: March 31, 2024

2022-001 Income Certifications Name of contact person ? Angela Riley, CFO Corrective action ? The Corporation agrees with the finding, and has continued to implement strategies to address these issues throughout 2021 and 2022, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date ? Management has begun the corrective action and is expected to have additional internal controls and training done by December 31, 2023.

View of Responsible Officials The Department does not concur. The Department notes extensions are in place related to COVID-19 and the Tydings Amendment through the Department of Education mitigating the condition noted. The Department will confer with the US DE to clarify the extensions in place and resolve any disparities identified within the finding. Anticipated Completion Date: Completed as of the date of this report Contact Person: Lindsey Labonville, Melissa White Rejoinder Based on the supporting documentation provided by the Department, it did not appear that the expenses identified within the condition found were charged to the correct period of performance during the liquidation period. Subsequently management adjusted the CAN the expenses related to which would correct the condition found.

View of Responsible Officials The Department acknowledges the misinterpretation of the agreement as a subaward has led to a failure to comply with 2 CFR 170. Underlying this misinterpretation was the Department?s failure to differentiate between entering into agreements with other state agencies and entities recognized as component units of state government such as the NH Business Finance Authority; noting FFATA reporting would not apply to agreements between state agencies. Accordingly, the Department will review existing policies and procedures related to FFATA reporting to ensure agreements with component units of state government are properly considered and reported. Anticipated Completion Date: June 30, 2023 Contact Person: Taylor Caswell

Quarterly Reporting The State concurs in part with the condition and recommendation. A unique challenge with ERA reporting has been changes in the U.S. Treasury portal for that program, which have impacted the State?s ability to download and provide copies of past reports that have been submitted. In addition, this issue in the reporting portal has been inconsistent, as some previously submitted reports were made accessible by Treasury, while others were not, which resulted in the State being able to access some requisite materials but not others. The State did not have documented procedures to ?pull down? copies of reports it had submitted to Treasury because the State has otherwise been able to rely on access to its previously submitted reports within reporting portals in order to enable the testing required during audit for the relevant periods. Meaning, in the State?s experience with COVID-19 related federal funds reporting, it has been able to access and download past reports for purposes of audit. However, also noted above is that the Treasury portal was recently revised and updated to allow for accessing previously submitted ERA reports that were not otherwise available (the communication from Treasury acknowledging this change was provided by the State). However, the reporting portal change did not take place in time for the State?s auditors to reasonably conduct the necessary testing. The State did provide the data and materials it reported to Treasury for the relevant periods, but auditors were unable to test and validate that data because the State could not access and provide a copy of what was actually uploaded into the portal. Nevertheless, to avoid any such potential issues in the future, the State has already implemented a procedure that involves downloading copies of reports as soon as they are submitted and taking screenshots of portions of the portal where perceived necessary to support what the State has submitted to Treasury. This updated procedure will be memorialized in the program?s transaction processing memo during its next update. Monthly Reporting The State concurs in part but has already implemented related corrective action in line with the recommendation above. The State would also like to note that as part of the ERA reallocation process U.S. Treasury has relied on both quarterly and monthly reporting, and that the State has continued to engage in thorough monitoring of its subrecipient and receives regular reports from that subrecipient, including weekly, biweekly, and quarterly data, which also includes quality control reports. This is inclusive of the monthly reports that were required by U.S. Treasury at one time but no longer are. The State reviews and then discusses reports received at standing, calendared, weekly meetings with the subrecipient and often engages in e-mail correspondence concerning those reports, especially if any questions concerning the data provided arise. However, the State has acknowledged that its documentation of those weekly conversations needed to be more formally memorialized. During the current fiscal year, the State began providing agendas and summaries of topics discussed during the weekly check-ins and will ensure that the program?s transaction processing memo adequately documents this requirement and procedure. The very nature of this program and U.S. Treasury?s facilitation of it has required the State and its subrecipient to stay in close contact, make regular decisions on strategies and policies within the program, and closely consider data relative to it. Anticipated Completion Date Quarterly reporting - Corrective action relative to acquisition of submitted federal reports has already been implemented and this revised procedure will be memorialized in the transaction processing memo for the program during its next update in Q1 2023. Monthly Repotting - Corrective action relative to documentation of weekly meetings was already complete as of the State?s response to this finding, and the State will ensure that the transaction processing memo for the program reflects these measures during its next update in Q1 2023. Contact Person Chase Hagaman, Lisa Cota-Robles, and Emily Larson

FINDING 2022-003 Contact Person Responsible for Corrective Action: Robert Glover Jr. Contact Phone Number: (219) 945-0250 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: COVID-19 ? Education Stabilization Fund ? Equipment and Real Property Accounts Payable will track purchases of equipment over the capitalization threshold and notify the Business Manager of qualifying expenditures. The Business Manager will confirm that the items have been barcoded with the appropriate fund administrator.

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There has been turnover in the finance department and the past employees who would have been responsible for this are no longer here. There are already internal controls in place to ensure that the monthly sponsor claims submitted match the school?s meal count reports. The Treasurer will continue to ensure that everything is correctly entered before submission. Anticipated Completion Date: March 2023

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Spokane Housing Authority January 1, 2022 through December 31, 2022 This schedule presents the corrective action planned by the Housing Authority for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-01 Finding caption: The Housing Authority had inadequate internal controls for ensuring compliance with Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Housing Authority contact person: Kathy Clark, Finance Director 25 W. Nora Avenue Spokane, WA 99205 (509) 252-7109 Corrective action the auditee plans to take in response to the finding: Spokane Housing Authority acknowledges the above reference finding. Although personnel responsible for conducting the HQS inspections and ensuring owners corrected the cited life-threatening deficiencies were trained on policy and procedure, SHA did not establish the internal controls to ensure proper follow-up was made. In September 2022, SHA, established a Housing Support Specialist position, which will log life-threatening HQS deficiencies as documented on the HQS inspector?s reports daily and follow-up with the landlord within the 24-hour timeframe to ensure that repairs have been addressed and completed. If repairs have been made pursuant to the directive given by the inspector, then a letter will be sent to the landlord and tenant indicating that the 24-hour hazards have been fixed. If the landlord fails to comply within the 24-hour timeframe, then the unit fails, and a Notice of Termination of HAP letter will be sent to the landlord and tenant. SHA will work with the tenant to start the process of locating a new unit that passes HQS. The log of deficiencies will be reviewed by the Inspections Coordinator regularly as an additional internal control. Anticipated date to complete the corrective action: January 1, 2023

Finding 2022-002: Internal Controls (Material Weakness) The Chief Executive Officer will ensure that the Accounting Officer makes adjustments to record all grants ahead of time in Quickbooks and deduct funding as we spend from these areas to directly show grant balances and that the restricted funding is spent in compliance with the funding received. We will also provide these findings to a certified public accountant to make sure they are adhered to correctly and meet the requirements of both state and federal funding. To address these findings and ensure compliance with Title 2 requirements, Habitat for Humanity Yuba/Sutter will implement the following corrective action plan: 1. Operationalize the Grants Management Standards ? Habitat for Humanity Yuba/Sutter will conduct a comprehensive review of its current grants management policies and procedures to identify any gaps or deficiencies in compliance with Title 2 requirements. ? The organization will update its grants management policies and procedures to align with Title 2 regulations, including documentation requirements, financial management, reporting, and record keeping. ? Habitat for Humanity Yuba/Sutter will provide training and resources to its staff involved in grants management to ensure they are knowledgeable about the updated policies and procedures. ? The organization will establish a system for ongoing monitoring and internal audits to ensure compliance with grants management standards, and make necessary adjustments as needed. 2. Establish a Robust Marketplace of Modern Solutions ? Habitat for Humanity Yuba/Sutter will conduct a thorough review of its current marketplace of solutions, including vendors, software, and technologies used in its operations. ? The organization will identify opportunities to modernize its systems and processes to enhance efficiency, streamline operations, and ensure compliance with Title 2 requirements. ? Habitat for Humanity Yuba/Sutter will develop a plan to implement modern solutions, including budgeting, procurement, and implementation timelines. ? The organization will establish a process for ongoing evaluation and monitoring of the effectiveness of the modern solutions implemented, and make necessary adjustments as needed. 3. Manage Risk ? Habitat for Humanity Yuba/Sutter will conduct a comprehensive risk assessment to identify potential risks associated with grants management and compliance with Title 2 requirements. ? The organization will develop and implement risk mitigation strategies, including internal controls, monitoring mechanisms, and contingency plans. ? Habitat for Humanity Yuba/Sutter will establish a system for ongoing risk management, including regular risk assessments and reviews, and updates to risk mitigation strategies as needed. ? The organization will ensure that all staff involved in grants management are aware of the risk mitigation strategies and trained on how to implement them effectively. 4. Achieve Program Goals and Objectives ? Habitat for Humanity Yuba/Sutter will review and align its program goals and objectives with the requirements of Title 2. ? The organization will develop a comprehensive plan to ensure that its programs are designed, implemented, and evaluated in accordance with Title 2 guidelines, including outcome measurement, data collection, and reporting. ? Habitat for Humanity Yuba/Sutter will establish regular monitoring and reporting mechanisms to track progress towards program goals and ensure compliance with Title 2 requirements. ? The organization will provide training and resources to its staff involved in program management to ensure they are knowledgeable about the updated program goals and objectives and the requirements of Title 2.

Finding 2022-003 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster CFDA #: 84.063, 84.007, 84.268, 84.033 Finding Summary: Due to the changeover in software in the current year, the College did not have an internal control process in place to provide for an independent review over the return of Title IV calculations. Responsible Individuals: Frankie Everett, Director of Financial Aid Corrective Action Plan: The department will assign an individual to randomly sample 30% of the R2T4?s each term, documenting the results and ensuring the system is calculating and reporting these accurately throughout the year. Anticipated Completion Date: January 15, 2022

Recommendation: Recommend management review their policies to ensure distributions are made based on the biannual surplus cash calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and update their policies and procedures to ensure distributions are made based on the biannual surplus cash calculations based on the dates in the regulatory agreement. Name of the contact person responsible for corrective action: Connie Bednarek, Controller Planned completion date for corrective action plan: June 30, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Donya Jordan Contact Phone Number: 219-866-4654 Views of Responsible Officer: We concur with the finding Description of Corrective Action Plan: We will have the Interim Report and Project and Expenditure Reports be reviewed by one of the deputies in the office which would ensure accurate and timely reporting. Anticipated Completion Date: 07-01-23

Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the reserve funds for the federal program. Responsible Individuals: Nina Hollingsworth, CFO and Marcus Lewis, CEO Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the Health Center?s reserve fund is completed with formal documentation noting the review. Anticipated Completion Date: 10/31/2023

2022-005 Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Activities Allowed or Unallowed and Allowable Costs/Costs Principles Material Weakness in Internal Control Over Compliance Finding Summary: There was no review and approval by a separate individual outside of the preparer over the lost revenue calculation utilized to claim expenditures under the federal program. Responsible Individuals: Kelly Johnston, Interim CFO; Larin Jones, Controller Corrective Action Plan: There will be a secondary review and approval by a separate individual outside of the preparer over future lost revenue calculations, if applicable. The secondary review and approval will be documented and recorded. Anticipated Completion Date: December 31, 2023

2022-004 Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #840428757 Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Material Weakness in Internal Control Over Compliance Finding Summary: There was no review and approval by a separate individual outside of the preparer over the lost revenue calculation and the special report submitted to the Department of Health and Human Services Responsible Individuals: Kelly Johnston, Interim CFO; Larin Jones, Controller Corrective Action Plan: There will be a secondary review and approval by a separate individual outside of the preparer over future lost revenue calculations and expense listings, if applicable, and the special report submitted to the Department of Health and Human Services. The secondary review and approval prior to submission will be documented and recorded. Anticipated Completion Date: December 31, 2023

Finding 2022-004 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: The Hospital?s Federal Financial Report for grant number 02-001-916646223 through the period ending June 7, 2022, was marked as final and indicated the Hospital expended the full $435,625 federal award, which was not accurate. Responsible Individuals: Ashley Jaramillo, Chief Financial Officer Corrective Action Plan: Informed USDA of actual expended. Anticipated Completion Date: September 29, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have complete and accurate information for the P & E report. In addition to the policy and procedure, an added person will assist with these reports by creating the reports through our financial software and reviewing before giving the reports to the Auditor who will prepare the P & E reports and then the Commissioner?s will review before the Auditor submits the report to the Treasury. The Bartholomew County Auditor?s Office is continually designing and implementing a proper system of internal controls so that any errors are detected and corrective measures are made as needed, Anticipated Completion Date: December 31, 2023

United States Department of Health and Human Services Ascentria Care Alliance respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS United States Department of Health and Human Services 2022-001 COVID-19 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: The Organization should review the PRF Reporting Portal instructions detailing how to complete individual schedules in the Reporting Portal, and ensure that all costs claimed are fully supported. The Organization should also ensure that an individual with sufficient training and experience is assigned to review and approve all grant reports submitted through the Reporting Portal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement controls over reviewing and approving schedules to ensure that all schedules are complete before submission on the reporting portal. Name(s) of the contact person(s) responsible for corrective action: Sergio Plaza Planned completion date for corrective action plan: 6/30/2023 If the United States Department of Health and Human Services has questions regarding this plan, please call Sergio Plaza at 508-688-5608.

FINDING 2022-004 COMMENT: Under Uniform Guidance requirements, the County may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity. Each individual project under this program has a specified work deadline, which may be extended at the discretion of FEMA. RESPONSE: The County has requested an extension related to the FEMA work, but as of the date of the report, the extension has not been approved. Effective June 26, 2023, Rett Daniels, Deputy County Administrator, and Sarah Sun, Budget Director, will continue to seek and obtain the proper extensions needed for the FEMA project in question.

FINDING 2021-003 COMMENT: Per the County's grant agreements with Florida Division of Emergency Management (FDEM), quarterly reports are required to be submitted through FloridaPA.com that include project costs and expenditures for each large project. Amounts in the quarterly reports should reconcile to the County's accounting records and represent actual expenditures. The two large projects were tested for compliance with this requirement, including all quarterly reports submitted during the 2021 fiscal year for these projects. This was not a statistically valid sample. For all quarterly reports tested, the reported expenditures per quarter were unable to be reconciled to actual expenditures in the quarter per the invoices and other supporting documentation in the County's files. RESPONSE: Rett Daniels, Deputy Administrator, Sarah Suhn, Budget Director, and Tony Pumphrey, Finance Officer, will develop controls that will be effective July 31, 2023, to ensure quarterly reports submitted are reconciled to actual quarterly expenditures per invoices and other supporting documentation.

Corrective Action Plan Finding 2022-001 Name of Contact Person: Tracy Biesecker Corrective Action Plan: Management will implement enhanced controls over the preparation of schedules used to input amounts into the Portal and someone independent of compiling the data review the schedules before the amounts are submitted to HRSA. Specifically, amounts reported will be compiled in a source worksheet with all necessary supporting detail. These amounts will be reviewed by a person independent of the source worksheet preparer. Amounts will be submitted to HRSA only after the preparer and independent reviewer agree to the proper classification, valuation and other criteria of the data submitted. This process will be evidenced by a preparer and reviewer signature indicating an attestation that all amounts are properly classified and valued in accordance with the terms and conditions of the PRF. Proposed Completion Date: March 31, 2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding activities allowed and allowable costs within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.