Corrective Action Plans

Finding #2022-003 ? Material Adjustments Condition: Johnson Block and Company, Inc., proposed numerous adjusting journal entries. We deem these entries to be significant in relation to the financial statements. Since the District did not make these adjustments in its accounting system prior to the audit, a material weakness exists in the District?s internal controls. Effect: This means that the proper recording and reporting of financial information may not occur within a timely manner. Cause: Financial information was not recorded in a timely manner and material adjustments were needed in order to correct various transactions. Criteria: Material adjusting journal entries not prepared by the District before the audit are considered an internal control weakness. Recommendation: Policies and procedures should be implemented to ensure account balances are properly recorded in a timely manner. Response: The District will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditors. In addition, new finance accounting staff are receiving training to assist with correcting this finding. Contact Person: Gary Syftestad Anticipated Completion: Ongoing

Condition: The Health Center?s Period 2 report to HHS included duplicate amounts for utilities expenses. Planned Corrective Action: Management will continue to refine processes to more diligently review expenses to ensure no duplicate expenses are included in the underlying supporting documentation. However, the Health Center included as eligible expenses in the Period 2 submission only those amounts up to the funding received, plus accrued interest. Had the noted questioned costs been identified prior to submission, the Health Center would have included additional amounts in the eligible expenses reported in the PRF reporting portal to demonstrate satisfactory use of the PRF funding received. The Health Center had $418,778 in additional eligible operating expenses which were not included in the Period 1 submission and $1,916,769 in additional eligible capital expenses not included in the Period 2 submission which would have been used to replace the identified questioned costs. Person Responsible: Wade Eschenbrenner, CFO Anticipated Completion Date: Ongoing

REPORTING Recommendation: We recommend the Department review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete and timely. We recommend the Department implement effective processes and procedures to maintain the submitted reports and the documentation used to prepare the reports in the files of the Department. Corrective Action: The Department understands the issues and is taking corrective action to improve reporting. Due to the New Mexico emergent events that took place in FY22, the Department made the emergent events the Department?s priority and onboarding became a secondary focus for the Department. In FY23, the Department has shifted its priority to onboarding across the Department, and we have onboarded a Grants Unit Manager to oversee the reporting requirements of all federal grants. A procedural checklist will be implemented to ensure that: 1. the recipient share section is completed, 2. that financial reports are submitted to the Department timely, and 3. all Performance Progress Reports as submitted. Due Date of Completion: June 30, 2023 Responsible Person(s): Chief Financial Officer

CASH MANAGEMENT Recommendation: We realize the Department continues to have staff turnover. We recommend the Department review its process and implement effective policies, procedures, and controls to ensure the accounting records appropriately reflect the activity of the grant. The Department should consider efficiencies to make the process less cumbersome. While the Department has existing processes at the federal program level, there appears to be a need for higher level monitoring and reconciliation of federal program activity to ensure the completeness of federal program-level reconciliations and reimbursements. The Department should consider further contracting with an outside third party to aid in the process of performing reconciliations and billings. The deficit fund balance in the Federal Grants Fund (40280) should be reviewed and addressed. The Department should evaluate the need to obtain a deficiency appropriation or some other funding to cover this deficit. Corrective Action: The Department partially understands the issue. The Department will internally audit our expenditures to ensure that all transactions include an operating unit. The Department will also establish a checklist to include that all signatures are collected and that applicable documentation is received for reimbursement purposes. As part of our Sub Grant recipient review for Assistance Listings 97.036 and 97.067, we cannot reimburse the subrecipient until they submit applicable receipts for reimbursement and answer all requests for information as required by FEMA. Due Date of Completion: June 30, 2023 Responsible Person(s): Chief Financial Officer, Grants Unit Manager

Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of School District contact person: Heather C. Pinkerton 310 SW 16th St Chehalis, WA 98532 360-807-7207 Corrective action the auditee plans to take in response to the finding: It is highly unusual for the district to utilize federal funds for construction projects; the Covid-19 Education Stabilization Funds were an anomaly. The District?s Director of Business and Operations was unaware that prevailing wage clauses are required to be included in all public works contracts over $2,000 that are paid with federal funds. She was aware that prevailing wages need to be paid. The audit finding does not dispute that prevailing wages were paid appropriately, just that the clauses were not included in the contracts. To be very clear, this finding is for not having required language in contracts. The District is now aware that inclusion of the clauses is a compliance requirement. Going forward, it is unlikely that federal funds will be used for construction projects; however, when federal funds are utilized for construction projects, the District will either include the required prevailing wage rate clauses in its contracts or will obtain a separate signed clause with the required prevailing wage rate information. Anticipated date to complete the corrective action: Immediately

Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management reported all the general distributions received by the subsidiaries under the Parent entity in the portal, including the general distributions received by CaroMont Regional Medical Center (?Hospital?). Management listed the TINS of the subsidiaries, including the Hospital, in the Subsidiary Data section in the Parent?s portal. Management reported lost revenues utilizing option i, 2019 Actual Revenues, for the subsidiaries in the Parent?s portal. Reporting Period 2: During Reporting Period 2, the Hospital received both general and a targeted distributions (High Impact Area) from the CARES Act PRF. Management was unsure how to report so it contacted the HRSA Provider Support Line. HRSA opened case #00025470 and on January 18, 2022, Management had a phone conference with a representative of HRSA to discuss Period 2 reporting. HRSA advised management to report as follows: ? Hospital ? report the targeted distribution. Only report revenue, expenses, and data for the Hospital. ? Parent ? report general distributions. Don?t change any numbers from Period 1. Report revenue, expenses, and data for all subsidiary TINS listed in the portal. Management specifically remembers explaining to the HRSA representative that this approach would result in double counting of Total Unused Lost Revenues because Hospital revenues would be reported in both portals. The HRSA representative said that would be okay because Management answered YES to ?Is the parent entity reporting on your General Distribution payments?? in the Hospital portal, because the Hospital?s TIN is listed in the Subsidiary Information section in the Parent?s portal, and because the Parent?s TIN is listed in the Subsidiary Questionnaire section in the Hospital?s portal. Management documented these instructions in their notes made during the call. Management also specifically remembers asking the HRSA representative if the Hospital revenue should be removed from the prior quarters in the Parent portal when reporting Period 2 to which the representative replied, ?don?t change any numbers?. Management documented these instructions in their notes made during the call. Management filed the Period 2 reports for the Parent and the Hospital in accordance with HRSA?s instructions received during this phone conference. Management reported lost revenues under option i, 2019 Actual Revenues, for the listed subsidiaries in the Parent portal and for the Hospital in the Hospital portal. However, since Management was concerned this approach would result in double counting of unused lost revenues, they created a reconciliation spreadsheet on February 1, 2022. This spreadsheet documented unused lost revenues from the PRF Financial Reporting Summary Reporting pages in the Parent and Hospital portals for Period 1 and Period 2 and calculated the correct total unused lost revenues when the reports were combined and the double counting was eliminated. Management?s intent was to update this reconciliation during Period 4 reporting to ensure the remaining unused lost revenues in both the Parent and Hospital portals exceeded the combined reconciled lost revenue ? thereby ensuring there would be no double counting of lost revenues after all PRF reporting was completed. Reporting Period 4: During Report Period 4, several subsidiaries of the Parent received general distributions from the CARES Act PRF and targeted distributions from the American Rescue Plan (?ARP?). By the time the Portal Reporting opened for Period 4, CaroMont?s auditors were conducting the Single Audit for the year ended June 30, 2022, and reached out to Management to discuss their concerns about potential double counting of lost revenues in the Period 2 portal reporting. Management explained their process for reporting Period 2 and shared with the auditors their reconciliation spreadsheet that was created on February 1, 2022. The auditors had also performed a reconciliation that resulted in the same outcome. The auditors and management subsequently had several discussions on the different alternatives available to correct the Period 2 overstatement. Management evaluated the alternatives and ultimately decided to change its calculation of Lost Revenues in the Parent portal for Period 4 from option i, 2019 Actual Revenue, to option iii, Alternative Method of Calculating Lost Revenues Attributable to COVID-19. However, management continued to report lost revenues in the Hospital portal for Period 4 utilizing option i, 2019 Actual Revenue, as it had in Period 2. Management created another reconciliation spreadsheet on February 23, 2023 that demonstrated the Hospital revenue was excluded from the Parent?s lost revenue calculations in Period 4. This spreadsheet was uploaded as supporting documentation for option iii in the Parent?s portal. By changing from option i to option iii for lost revenues in the Parent portal for Period 4, management corrected the overstatement of lost revenues identified in the Audit of Federal Awards Performed in Accordance with U.S. Office of Management and Budget Uniform Guidance for the year ended June 30, 2022.

The District concurs and will review current year?s indirect rates for ESSER reimbursements.

Finding 2022-001 ? EXCESS FUND BALANCE IN FOOD SERVICE FUND Type: Material Weakness in Internal Control / Noncompliance ? Special Tests and Provisions Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: As of year-end the District had a fund balance in the non-profit food service fund in excess of three months' operating expenses by approximately $165,196. Criteria: The USDA requires that the District limit its net cash resources to an amount that does not exceed 3 months average expenditures of the nan-profit food service fund per requirements in 7 CFR Part 210. 14(b). Cause: This condition was caused by the meal claims increasing and having more reimbursements come in than anticipated. Effect: The District will be required to develop a spending plan for reducing the balance to an acceptable level during the following school year. The plan must be submitted to MDE, Office of School Support Services, for prior approval. Recommendation: We recommend that the District develop a spending plan as required by MDE, and submit the plan at their earliest convenience. Corrective Action Plan: Shepherd Public Schools will work with MDE to create a spenddown plan to address the excess fund balance in the food service fund. This plan will include allowable equipment upgrades and replacements to be crafted in collaboration with the food service director, district business manager and superintendent, as well as any other members deemed appropriate by superintendent. The process of creating the plan is expected to begin immediately, with compliance of 7CFR Part 210.14(b) to be met no later than June 30, 2023.

Finding 2022-001 Enrollment Reporting Views of Responsible Officials The University agrees with the auditor?s findings and recommendations. Corrective Action Plan The University has implemented additional training for this compliance requirement to ensure that changes in enrollment status are recorded correctly in the system and reported accurately. Additionally, the University will resolve status change discrepancies and review status change reporting output monthly to ensure that changes are reported accurately. Implementation Date Immediate Individual(s) Responsible Yvonne Harwood, Vice President of Institutional Effectiveness and Becky Wilson, Assistance Vice President of Financial Assistance

Finding #2022-003- Material Adjustments Condition: Johnson Block and Company, Inc. proposed numerous adjusting journal entries. We deem these entries to be significant in relation to the financial statements. Since the District did not make these adjustments in its accounting system prior to the audit, a material weakness exists in the District?s internal controls. Effect: This means that the proper recording and reporting of financial information may not occur within a timely manner. Cause: Financial information was not recorded in a timely manner and material adjustments were needed in order to correct various transactions. Criteria: Material adjusting journal entries not prepared by the District before the audit are considered an internal control weakness. Recommendation: Policies and procedures should be implemented to ensure account balances are properly recorded in a timely manner. Response: The District will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditor. Contact Person: John Costello Anticipated Completion: June 30, 2023

Finding 2022-01 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #: 93.498 Finding Summary: We reported expenses reimbursed from other sources as Unreimbursed Expenses Attributable to Coronavirus in the Period 2 Department of Health and Human Services (HHS) report. Additionally, due to a formula error, we omitted certain patient revenues in Q2 ? Q4 of 2021 - actual in the HHS Period 2 Report. These errors in reporting did not result in any questioned costs because we reported lost revenues attributable to the impact of the coronavirus well in excess of the funding received when using the corrected calculation. As a result, there were no questioned costs. Responsible Individuals: Carter Bair, CFO Corrective Action Plan: Management agrees that the reporting was in error for the Provider Relief Fund and American Rescue Plan. The issue arose due to some confusion in the instructions over Reimbursed and Un-Reimbursed funds. Though the reporting error did not affect the allowability of our expenses that were applied to these funds, it did affect the reporting. We have agreed that in the future we will have more than one individual reviewing the reimbursement rules and calculations used for reporting. Anticipated Completion Date: December 1, 2022

Finding 2022-003 Federal Agency Name: Legal Services Corporation Program Name: LSC Basic Field Grant; LSC Technology Improvement Grant. CFDA#: 09-542026 Finding Summary: Total hours and LSC hours worked used to drive monthly allocation of indirect expenses by grant did not agree to total hours and LSC hours worked in the Organization?s timekeeping software for eight of the twelve months. Additionally, one instance identified in which the rate of pay paid to an employee did not agree to the approved rate of pay. Responsible Individuals: Kathy Schroeder, 3rd party accountant, and Lea Wroblewski, Executive Director. Corrective Action Plan: Additional procedures are being followed to ensure that the timekeeping software is completed on a timely basis and locked down by the Executive Director or Technology Consultant when all entries have been made and reviewed. The time report used for the indirect expense allocations is not processed until the software is locked down. All changes to employees pay calculation are made after the submission of an approved Personnel Action Form is provided to the staff accountant. Each payroll is then reviewed by the Executive Director and a board member before processing. Completion Date: 06/30/2023

Special Tests and Provisions ? Wage Rate Requirements There is no disagreement with the finding. District management will review policies and procedures in response to the finding. Additional Response Patti Degnitz, Business Manager, is the contact person for the District. She performs the following mitigating controls: 1. Reviews and approves all adjusting entries proposed by the auditor. 2. Compares final adjusted trial balance with audited financial statements. 3. Compares the schedule of expenditures of federal awards and state financial assistance to: a. Final adjusted trial balance b. Submitted final reimbursement claims c. State payment register and DPI website

View of Responsible Official and Planned Corrective Action: Oversight of time cards has been established and assigned. Southeast Health Group management is confident that there were no erroneous invoicing charges nor inaccurate requests for reimbursement. SHG?s time and effort reporting guidelines ensured proper accounting and compliance standards were followed and oversight has been added to ensure proper documentation.

Reference Number 2022-004: The Office of Property Operations has reviewed the audit finding report and recommendations. The department will implement steps to monitor compliance with Public Housing program policies to ensure staff perform timely annual re-certifications, following established guidelines and retaining acceptable documentation to support resident eligibility determinations and subsequent re-certifications. These items include: ? Ensuring all initial eligibility information is received at the time of unit leasing ? Updating protocols for documenting the re-certification process, including file checklists to ensure all documents are in the resident file ? Re-establishing a file audit protocol to be performed on a quarterly basis ? Closely monitoring delayed re-certifications, including written documentation regarding any delays ? Creating a standard operating procedure to document any delays in re-certifications that may impact the timeliness and accuracy of data reported to the HUD system ? Scheduling recertification training for all staff involved in the re-certification process before June 30, 2023 Contact Information: Michelle Hasan, Director of Leased Housing

FINDING 2022-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, After School Snacks, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Context: We noted that for four claims in a sample of four, the meal counts were over/under claimed for the month. We noted that in October 2020, the School Corporation had underclaimed lunches by 212 meals and overclaimed breakfast by 42 meals. In April 2021, the School Corporation had overclaimed breakfast by 397 meals. In October 2021, the School Corporation had underclaimed lunches by 48 meals and snacks by 36 meals. In April 2022, the School Corporation had overclaimed lunches by two meals, snacks by 45 meals, and underclaimed breakfast by 2 meals. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Going forward, we will have multiple people verifying the data before submission to reimbursement for claims to make sure all meals submitted are accurate and meet the criteria and eligibility of the Child Nutrition Cluster. Responsible Party and Timeline for Completion: The Food Service Director and the Corporation Treasurer are the responsible parties for this corrective action. This will be implemented 4/1/2023.

Finding Number: 2022-014 ? SEFA Preparation Corrective Action Plan: In 2022, the office had downsized due to turnover in staff. While a process was in place for reconciling, a secondary review was not performed to verify accuracy of the residual value calculations. To strengthen the oversight of financial management in the School, Academica Nevada, the School?s management company, has filled all the open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. The grant manager will reconcile all grants to ensure proper cutoff, with a secondary review performed by a member of management. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

Finding Number: 2022-013 ? Reporting Corrective Action Plan: A process has been put in place for the school principal to review the Per Pupil Expenditure Report prior to submission to the grantor. Approval is evidenced by email sent by principal to the Director of Grant Management, which is saved with the Per Pupil Expenditure Report as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

Finding Number: 2022-012 ? Level of Effort ? Maintenance of Effort Corrective Action Plan: A process has been put in place for the school principal to review all Maintenance of Efforts (MOE) prior to submission to the grantor. Approval is evidenced by email sent by principal to the NSLP Grant Manager, which is saved with the MOE as support. Responsible Individuals: Nachum Golodner, Director of Accounting Anticipated Completion Date: June 30, 2023

REPORTING Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster CFDA Number: 10.553, 10.555, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0381-000 Award Period: June 30, 2022 Type of Finding: ? Material Weakness in Internal Control over Compliance CORRECTIVE ACTION PLAN (CAP): Recommendation: We recommend the District review and approve the CLiCS meal counts timely before they are submitted. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing a process to ensure all CLiCS meal counts are reviewed and approved timely. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2023.

Federal Award Findings and Questioned Costs - Major Federal Awards Finding 2022-001 Material Weakness and Nonmaterial Noncompliance in Internal Control over retention of supporting documentation relating to sliding fee test. 2022-001 Recommendation: The Organization should ensure that controls and procedures are implemented to ensure that all supporting documentation substantiating all patient household income and the number of residents who reside within their household is obtained and verified before services are provided. It should then be retained as supporting documentation that this compliance test has been completed and validated. Action Taken: We concur with the recommendation and will establish procedures to ensure supporting documentation substantiating all patient household income and the number of residents who reside within their household is obtained and verified before services are provided. Date of Completion: June 30, 2023 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Valerie Butt, Chief Financial Officer, at 757-618-0476. Sincerely, Valerie Butt Chief Financial Officer.

Name of Contact Person: Dr. Kim Scott, Director of Public Housing Corrective Action/Management?s Response: The issues regarding applicant files was one of the first control issues identified when I came to the City. A written action plan has been developed with the approval of our local Housing and Urban Development field office. Each applicant is being reviewed at their anniversary date to obtain complete records of documentation to support eligibility. Proposed Completion Date: Immediately and ongoing.

Condition: The College did not timely and accurately complete refund calculations in the Fall. In review of the Fall 2021 calculations the number of days in the break were not calculated correctly, resulting in the incorrect days in all Fall 2021 return of Title IV funds calculations. As a result of the incorrect number of days, the amounts of Title IV amounts returned for all withdrawn students were incorrectly calculated for 6 out of the population of 11 (54.5%) Fall withdrawal calculations. A sample of Spring withdrawal calculations identified no errors. We consider this finding to be a material weakness in relation to Special Tests and Provisions and is a repeat finding shown in Section IV of this report as prior year finding 2021-004. Statistical sampling was not used in making sample selections. Corrective Action Plan: It is important to note that the entire 2021/2022 award year was processed by 3rd party servicer, Fully Disbursed. The current Financial Aid staff at Blackburn College started in October of 2021 but the processing was conducted by Fully Disbursed as they were under contract with Blackburn College for all 2021-2022 processing and packaging until August 2022 at the completion of the summer semester. The Financial Aid staff at Blackburn Colleges understands that when calculating Return of Title IV funds, it is important to carefully review and accurately count the number of calendar days in the payment period. Currently, we review the College Academic Calendar for all vacations periods and ensure that any periods that are 5 or more days in length are added when setting up the School Calendar Profile in the R2T4 screen each academic year. This will help to make certain that all relevant dates are properly documented and that we are using the correct formula for calculating R2T4. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: Fall 2022

Condition: The College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 23 of the 40 students in the sample (57.5%). We consider this condition to be a material weakness in internal control over compliance relating to the Eligibility compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2021-003. Statistical sampling was not used in making sample selections. Corrective Action Plan: It is important to note that the entire 2021/2022 award year was processed by 3rd party servicer, Fully Disbursed. The current Financial Aid staff at Blackburn College started in October of 2021 but the processing was conducted by Fully Disbursed as they were under contract with Blackburn College for all 2021-2022 processing and packaging until August 2022 at the completion of the summer semester. The Financial Aid Office must emphasize the importance of accurate record-keeping in financial transactions. As a department we will continue to work closely with the Business office to ensure that every drawdown is properly documented and matches the corresponding dates and amounts. Additionally, we will continue to perform monthly reconciliations to ensure that any discrepancies are identified and addressed promptly. This process helps to minimize errors and maintain transparency in our overall financial aid operations. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: Fall 2022

Finding 2022-006: Direct Loan Reconciliation ? Material Weakness and Noncompliance Condition: Documentation that the required monthly School Account Statement (SAS) reconciliations were not completed for any of the three monthly tested for the year ended June 30, 2022. Responsible for the Plan: Janet Davidson, Director of Financial Aid Dennis Zeh, Director of Financial Operations Planned completion date: June 30, 2023 Corrective Action Plan: To ensure compliance with the Direct Loan Reconciliation requirements the college will adopt the following procedure. ? On a regular basis the Financial Aid Assistant/Loan Officer will process disbursements of direct loans using Powerfaids. This process will include sending files back and forth through CPS to update the Common Origination and Disbursement (COD) site as well as processing files to Jenzabar to make awards to student accounts. The Financial Aid Assistant/Loan Officer will be responsible for resolving any rejects that are returned through CPS into Powerfaids to ensure that all disbursements are approved and accepted in COD. ? At the beginning of the month the Financial Aid Assistant/Loan Officer will send the Director of Financial Aid the SAS report from CPS. ? The Director will pull the FA transactions from Jenzabar for the previous month and compare it to the COD disbursements to ensure the records match. The Director will prepare the reconciliations detailing the disbursements and drawdowns from COD as well as the disbursements and drawdowns reflected in Jenzabar. The Director will identify any discrepancies. ? Upon completion of the Reconciliation the Director of Financial Aid will review with Financial Aid Assistant/Loan Officer and the Director of Financial Operations ? Additionally, the DFO will ensure that independent reconciliations are performed from the General ledger back to AR Student accounts, this adds an essential third component on the FA review process to enable our identification of funds that are in scope for return but have been incorrectly posted or otherwise not available to the FA reconcilers under the proper AR accounts.