Corrective Action Plans

FINDING 2022-002 Contact Person Responsible for Corrective Action: Cynthia Barhydt Contact Phone Number: 260 627 5227 ext 1 Views of responsible Official: We concur with finding Description of Corrective Action Plan: I will check and sign off on any federal grant union wage payrolls before submitted for pay to federal grant department. Anticipated Completion Date: August 29, 2023

Finding: 2022-001 ALN and Title: 10.565 ? Commodity Supplemental Food Program Cluster Name: Total Food Distribution Cluster Federal Agency: U.S. Department of Agriculture Passthrough Entity: State of Nevada Department of Agriculture Name of Contact Person: Sue Saunders, Director of Finance Corrective Action Plan: Management has implemented a filing system to ensure the collection of current clients as well as a recertification process. CSFP/SNW created a monthly, site specific, year and alphabetized list filing system to aid in the assurance of the certification & recertification. Certification and recertification are occurring at CSFP/SNW distribution sites. In addition, we have a tracking system in our TJOP Salesforce Software System. Currently, we are working towards establishing a digital certification application process. Proposed Completion Date: September 30, 2023

Finding Number 2022-001. Planned Corrective Action: District management will review all grant and loan award documents in order to execute policies and procedures which help ensure compliance with grant and loan requirements, including Schedule reporting requirements. The District will implement a system to track all federal expenditures and related information separately from other expenditures and report federal expenditures with proper support including, but not limited to, grant agreements, calculation of the expenditures, and any federal reporting requirements. The treasurer did not use September 30th as the end date for the final expenditure reports (FER). The treasurer used September 9th as the end date and expenditures were incurred later in the month. When filing the FER in September, the Treasurer will make sure no more expenditures are incurred in September, after the FER is completed. Anticipated Completion Date: 6/30/2023. Responsible Contact Person: Bradley Panak

FINDING 2022-001 Contact Person Responsible for Corrective Action: Leslie Ellis Contact Phone Number: 812-244-2359 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: New procedures have been established to track and monitor all grants that the City receives. The Controller?s office will receive all grant documents (Funding Approval Agreements, Award Letters, etc.) from City Departments as grants are awarded. All grant documents will be reviewed to determine which grants are federal grants. When federal reimbursement requests or draws are made, the department will submit a copy to the Controller?s office. The Senior Financial Analyst in the Controller?s office tracks all grant receipts and disbursements. At the end of each year a grant worksheet will be sent to each department to complete with the year?s federal grant information. The Senior Financial Analyst will reconcile the worksheets to the Controller?s office records. Once reconciled, the Chief Deputy Controller will review the documents for approval. The Senior Financial Analyst will then enter the federal grant information into the Annual Financial Report in the State?s Gateway website. The Chief Deputy Controller will review and approve the information entered into Gateway. The Controller will perform a final review before the information is submitted and authorized in Gateway. Anticipated Completion Date: March 1, 2024

2022-003 Material Weakness in Internal Control, Finding related to Compliance with Federal Regulations Finding: Internal Control over Representative Payee Accounts Condition: The Representative Payee account had a number of budget sheets or check requests that were signed by phone with no additional notation of date of contact, one was missing an authorizing signature, and one was missing a document. Cause: There was significant turnover in the Representative Payee accounting position, as well as with Case Management staff that work with Transitional Resources? clients to budget and receive Social Security funds. Effect: As a result of the above, internal controls were weakened that minimize the risk to client accounts. Response: Effective July 12th, 2023, the Representative Payee accounting staff, Case management staff and the Supervisor that authorizes fund distribution shall receive training on the proper procedures for completing budget sheets and check requests. To ensure the process is being followed correctly, an internal review process shall be developed. The Representative Payee staff member shall check each budget sheet or check request for completion before distributing any funds and prior to filing documents at month end. Any missing information shall be returned for completion. Patterns of incomplete information shall be brought to the Supervisor?s attention for additional training. To better monitor Transitional Resources? internal control processes, a year-end risk assessment report shall be provided to the Finance Committee to ensure progress has been made on the areas identified above. Submitted by: Darcell Slovek-Walker, LMHC Chief Executive Officer

2022-002 Material Weakness in Internal Control Finding: Internal Control over Reconciliation of Accounting Records Condition: The audit confirmation process did not go smoothly and resulted in confirmations being sent multiple times. Cause: The Accounting Manager did not have the adequate skills, knowledge, and experience to complete the audit confirmation process independently as previously believed to be the case by the Supervisor. Due to turnover in the accounting department, this was the first year for the Accounting Manager to send the confirmations independently. The Supervisor assessed that the Accounting Manager was ready to perform this task, however, this was not the case. Effect: The audit confirmation errors delayed the audit process. Additional oversight should have been provided to the Accounting manager. Response: Effective, August 1, 2023 or within 60 days of hire, the agency?s Accounting Manager shall receive training on the appropriate procedures for completing an audit confirmation. The Accounting Manager?s Supervisor shall review all confirmations for completeness prior to sending until such time it is determined that the Accounting Manager is able to perform this task independently.

Transitional Resources submits the following corrective action plan for the year ending December 31, 2022. Name and address of independent accounting firm: Lindley & Associates LLC, 1603 116th Ave NE, Suite 100, Bellevue, WA 98004-9003, Bellevue, WA 98004-9003 Audit period: January 1, 2022 to December 31, 2022 Contact person responsible for corrective action: Deb Orsillo, Director of Administration 2022-001: Material Weakness in Internal Control Finding: Internal Control over Timely Bank Reconciliations Condition: Transitional Resources? bank reconciliations were not completed in a timely manner. While supervisory personnel were aware the Accounting Manager was behind in accounting functions, they were unaware the bank reconciliations had not been completed in a timely manner. Cause: There was turnover in Transitional Resources? Accounting department which resulted in delays in completing the bank reconciliations. Due to the delay of the monthly accounting packets, which contain the bank reconciliations, Supervisory personnel did not initially identify those reconciliations were not completed in a timely manner. Effect: Safeguards of the agency?s accounts were in place by a thorough review of monthly bank statements by Supervisory personnel, however these reviews did not provide the same level of internal control as having timely bank reconciliations. Response: Effective June 26, 2023, bank reconciliations shall be prepared within 30 days of the receipt of the statement. The bank statement and bank reconciliation shall be reviewed by a person other than the preparer, initialed, and dated. The bank reconciliation balance shall agree with the general ledger balance. Both statements shall be initialed and dated as approved by supervisory personnel. In most cases, bank reconciliations shall be prepared by the Accounting Manager and reviewed by the Director of Administration. The Director of Administration shall not only ensure that monthly reviews of bank reconciliations are conducted but shall ensure all accounting information provided to the auditor is verified as complete, accurate, and timely.

2022-001 Child Nutrition Cluster ? Assistance Listing No. 10.553 & 10.555 Recommendation: Recommendation: We recommend the School review its procedures to ensure it retains documentation sufficient to detail the history of all procurements in accordance with the Uniform Guidance. We also recommend the School review its procedures over procurement controls to ensure all controls are also sufficiently documented with records that include, but are not necessarily limited to, the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review policies and procedures to ensure compliance with Uniform Guidance and MN Statute regarding contract and bid laws. Institute a schedule of periodic review of existing contracts to determine if contract costs are still competitive. We will ensure all award documentation is retained for five years or until the contract is reawarded. Name(s) of the contact person(s) responsible for corrective action: Lynn Peterson, CEO Planned completion date for corrective action plan: September 1, 2023

Corrective Action Plan: Agency of Human Services Internal Audit Group (AHS-IAG) is a designated centralized reporter of subawards for a Medicaid cluster (AL No. 93.775, 93.777, 93.778) that is shared between all AHS departments. To address omissions and timeliness of subawards and subaward modifications reporting to FSRS, IAG will conduct additional training tailored to each AHS Department to examine the results of FFATA testing conducted internally, and reemphasize the FFATA compliance regulations. This will ensure the Internal Audit Group (IAG) is provided with complete, accurate and timely subaward information for reporting in FSRS going forward. Further, on at least an annual basis, IAG will conduct a review of current federal rules and regulations pertaining to FFATA reporting for FSRS to assure the Agency?s procedures are up-to-date. Coincidentally, IAG will also select a random sample of subawards and subawards modifications that meet the required threshold for FFATA reporting to ensure they are reported in FSRS system on a complete, accurate and timely basis. Scheduled Completion Date of Corrective Action Plan: Annual review of FFATA rules and regulations including subawards sample testing December 31, 2022 Individualized training for each AHS Department January 31, 2023 Contact for Corrective Action Plan: Peter Moino AHS Director of Internal Audit peter.moino@vermont.gov

Corrective Action Plan 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expansion of automated search services, progress reports and overall reduction of manual processes. By 5/1/2023 Gainwell will provide the DVHA Oversight & Monitoring Unit with Progress Reports that will be shared at the Fiscal Agent meeting and with DVHA Leadership to track progress and/or report roadblocks and escalate issues of any actual or potential failures to timely perform provider revalidations. Gainwell will use the Provider Management Module (PMM) and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiration date. Gainwell shall submit to DVHA on a weekly basis a list of providers who have been notified that they are due for re-validation and have not responded within 14 days of license expiration date. Gainwell will use PMM and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiring. The written detailed procedure for license updates will be finalized by 04/01/23 between the State and Gainwell and will include the following: a. Update the look forward period in the license screening service to 45 days. As a result, PMM will be updated automatically when the license screening service is available to locate an updated license. This configuration update will be in place by 04/01/23. For those licenses that the screening service is not able to locate an updated license, Gainwell will review and manually check for an updated license. If a new license is found, Gainwell will update accordingly. Gainwell will explore using Lexis Nexis as an additional service for manual review of license information and provide an update of potential solution by 03/17/23. If determined the Lexis Nexis solution is not viable, Gainwell will propose additional solution options by 05/01/23. b. Any provider whose license was not automatically updated as part of the screening service and could not be manually updated through the review process, an expiring license notification will be sent to the Mail-To contact information on file 30 days prior to their license expiration date. The expiring license notifications will be activated in PMM as of 04/01/23. Providers will be notified of this change in process as of 03/01/23 via banner. c. Gainwell will provide a weekly report of any providers whose license is set to expire in 14 days. This report will be delivered weekly beginning 04/17/23, two weeks after start date of license notifications. DVHA will work with Gainwell to finalize a process to address those providers listed. d. Gainwell will activate the termination job within the PMM that will automatically end a provider?s contract with VT Medicaid when no license was obtained through the process listed above by the license end date. This termination job will be activated on 06/05/23, two months after starting license notification. Notification to providers of this change in process will be sent no later than 05/01/23, via banner. Prior to the termination job being activated, Gainwell will continue to manually terminate when no updated license information is obtained, unless written exception is received from DVHA. All exception requests will be stored as part of the provider?s electronic record within PMM. By March 1st, 2023, Gainwell will provide the following information to DVHA: The databases, services, and available in state and out of state agencies Gainwell currently uses and plans to use in order to monitor and verify provider licenses and certifications; and 2. As of December 31, 2023, all revalidations will electronically reside in PMM. By December 31, 2023, All paper files, maintained prior to the implementation of the PMM, will be cataloged and sent to secure storage. To ensure all records are available for review, all application data is now being processed through PMM and available on demand. This includes paper application sent in by providers, Gainwell inputs the paper application into PMM. 3. The Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. At this time, the State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. January 1, 2024 2. December 31, 2023 3. Completed Contacts for Corrective Action Plan: Suellen Bottiggi, DVHA Director of Member and Provider Services suellen.bottiggi@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

Corrective Action Plan: 1. The corrective measures pertaining to DVHA?s enhanced oversight of Gainwell?s contractual obligation to DVHA to provide licensure validation service and documentation of active licensure will include established benchmarks for the overall improvement of the service, expansion of automated search services, progress reports and overall reduction of manual processes. By 5/1/2023 Gainwell will provide the DVHA Oversight & Monitoring Unit with Progress Reports that will be shared at the Fiscal Agent meeting and with DVHA Leadership to track progress and/or report roadblocks and escalate issues of any actual or potential failures to timely perform provider revalidations. Gainwell will use the Provider Management Module (PMM) and other services available to validate license of a provider. For those providers that cannot be validated through PMM or other services, Gainwell will send a letter notice to those providers. Letter notice must be sent no later than 30 days prior to a license expiration date. Gainwell shall submit to DVHA on a weekly basis a list of providers who have been notified that they are due for re-validation and have not responded within 14 days of license expiration date. The written detailed procedure for license updates will be finalized by 04/01/23 between the State and Gainwell and will include the following: a. Update the look forward period in the license screening service to 45 days. As a result, PMM will be updated automatically when the license screening service is available to locate an updated license. This configuration update will be in place by 04/01/23. For those licenses that the screening service is not able to locate an updated license, Gainwell will review and manually check for an updated license. If a new license is found, Gainwell will update accordingly. Gainwell will explore using Lexis Nexis as an additional service for manual review of license information and provide an update of potential solution by 03/17/23. If determined the Lexis Nexis solution is not viable, Gainwell will propose additional solution options by 05/01/23. b. Any provider whose license was not automatically updated as part of the screening service and could not be manually updated through the review process, an expiring license notification will be sent to the Mail-To contact information on file 30 days prior to their license expiration date. The expiring license notifications will be activated in PMM as of 04/01/23. Providers will be notified of this change in process as of 03/01/23 via banner. c. Gainwell will provide a weekly report of any providers whose license is set to expire in 14 days. This report will be delivered weekly beginning 04/17/23, two weeks after start date of license notifications. DVHA will work with Gainwell to finalize a process to address those providers listed. d. Gainwell will activate the termination job within PMM that will automatically end a provider?s contract with VT Medicaid when no license was obtained through the process listed above by the license end date. This termination job will be activated on 06/05/23, two months after starting license notification. Notification to providers of this change in process will be sent no later than 05/01/23, via banner. Prior to the termination job being activated, Gainwell will continue to manually terminate when no updated license information is obtained, unless written exception is received from the DVHA. All exception requests will be stored as part of the provider?s electronic record within PMM. By March 1st, 2023, Gainwell will provide the following information to DVHA: The databases, services, and available in state and out of state agencies Gainwell currently uses and plans to use in order to monitor and verify provider licenses and certifications; and 2. To ensure all providers revalidate a minimum of every 5 years, PMM is automatically assigning the revalidation due date. Providers are notified 90 days prior to the due date and again at 45 days, if the provider does not revalidate by the due date, their contract is automatically terminated. At this time, all active providers are assigned a revalidation due date and every provider converted from the old system to PMM has a schedule that will result in revalidation of all legacy providers by December 31, 2023. Exception: If a provider?s revalidation application is returned to them, the provider has until their revalidation due date, or 30 days, whichever is greater, to correct and resubmit their revalidation. Example: Provider?s revalidation due date is 12/30/23 and their revalidation application is returned on 12/29/23. The provider will have until 01/29/24 to correct and resubmit. 3. The Letters of Good Tax Standing have been obtained. A standard operating practice is in place documenting the process. The process of validating tax standing in writing from the Tax Department has been in effect since April 2022. Providers who had their tax standing validated prior to April 2022 via phone or email were not solicited to obtain a written notification from the Tax Commissioner. At this time, the State has determined that it is not necessary to obtain a retroactive written notification from the Tax Commissioner for tax standing prior to April 2022. As of April 2022, all tax standing reviews are validated with a letter from the Tax Department and documented in the PMM. Scheduled Completion Date of Corrective Action Plan: 1. January 1, 2024 2. December 31, 2023 3. Completed Contacts for Corrective Action Plan: Suellen Bottiggi, DVHA Director of Member and Provider Services suellen.bottiggi@vermont.gov Peter Moino, AHS Director of Internal Audit peter.moino@vermont.gov

Corrective Action Plan: The Agency will identify if a new ESEA Federal grant (or a grant based on an ESEA program) includes an Equitable Service requirement during the program completion of the ?New Grant Checklist?. If a new grant includes an Equitable Service requirement, the ESEA Equitable Service?s Ombudsman will be notified and will work with the grant program manager to ensure the build of the GMS application includes the correct level of detail and controls to meet the SEA requirements for oversight. When appropriate, the Agency will use its process for handling of Equitable Services associated with the Consolidated Federal Programs as models for determining the correct calculation method. The Agency will utilize built in business rules and internal controls within the Grants Management System (GMS) to gather the following information in the grant application for AOE review and approval prior to issuing a grant award agreement: 1. Calculation of the total proportionate share dollars an LEA must set aside for Equitable Services 2. Identification of Independent Schools participating in Equitable Services applicable to each LEA 3. Calculation of the dollars available for Equitable Services for each participating Independent School For each Federal grant that requires an equitable services component, the Agency will document the review and approval of the Equitable Services information through one of two processes prior to the grant award agreement: 1. A dedicated review assignment specific to equitable services, or 2. Verification statements on the review checklist for a general application reviewer Position Responsible for Implementation of Corrective Action: Anne Bordonaro, Division Director, Federal & Education Support Programs anne.bordonaro@vermont.gov 802-828-1388 Date of Implementation of Corrective Action: July 1, 2023

Condition Management should have a process in place to ensure the internal completion of the schedule of federal expenditures (SEFA) including all required disclosures. Views of responsible officials and planned corrective actions We will continue to monitor and, although we have limited personnel, we will continue to enhance our internal controls over the completion of the SEFA. Anticipated completion date Ongoing

Condition During the process of identifying expenses eligible under the COVID-19 Testing and Mitigation for Rural Health Clinics program, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare. Views of responsible officials and planned corrective actions Management will continue to refine processes to ensure only allowable costs are reported.

Condition During the process of completing the HRSA PRF reporting form, various reporting errors were made. Views of responsible officials and planned corrective actions We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met.

Condition During the process of identifying expenses incurred to prevent, prepare for or respond to the coronavirus pandemic, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare and included certain cost items reimbursed through the COVID-19 Testing and Mitigation for Rural Health Clinics program (Federal Assistance Listing Number 93.697). Views of responsible officials and planned corrective actions Management will continue to refine processes to ensure only allowable costs are reported. Additionally, we have other costs in our cost tracking workbook we believe are allowable and sufficient to cover the $264,243 of questioned costs. We had intended to report these in the unreimbursed expenses section of the PRF reporting portal but inadvertently missed inputting them. Anticipated completion date Ongoing

Finding Number: 2022-001 Condition: During fiscal year 2022, the School District utilized funds from the Education Stabilization Funds to pay payroll expenditures related to contractors for minor remodeling and renovations of the school buildings. Per the 2022 Compliance Supplement, recipients and subrecipients that use ESF funds for minor remodeling, renovation, or construction contracts that are over $2,000 and use laborers and mechanics must meet Davis-Bacon prevailing wage requirements. The South Redford School District failed to meet the prevailing wage requirements using the funds during the fiscal year. Planned Corrective Action: As it pertains to the use of ANY Federal funds for construction projects in the South Redford School District (SRSD), when said funds will be used to compensate for labor for any construction project: We must stipulate in all RFP?s, Davis-Bacon requirements for prevailing wages as it relates to the use of laborers and mechanics, for all projects over $2,000. All responses to RFP?s must: 1. Acknowledge the Davis Bacon prevailing wage requirement; 2. All bid pricing must reflect prevailing wage requirements; 3. Bid recipients must have a process in place for reporting their compliance to the prevailing wage requirement and submit documentation along with all invoices, be it directly to SRSD or to the construction management firm, who will then include said documentation with their backup and invoices to SRSD. Verbal communications have been made to all stakeholders, including the Superintendent, Owner Representative (who oversees all construction projects for the district), construction management team, Asst. Superintendent of Operations, and all Finance Team members. A written copy of the corrective action will be delivered to each of the stakeholders listed above. Further, the Director of Finance will review all RFP?s to ensure prevailing wage requirements are met. Contact person responsible for corrective action: Linda Earl, Finance Director Anticipated Completion Date: July 1, 2022

Management's View: The College's term calendar did not properly reflect all semester breaks and holidays resulting in improper return calculations. Moving forward , the College will include all semester breaks and holidays in the calculation. Further, administrative withdrawal procedures were not concise which caused discrepancies in student registration status. The student registration status is key to the calculation of the Title IV funds to be returned to the Department of Education. The discrepancy resolution was outside of the 45-day requirement causing the returns of Title IV funds to be untimely. Corrective Action Plan: The Director Student Financial Services, the Registrar and the Vice President of Instruction will work together to ensure communication and compliance with Faculty regarding administrative withdrawal policy and procedures.

Finding Number: 2022-001 Condition: The Health System's controls in place for reporting submissions did not ensure the accuracy of the reporting submissions. Planned Corrective Action: Preparer will conduct a full walk-through of the entire submission with a reviewer who did not participate in preparation of the submission. Contact person responsible for corrective action: Matthew Nobis Anticipated Completion Date: Completed

Diabetes, Digestive, and Kidney Diseases Extramural Research (ALN 93.847) Mental Health Research Grants (ALN 93.839) Blood Diseases and Resources Research (ALN 93.242) Allergy and Infectious Diseases Research (ALN 93.855) Recommendation: We recommend that the Organization review their approval policy around cash management and ensure review is performed before drawdowns and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have implemented the use of a preparer and reviewer for all drawdowns and added a cumulative review to the procedure. Additionally, we have moved from a quarterly to a bimonthly drawdown cycle. Name(s) of the contact person(s) responsible for corrective action: Mahtab Khan Planned completion date for corrective action plan: August 31,2022

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 District contact person: Stephanie Hance, 2 Hornet Ave, Inchelium, WA 99138 509 789-3513 Corrective action the auditee plans to take in response to the finding: When or if the District enters into another project funded with federal dollars, they will ensure that Davis Bacon language is included in all contracts/purchasing documents. The District will create a spreadsheet to track the submittals of weekly certified payrolls. This tracking document will include the following data: Project Description/Subcontractor Vendor/Date SAM verified/Date Intent Filed and Project Number/Date Affidavit Filed/Position & Dates/Verified Prevailing Wage (State or Federal, whichever is higher). Federal purchasing requirements will be shared with all staff tasked to manage the project. Anticipated date to complete the corrective action: 08/31/23

FINDING 2022-001 Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number: 765-456-2804 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will establish an effective internal control system that will segregate duties when it comes to federal compliance reporting. The Chief Deputy will continue to prepare and submit reports. The Auditor will review and approve any reporting prior to submission. Initialed reports will be kept within the grant file. Anticipated Completion Date: 07/31/2023

U.S. Department of Treasury Community Development Investment Financial Institutions Rapid Response Program - Assistance Listing number 21.024 Material Weakness Recommendation: Lowell Community Loan Fund, Inc. dba Mill Cities Community Investments put procedures in place to ensure proper accounting and reconciliation of revenue and net asset accounts. Views of Responsible Officials and Planned Corrective Action: Lowell Community Loan Fund, Inc. dba Mill Cities Community Investments agrees with the finding and the recommended procedures will be implemented.

Finding Number: 2022-001 Condition: The Organization does not have a review process in place related to the required reporting submissions to the U.S. Department of Health and Human Services for the PRF program. The Organization selected Option iii for reporting lost revenues, however the Organization had mathematical footing errors in the calculation/determination of lost revenue for the second quarter of 2021 and second quarter of 2022. Planned Corrective Action: Mary Rutan will implement a process to ensure an independent review of the reporting submission is completed in future periods. Mary Rutan has updated the lost revenue calculations to correct the mathematical footing errors that were identified. Given the lost revenue reported in the period 4 portal submission was under reported to HHS, no further correction action is deemed necessary as the portal submission can no longer be modified. If any further funding is received that requires further reporting of lost revenues to HHS, Mary Rutan will ensure the lost revenue reported for quarter two of 2021 and quarter two of 2022 are properly reported based on the corrected calculations. Contact person responsible for corrective action: Tom Denbow, VP of Finance & Development Anticipated Completion Date: 9/30/2023

Finding Number: 2022-001 Finding Title: Performance Reporting Program: 97.036 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) Name of Contact Person Responsible for Corrective Action: Nick Brozek Corrective Action Planned: FEMA reports will be submitted quarterly. Reports will be prepared and signed by the Ditch Inspector, and verified by the Director. Director will initial reports. Anticipated Completion Date: 6/30/2023