Corrective Action Plans

FINDING 2022-001- U.S. DEPARTMENT OF HOUSING AND DEVELOPMENT- ELIGIBILITY MATERIAL WEAKNESS Federal Assistance Listing Number: 14.239 HOME Investment Partnerships Program Grant Number: Various Grant Period: Various We are implementing the following procedures to address the auditing finding 2022-001: Prior to the recent internal audit of PH3, we were still rebounding from the effects COVID 19 had on our procedures at Pinellas Hope Apartments. We went through a period of significant staff turnover which resulted in falling behind on a procedure of reviewing files on a regular basis. We have subsequently hired new staff with Property Management experience and have reviewed and corrected all the current files. We also have restarted our procedure of Monthly peer reviewed audits of files for new move-ins.

Finding Number: 2022-004 Condition: The schedule of expenditures of federal awards (SEFA) initially presented for audit was not complete and accurate. Planned Corrective Action: A new report in Workday is being created to ensure all expenditures for federal awards are included. Contact person responsible for corrective action: Laura Randall Anticipated Completion Date: 10/31/2023

Finding: 2022-003? Cash Management (repeat) Auditor Description of Condition and Effect: During our audit procedures over the District?s cash management process, we noted that one of the claim requests selected for testing did not agree to the District?s actual meal counts. As a result of this condition, the District does not have proper controls in place over its procedures for submission of claim requests. Auditor Recommendation: The District should establish procedures to ensure that the number of meals being submitted for reimbursement agrees to the actual meal counts. Corrective Action: The District implemented review and approval changes in March 2022 to correct this prior year finding. The process that the District uses currently allows for the correction of errors on meal claims before submission. Responsible Person: Shelbi Frayer, Contracted Finance Director Anticipated Completion Date: June 30, 2022

Finding: 2022-002? Budgetary Control Auditor Description of Condition and Effect: During our audit, we noted that multiple departments had material actual expenditures in excess of the amounts appropriated. As a result of this condition, the District?s general fund budget amendments were not sufficient to cover the actual expenditures. Auditor Recommendation: The District should perform a detailed analysis of actual expenditures for the general fund and each special revenue fund, at a minimum by department, throughout the year and, as it becomes known that budgeted expenditures are no longer realistic, that the Board take action to amend the budget(s) accordingly. Corrective Action: The District continues to evaluate and improve it?s budget process and will evaluate the cost benefits of more budget amendments throughout the year. Responsible Person: Shelbi Frayer, Contracted Finance Director Anticipated Completion Date: June 30, 2022

Finding: 2022-001 ? Segregation of Duties Auditor Description of Condition and Effect: During our audit, we noted the following areas in which the District should improve segregation of duties: The District does not have procedures in place to allow for an independent review of payroll registers when payroll disbursements are made and recorded in the accounting records. The District currently does not have procedures in place to allow for an independent review of manual journal entries As a result of this condition, the District is exposed to increased risk that misstatements, whether caused by error or fraud, could occur and not be detected by management on a timely basis. Auditor Recommendation: The District should evaluate its processes and procedures to ensure that a sufficient segregation of incompatible duties exists. Corrective Action: The District will implement a review and approval process for payroll; manual journal entries are entered by one employee and approved and posted by a separate employee, which allows for segregation of duties. The Business office will continue to evaluate the cost benefits of additional segregation of duty procedures on an ongoing basis. Responsible Person: Shelbi Frayer, Contracted Finance Director Anticipated Completion Date: June 30, 2022

Type of Finding: Noncompliance, material weakness Condition/Context: The District did not ensure that monies spent on equipment were properly budgeted within the grant agreement and that ADE had prior approval of equipment purchases. Action planned in response to finding: The District will establish proper internal controls over property and equipment to ensure all equipment purchases are budgeted for within the grant agreement. Planned completion date for corrective action plan: For the period ending June 30, 2023. Name of the contact person responsible for corrective action: Aaron Whittle, Business Manager

Condition/Context: The District spent $12,772 of federal funding on video conferencing, COVID-19 testing, charging stations, fire and alarm testing, palm tree trimming, ADEQ monitoring, and a printer. These expenditures were not explicitly authorized within the budget approved by the passthrough agency for the related grant. In addition, the District expended $31,500 in payroll for retention stipends that were not explicitly written into the budget approved by the passthrough agency. Lastly, for eleven of 25 general disbursements tested, an approved purchase order or requisition was not maintained to support the authorization of the purchase. Among those eleven purchases, five did not have invoices approved for payment. Action planned in response to finding: The District will establish proper internal controls over processing expenditures to ensure that only those expenditures that are allowed and approved within the budget be spent out of grant funds. Those expenditures should be approved within a purchase order and requisition and the related invoices should be approved for payment. Planned completion date for corrective action plan: For the period ending June 30, 2023.

In October 2021, the Organization created a full-time staff position whose primary responsibilities were to collect, review, and track invoices and receipts. The individual was instructed to use the Journal Ledger Spreadsheet provided by MDE. However, the spreadsheet does not include a cross-check to verify that the receipts and invoices entered into the spreadsheet have associated images or scans of receipts. The Organization will begin utilizing the My Food Program software to enter invoices and receipts to track the nonprofit food service. The software will be configured to require the upload of a photo or scan of the actual receipt or invoice in order to create the expense, thus guaranteeing that documentation of the expense exists and is appropriately maintained. This procedure will also resolve any issues with corrupted files as the reports can be generated from the cloud-based software. The Organization abruptly ceased operations in January 2022. It is our understanding that sponsored sites must prove that they expended all program funds on approved program-related expenses, but are not required to do so in the month the funds were received. In other words, sponsored sites would have had all of fiscal year 2022 to document the expenditures of all funds received in fiscal year 2022. It is reasonable to assume that sites with an excessive balance in their food service account would have been able to document appropriate expenditures if given sufficient time. The Organization is confident that the systems in place in fiscal year 2022 would have allowed the Organization to monitor the appropriate use of excessive nonprofit food service program balances in future periods; most notably through the Organization?s policies and procedures contained in the Management Plan and approved by MDE. The Organization holds future claims if the balance in the food service account exceeds a three-month average of expenditures. Monitoring forms were completed on paper during fiscal year 2022. Staff were instructed to scan and save an electronic copy of the monitoring form on the Organization?s cloud-based storage system. In some cases, staff failed to save an electronic copy and the only verification of the monitoring visit is contained in paper files that are currently in off-site storage. The Organization believes that staff adhered to the monitoring requirements, despite the documentation of those visits not being readily available. Going forward, all monitoring staff will be required to complete site visits electronically using the My Food Program software. The software will store the monitoring form electronically on the cloud, inclusive of sponsor and site staff signatures with date-time stamps. There are also comprehensive monitor tracking reports available to assist with monitoring frequency compliance. In the event of a loss of internet service, the monitors will be required to complete the visit on paper and upload a copy to the My Food Program software. The Organization agrees that the retained administrative fee should reflect the administrative fee percentage stated in the Sponsor Agreement. However, the Organization would like to note that the USDA Guidance for Management Plans & Budgets states that, ?A sponsoring organization may retain a portion of the reimbursement for costs associated with administering the CACFP. It may retain up to 15 percent of the total CACFP reimbursement received, or the actual net administrative costs incurred, whichever is less.? Further in the same document, it states, ?There is a concern that sponsoring organizations of centers may spend more on administrative costs than on food. The state agency?s review should investigate how reimbursements are disbursed and whether the food service is supported appropriately.? The Organization would like to emphasize that additional funds, in a miniscule amount, were spent on operating costs, such as food, and it did not retain additional administrative funds. The Organization?s policy in fiscal year 2022 was to track the administrative fee percentage in the claims tracking spreadsheet in lieu of referencing a signed agreement each month. This is supported by the Organization?s disbursement allocation policy, which is included in the fiscal year 2022 Management Plan and approved by MDE. In fiscal 2022, the claims staff would alter the administrative fee percentage upon the written direction of the Executive Director or Director of Operations based on their verbal or written interactions with the site. Going forward, claims staff will not be allowed to change the administrative fee percentage in the claims tracking spreadsheet unless a revised Sponsor Agreement is signed. The Site Information Form was used as a supplement to other operational information about the site. This form is not a federal requirement, nor a form provided by or required by the state agency. During fiscal year 2022, the processing time for the approval of site applications by the state agency was beyond the normal thirty business days. Therefore, sites interested in participating under the sponsorship of the Organization would often complete the Site Information Form as early as possible so that the Organization could submit the site application with MDE. Oftentimes, at the time the Site Information Form was completed, the site may not have finalized site operating times and meal times. The Organization maintained a complete record of all required site information at all times. Contact names and dates of birth of responsible individuals at the sites were documented in the Google sheet used to track information during the intake appointment. In addition, the hours of operation and licensed capacity were maintained in My Food Program software. Lastly, the sites? food preparation methods were also documented on the Google sheet with site information. Catering contracts with vended meal providers are maintained on-file as they are required to be uploaded to the state agency with the site application. Going forward, the Organization will no longer use the Site Information Form or the Google sheet to track required site information. Instead, all data to ensure that the sites are eligible to participate in the CACFP, and the information required to effectively perform subrecipient monitoring procedures, will be retained in the My Food Program software.

U.S. Department of Housing and Urban Development (?HUD?) Norwood Life Society respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 to December 31, 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 Department of Housing and Urban Development 2022-001 Mortgage Insurance_Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities ? Assistance Listing No. 14.129 Recommendation: We recommend that the Project work with their Regional HUD representative to discuss the unauthorized loan to result in either approval or a plan for resolution. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Rick Steffens, the CFO, will oversee this plan, and the plan has been implemented and fully resolved. The unauthorized loan was due to an increasing intercompany balance due from an affiliated nursing home (?Bethesda?) who was losing money and unable to reimburse Norwood Crossing for shared bills for items including benefits and insurance. Due to the size of the losses, we realized this issue was unable to be resolved without disposing of Bethesda and began working on selling Bethesda in the second quarter of 2022. Bethesda was supposed to close on the sale on November 30, 2022, which would have solved the intercompany issue during the 2022 audit year, which was our plan. However, the sale was continuously delayed due to numerous serious issues pushing the actual sale date all the way back to July 1, 2023. The audit finding for the unauthorized intercompany loan was for $1,724,731.69. However, the intercompany balance continued to grow in 2023 and had an additional $574,583.86 of expenses that built up in 2023 before the sale occurred. This made a grand total of $2,299,315.55 that needed to be repaid from Bethesda to Norwood Crossing for the unauthorized intercompany loans through the sale date. Bethesda worked to repay the intercompany loans the best it could during 2023 before the sale occurred, and completely paid down the remaining balance on the unauthorized intercompany loans shortly after the sale of Bethesda occurred. The following payments were made from Bethesda to Norwood Crossing: Payment Dates Payment Amounts 5/8/2023 $675,000.00 5/23/2023 $350,000.00 7/17/2023 $1,274,315.55 Total $2,299,315.55 These repayments above fully resolved the unauthorized intercompany loans that were 1) in the 2022 Audit as a finding, and 2) increases that occurred in 2023 after the 2022 year end. Furthermore, Bethesda has officially been sold as of July 1, 2023 and is no longer causing this issue to continue to occur going forward. Name(s) of the contact person(s) responsible for corrective action: Rick Steffens Planned completion date for corrective action plan: July 17, 2023 If the Oversight Agency for Audit has questions regarding this plan, please call Rick Steffens at 773-577-5334.

Finding 2022-002: Procurement Policy (Material Weakness) Information on the Federal Program: U.S. Department of State ALN 19.040 Criteria or Specific Requirement: 2 CFR Section 200.318 requires that the non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in ?? 200.317 through 200.327. Condition: FCE does not have a formal written procurement policy that conforms to the requirements of the Uniform Guidance. As a result, no procurement files were maintained to document FCE's procurement actions. Cause: FCE has no accounting policies and procedures in place to provide guidance to management on the documentary evidence requirements in accordance with proper internal controls and the Uniform Guidance. Effect or Potential Effect: Without either a procurement policy or procurement documentation, there is a risk that FCE did not perform a proper evaluation of each potential vendor whose costs were charged to federal programs. Recommendation: FCE should develop accounting policies and procedures to provide guidance to management regarding the proper internal controls over both financial reporting and compliance with federal awards. Included in those policies and procedures should be a procurement policy that conforms to the requirements of the Uniform Guidance. Furthermore, FCE should maintain documentation in its files to provide evidence to support that it followed the procurement policy. Action Taken: FCE acknowledges the requirements of the Uniform Guidance and the non-compliance implication for Federal awards. FCE is in the process of developing and implementing a procurement policy to ensure proper competitive procedures are followed with respect to its procurements, specifically its vendors. FCE will ensure that proper documentation is maintained in its files in accordance with the policy to be implemented.

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.