Corrective Action Plans

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

Management concurs with the recommendation as proposed and is implementing policies and procedures to provide for proper segregation of duties over grant activities. This has been implemented effective immediately.

Item # 2023-002 Net Assets with Donor Restrictions (Material Weakness in Internal Control) Criteria: Under GAAP, net assets with donor restrictions should be released from restrictions when the award terms of the related grants or contributions are met. Condition: Management did not release all restricted net assets within the proper period. Cause: Management did not examine grant and contribution agreements carefully enough to determine the nature of the applicable terms for restrictions and did not take necessary measures to ensure that net assets with donor restrictions were properly released throughout the fiscal year. Effect: Net assets with donor restrictions were overstated by $3,571,287 and net assets without donor restrictions was understated by $3,571,287. Recommendation: We recommend that management ensures that it examines grant agreements carefully to determine the nature of the applicable terms for restrictions, and to take necessary measures to ensure that net assets with donor restrictions were properly released throughout the fiscal year. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with GAAP. This exercise is anticipated to be complete by the end of the fiscal year.

Item # 2023-001 Conditional Grant Revenue Recognition (Material Weakness in Internal Control) Criteria: Under Generally Accepted Accounting Principles (GAAP), advances received for conditional grants for expenses not yet incurred are considered a refundable advance liability and should be recognized as revenue only once the barriers are overcome, which includes incurrence of allowable costs under Office of Management and Budget Circular A-122. Condition: Management did not recognize conditional grant revenue for the full amount of the award after allowable costs were incurred. Cause: Management was unaware that conditional grant revenue was required to be deferred until allowable costs under the federal grant agreement were incurred and did not record the related revenue in the proper period. Effect: Conditional grant revenue was understated by $593,838. This is considered a material weakness in the Organization’s internal control over financial reporting. Recommendation: We recommend that management ensure that conditional grant revenue is recognized upon incurrence of allowable costs under the federal grant. We also recommend that management enroll in a professional education program that covers Uniform Guidance compliance. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with GAAP and the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

Views of Responsible Officials: Management agrees. Processes will be put in place to document cost savings in writing when extended travel is necessary. This cost analysis will be filed along with board approval, so it is easily accessible upon request.

Finding Number: 2023-001- Schedule of Expenditures of Federal Awards (SEFA) Preparation – Material Weakness Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the federal award to ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. This includes properly identifying all federal awards subject to the Uniform Guidance and fairly presenting the required information in the schedule of expenditures of federal awards. Condition: Subsequent to the issuance of the Audit Report on the Consolidated Financial Statements and Supplementary Information for the year ended September 30, 2023, it was discovered that there was an omission of two federal grants with expenditures totaling $1,591,715 from the schedule of expenditures of federal awards. Cause: The Organization did not communicate with Care 1st Health Plan regarding the details of certain contracts to determine the amounts were subject to the Uniform Guidance and were to be included on the schedule of expenditures of federal awards. In addition, Care 1st Health Plan became the Regional Behavioral Health Authority for the Northern Arizona region effective October 1, 2022. Due to this transition, various changes occurred causing uncertainties with classifications of certain types of federal awards as subrecipient awards versus as contractor payments. Effect: The schedule of expenditures of federal awards was understated by $1,591,715, which resulted in the restatement of the previously issued schedule of expenditures of federal awards to correct the omission. Questioned Costs: Not applicable. Recommendation: We recommend that all funding contracts are carefully reviewed to determine whether amounts awarded should be classified as contractor payments or as subrecipient payments. If there is any uncertainty, we recommend that the Organization contact the funding source for clarification. Name of Contact Person: Mike Fett, CFO Phone Number: 602-265-8338 Anticipated Completion Date: September 30, 2024 Views of Responsible Officials and Corrective Actions: Southwest Behavioral Health Services, Inc. and Subsidiaries will establish procedures to review all contracts and to if necessary, to communicate with funding sources to ensure that receipts of federal funding are properly classified as being subrecipient versus contractor arrangements to ensure completeness of the Schedule of Expenditures of Federal Awards.

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Prior to any cost reimbursement invoices submitted, the invoices will be reviewed and approved by the State Manager or a Director of State Engagement to ensure amounts requested for reimbursement were incurred prior to the reimbursement request and are related to costs that were properly allocated to the federal program. Anticipated completion date: Implemented October 2023

Finding Number 2023-001 SPECIAL TESTS AND PROVISIONS- ENVIRONMENTAL CONTAMINANTS TESTING AND REMEDIATION – MATERIAL WEAKNESS Agency Name FEDERAL AGENCY: U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 – PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Special Tests and Provisions - Environmental Contaminants Testing and Remediation As stated in the May 2023 Compliance Supplement, Public Housing must be decent, safe, sanitary, and in good repair. Public Housing Authority’s (PHA) must maintain such housing in a manner that meets the physical condition standards set forth in 24 CFR section 5.703 in order to be considered decent, safe, sanitary, and in good repair. Those standards address the major areas of the public housing: the site; the building exterior; the building systems; the dwelling units; the common areas; and health and safety considerations. Health and safety considerations require that all areas and components of the housing must be free of health and safety hazards. These areas include, but are not limited to, air quality, electrical hazards, elevators, emergency/fire exits, flammable materials, garbage and debris, handrail hazards, infestation, and lead-based paint. The housing must have no evidence of infestation by rats, mice, or other vermin, or of garbage and debris. The housing must have no evidence of electrical hazards, natural hazards, or fire hazards. The dwelling units and common areas must have proper ventilation and be free of mold, odor (e.g., propane, natural gas, methane gas), or other indoor air hazards such as radon. The housing must comply with all requirements related to the evaluation and reduction of lead-based paint hazards and have available proper certifications of such (see 24 CFR Part 35). For the period under audit, the PHA is required to test for and remediate environmental contaminates including but not limited to lead-based paint, radon gas, and mold to ensure that public housing met the physical condition standards for health and safety considerations set forth in 24 CFR section 5.703. Condition/Context The New York City Housing Authority (the “Authority”) performs environmental contaminates testing and remediation including but not limited to Lead-based paint, Mold, Pest Control, Elevators, Heating and Annual Apartment Inspections. To track compliance with the Agreement executed on January 31, 2019 by and among the Authority, the U.S. Department of Housing and Urban Development (“HUD”) and the U.S. Attorney’s Office for the Southern District of New York (SDNY) and The City Of New York (the “HUD Agreement”), the Authority maintains monthly inspection reports for the various inspections performed and provides that information to HUD, the SDNY and the Federal Monitor appointed under the HUD Agreement. Deloitte obtained the bi-annual lead-based paint compliance reports from the Authority and for the Period from June 16, 2023 through December 15, 2023 and December 16, 2022 through July 15, 2023, we read extermination, heat outage, mold inspections, annual apartment inspections, and elevator outage reports for the months of February 2023; April 2023; July 2023; September 2023 and November. 2023. During our audit, we noted that the Authority did not complete all corrective actions in the 2023 audit period and is in the process of addressing these issues. Recommendation We recommend that the Authority continue to ensure that all environmental contaminates are properly remediated during the audit period through the HUD Agreement. Corrective Action Plan In January 2019, the Authority entered into the HUD Agreement to address building conditions, including conditions related to lead-based paint, mold, pests, elevators, and heating. Among other things, the HUD Agreement appointed a federal Monitor and established three new Departments – Compliance, Environmental Health & Safety, and Quality Assurance. It also required the promulgation of action plans around these health and safety issues and other items. These action plans are publicly available https://www1.nyc.gov/site/nycha/about/reports.page, along with other reports on health and safety issues, which detail the Authority’s efforts to inspect for and correct deficiencies associated with environmental contaminants like lead-based paint and mold. The Authority plans to continue to work to address these health and safety issues, and to work towards meeting the multi-year obligations laid out in the HUD agreement in addition to the action plans. NYCHA has recorded $4,392,861,000 of pollution remediation obligations as of December 31, 2023, which relates to costs to inspect for, and correct deficiencies associated with environmental contaminants. Action Date Ongoing milestones through January 31, 2039 Final Implementation The latest in time obligation under the HUD Agreement is the Authority’s obligation to abate 100% of the apartment units that contain lead-based paint, and the interior common areas that contain lead-based paint in the same building as those units, by January 31, 2039 Name And Phone Number Of Person Responsible For Implementation Brad Greenburg Chief Compliance Officer 212-306-4240

Management Response Management acknowledges the recommendation of placing internal controls in place to ensure that costs are charged and allocated to the proper grant period. REMEDIATION PLAN Management has hired Jess Vaughn-Jansen as Director of Financial Strategy (Director) to ensure transactions are charged and allocated to the individual grants in the proper grant period. The Director has reviewed the process documents that are in place to assist in recording transactions. Excel Tracking Sheets have been created and are maintained by the Director for each grant. Per the grant agreements, the Grant Period (i.e., Effective Date and Expiration Date) has been documented on all the Tracking Sheets. This will allow the Director to properly include and exclude items that may occur before the Effective Date or after the Expiration Date. These Tracking Sheets have been used by the Director since February 2023. The 1 selection not in compliance was posted prior to the Director’s hire date. No findings have been identified after the Director’s hire date. The Director has and will continue to be cognizant of including and excluding items that may occur before the Effective Date or after the Expiration Date.

Finding Number: 2023-002 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Shannon Coyle, County Auditor-Treasurer Corrective Action Planned: Morrison County management is aware that the annual Project and Expenditure Report submitted for Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) to the U.S. Treasury was done so incorrectly. The County has reviewed the U.S. Department of the Treasury guidance and form instructions to ensure it is correctly reporting its CSLFRF activity going forward. Anticipated Completion Date: The correction will be made on the Annual Project and Expenditure Report due in April 2024, for the reporting period ending March 31, 2024.

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree with the data submitted in the Reports, therefore we could not determine their accuracy. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improve record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

Finding 2023-001: Local Assistance and Tribal Consistency Fund, Federal Assistance Listing No. 21.032, U.S. Department of Treasury Compliance Requirement: Reporting Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Noncompliance (material noncompliance) Recommendation: The County should strengthen its internal controls with adopted policies and procedures to ensure accurate financial reporting in compliance with the Reporting Guidance for the Local Assistance and Tribal Consistency Fund. Action Taken: Complete a spreadsheet that shows the exact revenue and expenditures to report exactly the amounts recognized/spent for the Local Assistance and Tribal Consistency Fund.

FINDING 2023-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All persons involved in the internal control; preparer, reviewer, etc. will be documented on the P&E Report document or with a checklist to show that we actually completed the internal controls we have in our policy. Anticipated Completion Date: immediately

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should follow established written policies and procedures regarding procurement and properly document the process for each procurement made. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments and the following actions have been taken to improve the situation. We hired a Contracts & Compliance Manager in 2024 who is now responsible for ensuring the procurement process is properly documented for each procurement made. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: September 30, 2024

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding allocation processes, including ensuring internal controls are in place. It would also be beneficial to eliminate or reduce the amount of manual inputs into the allocation process. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments, and the following action will be taken to improve the situation. We will establish written policies and procedures regarding allocation processes, including ensuring internal controls are in place by November 30, 2024. Simultaneously, we will also consider options to eliminate or reduce the amount of manual inputs into the allocation process. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Ronald Tran, Senior Finance Manager Plan completion date for corrective action plan: November 30, 2024

Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding firsttier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments and the following actions have been taken to improve the situation. We hired a Contracts & Compliance Manager in 2024 who is now responsible for reporting first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) by the reporting due date. Additionally, we established written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: September 30, 2024

Conservation Research and Development Program – Assistance Listing #81.086 Plan completion date for corrective action plan: October 31, 2024 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost- reimbursement related to federal grants which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Grants Accountant in 2024 to take over the responsibility of preparing invoices for cost-reimbursement. This allows for the additional control of the Senior Finance Manager reviewing the invoices. This review is now being documented in writing. Additionally, there are procedures in place to ensure if the Senior Finance Manager prepares the invoice, the Director of Finance & Operations reviews and documents approval of the invoice. We will establish written policies and procedures to document this process by October 31, 2024. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Ronald Tran, Senior Finance Manager

Department of Education Education Stabilization Fund – Assistance Listing No. 84.425 Recommendation: We recommend that internal policies and procedures be reviewed and updated to ensure underlying supporting documentation for payroll expenditures is fully retained going forward for this program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The organization has enhanced its internal policies and procedures to ensure underlying supporting documentation is fully retained and maintained.Name of the contact person responsible for corrective action: Shaina Rodriguez, Vice President of Human Resources and Managed Services. Planned completion date for corrective action plan: June 30, 2024

FINDING 2023-002 Finding Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds Summary of Finding: The US Treasury Quarterly Project and Expenditure Reports did not have documentation of internal review and approval prior to submittal to the US Treasury. Corrective action will include internal review and approval of the report, documented in writing, prior to submittal. Contact Person Responsible for Corrective Action: Jeff Plasterer, County Commissioner Contact Phone Number and Email Address: 765.973.9237 jeff.plasterer@co.wayne.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A form has been created for the specific purpose to document the internal review procedure for the US Treasury Quarterly Project and Expenditure Report. The Commissioners' staff who is responsible for the accurate and timely completion of the US Quarterly Project and Expenditure Report will make the completed report available to the President of the Board of Commissioners (or their designee), who will review the report prior to submittal, thus providing the proper segregation of duties, as well as avoid potential misstatements to go undetected. Anticipated Completion Date: The form has been created and will become effective immediately, and will be utilized for all future Quarterly Project and Expenditure Reports of the Coronavirus State and Local Fiscal Recovery Funds.

Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay County Social Services will take both immediate and long-term corrective actions. First, the case files identified with discrepancies will be revie.wed in detail, and necessary corrections will be made to ensure that the documentation in both the case files and the MAXIS system aligns with program requirements. Requests for case file numbers have already been submitted to the MA team lead to identify the cases needing correction. This will include reverification of asset amounts, we will match MAXIS's citizenship status with the appropriate documentation within the case file. In addition, one-on-one reviews will be conducted with the staff responsible for administering the affected cases. During these reviews, case-specific feedback will be provided, detailing the nature of the errors and explaining corrective actions to prevent recurrence. For long-term preventative measures, Clay County will implement a more comprehensive and mandatory training program for all staff involved in eligibility determination. This training will focus on key areas such as proper documentation for citizenship, asset verification, and data entry protocols to reduce human errors in MAXIS. We will continue conducting periodic case file audits with increased frequency to detect errors early and provide timely feedback to staff. Audit results will be shared with the entire team to promote learning from errors and reinforce best practices in documentation and data entry. Anticipated Completion Date: The cases found in error will be corrected by November 15, 2024. Case file reviews will continue monthly.

FINDING 2023-005 INDIANA STATE BOARD OF ACCOUNTS 30 Finding Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: The County submitted one Project and Expenditure report during the audit period; however, controls were not in place to prevent, or detect and correct, errors. As a result, the following errors were noted: • The current period expenditures for 8 of 16 projects were understated by $635,748. In addition, current period expenditures for 1 of 16 projects was overstated by $29,767. • The cumulative expenditures for 6 of 16 projects were understated by $285,748. In addition, cumulative expenditures for 1 of 16 projects was overstated by $29,767. Contact Person Responsible for Corrective Action: Janet Chadwell Contact Phone Number and Email Address: 812-663-2570 jchadwell@decaturcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Will create a better spreadsheet to track disbursements of appropriations/projects since the reporting period is April 1, 2024 to March 31, 2025. This grant will also be monitored by the ARPA Committee as part of the internal controls responsibility of the Auditor’s office.

Finding 2023-003 Contact Person Responsible for the Corrective Action: Willie Boles Contact Phone Numb er: 765-778-7937 Views of the Responsible Official: We concur with the findings. Description of Corrective Action Plan: 1. Prior to the submission of the annual P&E report, two deputy clerk treasurers will each calculate the totals within the project codes and review any variances in totals. Anticipated Completion Date: April 30th , 2025

GVHC implemented the physical review and controls described in the 2022 audit response. Our efforts were largely successful as the missing application was the only failure of the physical audit process we put in place. However, a failure of our technology and billing software was revealed. Our plan it to: 1. Continue to provide frequent education and training for front-desk staff to assist in preparation and required completion of the sliding fee applications and proof of income. 2. Continue to identify patients who have exhausted their limited Medicaid benefits and will now qualify for sliding fee scale for dental work. 3. Continue to review reports identifying patients with no end date identified for their sliding fee scale. For identified accounts, determine correct date and enter in the system. 4. Continue 100% audit of all sliding fee scale applications for accuracy of calculation and presence of necessary paperwork. Provide direct feedback to staff when errors are identified. Integrate changes to billing software into the process when sliding fee scales are adjusted and posted. Run reports of sliding fee scale discounts and audit for correct calculation. Anticipated completion date: October 31, 2024 Contact person responsible for corrective action: Mary Sterhan, CEO

Finding 2023-002 - Accounting Controls - Subsequent Bank Reconciliations Not Completed ALN 14.881- Noncompliance and Material Weakness Corrective Action Plan: All subsequent bank reconciliations are in progress. Person Responsible: Catherine Jackson Anticipated Completion Date: September 30, 2024

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster FFAL #10.766 Finding Summary: During review of expenditure listings, three expenditures were claimed under the USDA Grant Program after the Center received an advancement of USDA loan funds for those same three expenditures. We did not have a formal review process in place over the USDA Grant expenditure listing and the USDA loan advancement to ensure double dipping was not occurring. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: Due to staffing shortages there was no review of the grant applications to check for duplicate coverage. A Controller was hired November 20, 2023 to allow for reviews of documents and spreadsheets prior to submission. Anticipated Completion Date: 2025