Corrective Action Plans

We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have implemented a process that all grant claims/payment vouchers are formerly reviewed and initialed by our Executive Director.

Finding Reference Number: 2023-001 Identification of the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing No.: 10.557 Name of responsible official: James Geraghty Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: September 12, 2024 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Management was unable to provide evidence of a control being consistently performed to address the risk that the Health System may seek reimbursement for expenditures that are either out of contract period or are for non-permissible costs under the applicable contracts. Status Management concurred with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures, and that all expenditures were incurred in the proper period. Evidence of the monthly review and approval will be retained.

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to the Director of Finance. The Director of Finance reviews time and effort reports and compiles the data to allocate personnel expenditures, however, the time stamp of approvals was not effectively documented during 2023. The Foundation has implemented procedures to effectively time stamp the review and approval process, each month. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024

For Federal grants we will make it standard practice to request 1-2 months extension so that we get reimbursed for the work required to close out the grant after the grant end date. We have had federal employee's contact us as much as 4 months past the close date with erronious time consumming issues. Lynn Ketch, Executive Director, is the person responsible for the plan.

Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal audits. Person(s) Responsible: Sandi Weiss, AVP Finance Expected Completion Date: November 15, 2024

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID‐19 pandemic to support the receipt of the various allocations of the herein described COVID‐19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID‐19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID‐19 pandemic. The term “COVID‐19 Funds” means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020, through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021, through December 31, 2024. To provide further assurance that the COVID‐19 Funds were properly applied by the nursing home beneficiaries receiving COVID‐19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look‐back review plan. The framework of the lookback review plan will be for each nursing home beneficiary that received COVID‐19 Funds to submit during the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID‐19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in‐depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID‐19 Funds through the Foundation, plus another 10 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID‐19 Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID‐19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID‐19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID‐19 Funds to an unmet need for a qualifying purpose, those COVID‐19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID‐19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

FINDING 2023-005 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: Description of Corrective Action Plan: The Town of Upland will implement an oversight system to review the P&E Report before submission to the Federal Government. Anticipated Completion Date: Upon the submission of our next report due April 30, 2025

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.

Views of Responsible Officials: Management acknowledges that prior approval must be received before allocating any cost to an award that is incurred outside of the period of performance. While in this case approval was ultimately not granted, the cost was returned to the original project and removed from the affected project and subsequent drawdowns adjusted accordingly. To avoid incurring costs outside the period of performance, the following actions will be implemented:  Update the Global Center procurement guidelines to explicitly emphasize period of performance requirements when incurring expenses on grants and contracts.  Systematically confirm all purchase requests, vendor contracts, consulting agreements and subawards fall within the period of performance by including the start and end date of the grant or contract on all associated documentation. Responsible Officials: Daniel Grimshaw, Director of Finance Anticipated Completion Date: December 31, 2024

FINDING 2023-004 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Humphrey Nagila Contact Phone Number: 317-542-4554 Views of Responsible Official: We agree with this finding. The City will create a policy and procedure to ensure appropriate segregation of duties and reviews, approvals, and oversight are in place for reporting. This policy will require that two staff members from the Controller's Office prepare the quarterly Project and Expenditure report (P&E report). One staff member shall be responsible for preparing the report and the other will complete a review and submission of the report. Anticipated Completion Date: 12/31/2024

An internal procedure was created, in addition to former procedures that shows a more detailed approach of ensuring every invoice involved with each drawdown are accounted for and paid on a timely basis to each vendor. The Authority believes this instance was a one-time item that will be corrected.

Corrective Action: Management will update written procedures and train the Grants Accounting team regarding period of performance to ensure all requests are made within the proper period based on the period of performance. The procedures and training will include grant period close, cost allowability, requirements for documentation, and review of charges prior to requests. In addition, Grants Accounting has initiated monthly meetings with grantors to closely monitor grant spenddown, address any processing issues, and ensure proper cut-off. These meetings will be instrumental in tracking progress and oversight in our grant management process. Name of Responsible Individual(s): Jason Brenier, Shelly Courtois, and Judy Bokhari Anticipated Completion Date: April 2024

Corrective Action: Management will update written procedures and train the Grants Accounting team regarding period of performance to ensure all requests are made within the proper period based on the period of performance. The procedures and training will include grant period close, cost allowability, requirements for documentation, and review of charges prior to requests. In addition, Grants Accounting has initiated monthly meetings with grantors to closely monitor grant spenddown, address any processing issues, and ensure proper cut-off. These meetings will be instrumental in tracking progress and oversight in our grant management process. Name of Responsible Individual(s): Jason Brenier, Shelly Courtois, and Judy Bokhari Anticipated Completion Date: April 2024

A copy of the November 2023 Report has been filed.

FINDING 2023-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County submitted four P&E reports during the audit period; however, the errors as identified below were noted on all four reports.  Quarterly Report: October 1, 2022 to December 31, 2022 Current period expenditures reported 7 projects with errors totaling $77,234. Cumulative expenditures reported 22 projects with errors totaling $3,955,669.  Quarterly Report: January 1, 2023 to March 31, 2023 Current period expenditures reported 7 projects with errors totaling $173,169. Cumulative expenditures reported 25 projects with errors totaling $2,633,217.  Quarterly Report: April 1, 2023 to June 30, 2023 Current period expenditures reported 2 projects with errors totaling $0, since expenditures were posted to the incorrect project. Cumulative expenditures reported 24 projects with errors totaling $2,372,744.  Quarterly Report: July 1, 2023 to September 30, 2023 Current period expenditures reported 3 projects with errors totaling $13,412. Cumulative expenditures reported 26 projects with errors totaling $2,273,749. Contact Person Responsible for Corrective Action: Don Lopp, Director of Operations and County Planning Contact Phone Number and Email Address: 812-948-4110 and dlopp@floydcounty.in.gov Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: As Director of Operations and Planning, the American Rescue Plan quarterly reports are submitted through the office. During the last two audit, it appears data input errors have occurred with the reporting of total expenditures. The initial corrective action of review was not sufficient to correct the data input errors. During the recent July 2024 quarterly report, staff reviewed the items on line and believe that all reporting has been corrected. Starting with the September reporting, two staff members will review the data input Anticipated Completion Date: September 2024 – For the third quarter reporting period.

FINDING 2023-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The SLRF report did not include project information or amounts. Contact Person Responsible for Corrective Action: Auditor Contact Phone Number and Email Address: 765-653-5513, auditor@putnam.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We have reached out to Baker Tilly, who does the reports for the County, regarding our audit finding so they know the reporting requirements that will need to be done for the next project and expenditure report which is due to be filed by April 30, 2025. Once we receive the report from Baker Tilly we will have a county employee review for accuracy of the report. Anticipated Completion Date: April 30, 2025

FINDING 2023-002 Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: U.S. Department of Treasury Assistance Listing Number: 21.027 Federal Award Number: FY 2022 Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Material Weakness, Modified Opinion Condition: The City had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties that would likely be effective in preventing, or detecting and correcting, noncompliance. Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the Department of Treasury (Treasury). The reporting periods, as well as the respective due dates, are based upon type of recipient and its population, as well as the recipient's allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The City was classified as a metropolitan city with a population below 250,000 residents that received an allocation of less than $10 million in Coronavirus State and Local Fiscal Recovery Funds (CSLFRF). As, annual reports are to cover one calendar year and must be submitted to the Treasury by April 30 each year. Context: The City submitted one P&E report during the audit period; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent, or detect and correct errors. In addition, the P&E report was not properly supported by the City’s records. All but $100,000 of the expenditures were reported under the Eligible Use Category of “Administrative Expenses.” However, the City’s expenditures during the audit period consisted of assistance to business and households, sewer infrastructure, and tourism support, none of which qualified as Administrative Expenses. Furthermore, the City reported that it was electing to take the Revenue Loss Standard Allowance, but the amount reported as Revenue Loss was $0. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City of Crawfordsville management will follow the following process. 1. Before processing request from designated organizations the Clerk Treasurer and Mayor or a designated person, will review documentation and approve for payment/claim processing. 2. After approval a claim will be submitted to the Clerk Treasurer office for payment. 3. Clerk Treasurer will prepare and submit monthly expenditure report to the Mayor or designated person. 4. Annually before the Clerk Treasurer, reports to the U.S. Treasury expenditures the Clerk Treasurer and Mayor, or designated person, will review and confirm expenditures. 5. Clerk Treasurer will submit report to U.S. Treasury following prompts. 6. Clerk Treasurer will notify Mayor of the annual report submission. Responsible Party and Timeline for Completion: Clerk Treasurer and the submission that takes place in 2024 (2023 report).

FINDING 2023-003 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jessica Thome, Controller Contact Phone Number and Email Address: (812) 244-2360 and Jessica.thome@terrehaute.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We have utilized an outside consulting service to assist in the reconciliation of expenditures. Quarterly P&E Reports will be completed by the Controller and reviewed and approved by the Mayor. Anticipated Completion Date: Qtr3 P&E report required by end of Oct 2024

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds – Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jessica Thome, Controller Contact Phone Number and Email Address: (812) 244-2360 and Jessica.thome@terrehaute.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Controller will review any previously entered contracts that are paid from our federal grants including ARP to ensure we are in compliance. Anticipated Completion Date: October 2024

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the U.S. Department of the Treasury (Treasury). The reporting periods, as well as the respective due dates, are based on the type of recipient and the recipient’s population, as well as the recipient’s allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The County was classified as a metropolitan county with a population below 250,000 residents that received an allocation of less than $10 million in State and Local Fiscal Recovery Funds. As such, the initial P&E report, covering the period from March 3, 2021 to March 31, 2022, was required to be submitted to the Treasury by April 30, 2022. The subsequent annual reports are to cover one calendar year and must be submitted to the Treasury by April 30 each year. The County submitted one P&E report during the audit period, which was obtained from the Treasury's website. Although one employee prepared the P&E report and another reviewed the entries, the system of internal controls was not effective in preventing, detecting, or correcting errors. The data submitted included amounts which should not have been included and amounts which were not supported by the County’s records. Errors identified included the following: • Total Cumulative Obligations were overstated by $907,630. • Total Cumulative Expenditures were overstated by $4,332,524. The lack of effective internal controls and noncompliance were isolated to the P&E Report submitted during the audit period. Contact Person Responsible for Corrective Action: Britt Ostler Contact Phone Number and Email Address: (765) 659-6330 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 29 The County received guidance from a consultant in regards to reporting the SLFRF. The consultant had advised “if the County planned to spend $5M, then the total cumulative “obligations” would be $5M. Per review of the SBOA, two figures in the 2023 P&E Report were miscalculated: Cumulative Obligations and Cumulative Expenditures. The Cumulative Obligations reported should be the amount contracted for the project plus any change orders. The Cumulative Expenditures should be the amount expended in prior years, if any, plus the amount expended until March 31st of the year the P&E Report is dated. The current period for the 2023 P&E Report covered April 1, 2022 to March 31, 2023. Future P&E Reports submitted for this grant will use this understanding of Cumulative Obligations and Cumulative Expenditures and will be prepared by the County Auditor and reviewed by a second individual prior to submission. Anticipated Completion Date: April 1, 2025

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County did not have effective internal controls in place to ensure that P&E reports submitted were accurate. This allowed errors on P&E reports to remain undetected and uncorrected. It was recommended that policies and procedures be put in place to ensure that all reports were complete and accurate. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County implemented an additional procedure to ensure we have complete and accurate information for the P & E report. Beginning with the 3rd Quarter P&E report, the County had added a person to assist with these reports by creating the reports through our financial software and reviewing the figures and information before giving the reports to the Auditor. The County Auditor prepared the P & E reports and then the Commissioner’s reviewed before the Auditor submitted the report to the Treasury. Due to the financial software (Software Solutions), there were reporting issues between quarters. The Bartholomew County Auditor’s Office continuously strives to improve upon our process and during 2024, changed financial software to LOW Financial to help with reporting and will implement an additional check and balance prior to the Treasury. Anticipated Completion Date: December 31, 2024

Root Cause Analysis: 1. Report was incorrectly run in the accounting system. Report options were set to fiscal year view when it needed to be set to life-to-date view to see all expenditures of the grant. 2 I did not see on the DESE federal grant reporting instructions document anything stating the person completing the report and the authorized signature could not be the same person. In the Federal grant training I attended, it was not stated. I was added to the Commonwealth of MA Contract Authorized Signatory Listing (CASL) as a third authorized signature by the superintendent for this LEA. 3. Corrective Action(s): 1. A request for an amendment to the appropriate DESE staff member will be sent. 2. The Report will be completed by the Finance Department Accounting Clerk and I will be the authorized signature. If at any point I am the one completing the report I will have the Assistant Superintendent or the Superintendent serve as the authorized signature. 3. Action Item: o Description: A request for an amendment to the appropriate DESE staff member will be sent in June 2024. Once a response is received the report will be completed and filed. I expect it should be done by August 2024. o Responsible Person/Department: Director Finance for the Randolph Public Schools. o Expected Completion Date: August 30, 2024 o Description:The Report will be completed by the Finance Department Accounting Clerk and I will be the authorized signature. If at any point I am the one completing the report I will have the Assistant Superintendent or the Superintendent serve as the authorized signature. o Responsible Person/Department: Finance Department Accounting Clerk for the Randolph Public Schools and Director Finance for the Randolph Public Schools. o Expected Completion Date: Moving forward with all Final Financial Reports

Management’s Response: Management agrees with the finding. Management plans to complete a review of resources assigned to accounting and finance departments as well as identify and implement sufficient internal controls over expenditures cutoff to ensure compliance with the period of performance compliance requirement.