Corrective Action Plans

Management agrees with the finding. The necessary written documentation to comply with the Uniform Guidance will be prepared by December 31, 2024.

Management agrees with the finding and has established procedures to provide timely support for identify eligible loans deployed in the TM. Reports tracking these loans will be reconciled to the total financial products closed reported on future Annual Performance Reports.

Finding 2022-003 During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the new financial system, we believe adequate controls have been established and are working properly to ensure compliance with federal and program regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: May 2023

2022-004 - Year Ended December 31, 2022 Department of Health and Human Services CFDA #93.829 Section 223 Demonstration Programs to Improve Community Health Services (CCBHC) Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance Finding Summa,y: - Rimrock Foundation's final expenditures identified as eligible and claimed under the federal program were reviewed and approved by separate individuals outside of the preparer. However, the reports submitted for reimbursement had no evidence of review and approval by a separate individual outside of the preparer. Rimrock Foundation's statistical reports submitted under the federal program also had no evidence of review and approval by a separate individual outside of the preparer. Responsible Individuals: Jeffrey Keller, CEO and Shirley Ehlang, Lead Financial Accountant Corrective Action Plan: Rimrock will have the statistical reports prepared by the Grant Financial Specialist and reviewed by the Lead Financial Account. The payment will be requested by the Lead Financial Accountant and the CFO or CEO will review the entire packet of documentation. Completion Date: December 2022

Finding 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that funds are disbursed for incurred expenditures prior to reimbursement requests. Anticipated Completion Date: by March 31, 2024 Responsible Person: : Ann Metzger, Vice President Finance

Finding 2022-003: Costs Incurred Outside Period of Performance (Significant Deficiency over Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost Principles) Response and Corrective Action Plan: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that the costs incurred are appropriately charged based on the contracts’ performance periods. Anticipated Completion Date: by March 31, 2024 Responsible Person: Ann Metzger, Vice President Finance

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

The City’s Community Development Department is in the process of rewriting its Policies to include the CDBG-CV provisions. Those policies should be completed within the next couple of months.

Finding 2022-005: Activities Allowed, Allowable Costs, and Period of Performance – Material Weakness. Management Response: We are reviewing our internal controls (SOPs, Operational Manuals and Handbooks), including the document retention policy to assure retrieval. Interdepartmental review of the program contract and the Operations Manual will be held to assure understanding of allowable expenses. 1. Managerial training will be administered to assure Program expenditures are allowable. 2. Operations Manual is being updated to have a process that insures approval workflows for allowable costs. 3. Accounting Policies & Procedures Manual is being updated to improve internal controls & show clear process of compliance over expenditures.

Finding Reference Number: 2022-002 Federal Agency: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus Relief Fund ALN Number: 21.019 Responsible Official: County Commission Views of Responsible Individuals: We understand the importance of having adequate documentation for Federal Grant programs. We hired an outside agency to oversee the Coronavirus Relief Fund who did not provide us the adequate documentation needed. We did; however, provide email confirmations that the monies spent were reported to the Treasury. The County will handle all Federal Grant programs in the future to ensure that adequate documentation is maintained by the County.

(A) Colorado School of Mines will ensure appropriate reviews of expenditures occur to ensure they are within the period of performance for the federal award, and ensure that staff have an appropriate understanding of the related period of performance requirements or obtain clarification from the federal grantor, as appropriate. (B) Mines did not update published Procurement Policies specific to approval limits by position to accurately reflect the delegated approval authority. Mines will update the published policies to accurately reflect delegated approval limits and review the procurement approval process.

Finding 2022-03 Expenditure of Funds Outside Contract Period Condition: In the course of testing direct disbursements for adherence to appropriate cutoffs concerning the contract's period of performance, it was discovered that the Organization incurred a substantial amount of expenditures on contracts prior to the official contract start date. These disbursements took place without acquiring proper authorization for making disbursements prior to the contract's commencement. Despite the unique nature of Naloxone inventory being treated as a prepaid asset due to its delayed usage, the majority, if not all, of the Naloxone units were fully expended before the contract officially commenced. Corrective Actions Taken or Planned: The Organization?s Board and Executive Team consisting of the CEO and the COO acknowledge the finding of expending funds outside the contract period. This finding is connected to the purchase of the emergency medication naloxone. The Organization decided to purchase with no assurance of reimbursement in order to eliminate the lack of emergency medication in an overdose epidemic. The Organization had verbal approval but did not secure approval in writing. Numerous policies will be adopted in 2023 to ensure this does not occur again. Some of these policies include the transition to an experienced nonprofit bookkeeper, training for Finance and Grants Management and tracking mechanisms, monthly grants tracking meetings to ensure inventory and spending, and the adoption of a clear and documented approval process should spending, outside a contract period, be required.

Views of Responsible Officials and Planned Corrective Actions - Management recognizes the overall volume of transactions the Organization continues to grow each year and it being one of the reasons this is a repeat finding. The questioned costs were immaterial. While improvements were made during the year, the internal recordkeeping controls and protocols will continue to be reviewed with the new accounting service provider and improved measures implemented.

Finding 2022-001 - Schedule of Expenditures of Federal Awards United States Department of Education Pass Through Entity: Texas Education Agency Federal Program: American Rescue Plan ? Elementary and Secondary School Emergency Relief (ARP ESSER) Assistance Listing Number: 84.425U Federal Award Number: S425U210042 Federal Award Year 2022 Repeat Comment: No Type of Finding: Material Weakness Condition: When reviewing the net assets released from restriction in the draft financial statements presented to the board, management determined and brought to the attention of the auditors the net assets restricted for pre-award costs for the ESSER federal program ($1,976,911) should have been released from restrictions during fiscal year ending June 30, 2022. The auditor, when tying the draft schedule of expenditures of federal awards to the updated schedules, determined the Organization had not included the pre-award federal expenditures related to the ESSER federal program. As a result, the initial testing of the ESSER major program did not include $1,976,991 in ESSER expenditures. When this was brought to management?s attention, the schedule of expenditures of federal awards was updated and the additional expenditures provided for testing. Cause: The additional $1,976,991 was related to ?pre-award? dollars awarded during fiscal year ended June 30, 2022, where allowable expenditures incurred in the previous year were permitted by the grant to be used for the ESSER funds awarded in the current year. Management was not aware of the requirement to include these amounts on the schedule of expenditures of federal awards. Recommendation: We recommend management of the Organization strengthen their internal controls to ensure all federal awards are included on the schedule of expenditures of federal awards. Corrective Action Plan: Prior to June 30, 2023, management will prepare an administrative procedure that requires the auditor to provide a draft financial and compliance report at least one (1) week prior to the meeting of the Board. In the procedure, management will require staff to reconcile the Schedule of Expenditures of Federal Awards to the Statement of Activities and other relevant accounting information to ensure the accuracy and completeness of the amounts disclosed. Person Responsible: Kevin Byrne, Vice President of Finance Anticipated Completion Date: June 30, 2023

COSA has already strengthened year-end and grant period ending procedures by conducting monthly reviews to identify any expenses and unpaid expenses that should be captured and submitted for reimbursement. These reviews are being conducted by the Finance Director and Executive Director.

Finding: 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: National Bioterrorism Hospital Preparedness Program Federal Financial Assistance Listing #93.889 Compliance Requirement: Activities Allowed and Allowable Costs, Period of Performance, Cash Management and Reporting Finding Summary: No independent secondary level of review or approval is performed relating to compliance. One employee is involved in preparing, reviewing and approving information. Additionally, Internal control procedures documented within Coalition?s Grant Management Policy have not been updated since departure of the Grant Management Director. Responsible Individuals: Greg Santa Maria, Executive Director Corrective Action Plan: The SDHCC has updated its invoicing process to include an internal review of all invoices prior to submission for reimbursement by the state. Per the new process, the executive director reviews, prepares and completes the initial invoicing process. Once complete, the invoice is forwarded to the SDHCC treasurer for final review and approval prior to final submission to SD DOH. The review process is formally documented by treasurer signature on face document prior to submission to DOH. Grant management policy is currently in revision. Anticipated Completion Date: For Invoicing Process, practice was changed to reflect final review by SDHCC treasurer on January 10, 2023, beginning with BP4 Invoice number 227. Projected Grant Management policy revision first draft to Board is Friday April 7, 2023.

Federal Program Name: ? Block Grants for Community Mental Health Services ? ALN 93.243 ? Section 223 Demonstration Programs to Improve Community Mental Health Services ? ALN 93.958 Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on the incurred date, rather than paid date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: Management concurs with the audit finding. As the previous process for grant salary, fringe, and indirect billings was based on salary paid date this resulted in expenses on certain grants being allocated prior to the period of performance. While this was at least in part offset by eligible grant expenses not being billed at the end of the grant period, it was not in compliance with 2 CFR 200.1 for period of performance. The CFO, supported by the Controller and Grants Manager, will immediately update the controls and grants billing processes to be based on incurred date rather than paid date. Name(s) of the contact person(s) responsible for corrective action: CFO, Controller, and Grants Manager Planned completion date for corrective action plan: Will implement in fiscal year 2023.

Department of Treasury 2022-001 Coronavirus State and Local Fiscal Recovery Fund? Assistance Listing No. 21.027 Recommendation: The Office of Management and Budget (OMB) Compliance requires that funds granted through the COVID-19 Coronavirus State and Local Fiscal Recovery Fund may only be used to cover costs incurred during the period beginning on March 3, 2021 and ending on December 31, 2024. We recommend the County select a designated individual to perform a secondary review of program costs to certify claimed expenses have met all compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The covered costs were corrected and provided to the auditors. A designated individual will perform a secondary review before claimed expenses are submitted to ensure compliance in the future. Name(s) of the contact person(s) responsible for corrective action: Tanya Cannady Planned completion date for corrective action plan: N/A

Finding # 2022-003 Title of Finding Allowable Costs/Costs Principles Contact Person Julia Gump Anticipated Completion Date June 30, 2023 Corrective Action planned to be taken: Management will review regulations and implement controls to prevent noncompliance to grant agreements.

2022-001 Special Education Cluster ? CFDA No. 84.027 and 84.173 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: None. Action taken in response to finding: The School district paid for goods/services after the performance period of the grant. All purchase orders and invoices for payment are reviewed by the Town Wide Budget director before posting or processing. This review is to ensure compliance with local, state and federal laws and regulations. Name(s) of the contact person(s) responsible for corrective action: David Ljungberg, Superintendent and Leia Secor, and Town Wide Budget Director Planned completion date for corrective action plan: Procedure currently in place.

Finding 2022-001: Reporting Recommendation: Nebraska Pediatric Practice should strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials: Management agrees with the finding. Although reported in the incorrect quarter, the Entity did incur expenses in excess of the amount of ARPA funds received. In addition, the Entity also suffered lost revenues in excess of the ARPA funds received. Management will refine its review process of HRSA guidance and data entry into the portal to ensure appropriate designation between reporting periods. Nebraska Pediatric Practice, Inc. Corrective Action Plan: Management inadvertently reported expenses in the incorrect quarter of the Period 4 report submission. Although reported incorrectly, reported expenses were still above the total ARPA payments received. For future reporting, management will reinforce the reporting of activities in the proper quarter prior to submission. Completion Date: Completed Contact Person: Mindy Stetson 402-955-6765

See Corrective Action Plan

Finding Number: 2022-012 Federal Program, Assistance Listing Number and Name: ALN 21.027, Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) Condition: Original Finding Description: The CSLFRF subrecipient agreements did not include the CSLFRF assistance Listing Number (ALN) as required per 2 CFR 200.332 (a)(1)(xii). Contact Person Responsible for Corrective Action: Sandra Yu Stahl and Terri Daniels Anticipated completion date: July 2023 Planned Corrective Action: The City has implemented a process to ensure that all subrecipient agreements contain the Federal ALN as required by 2 CFR 200.332. All subrecipient agreements will include a new exhibit as an attachment in the agreement that will include the ALN and any other required grant elements.

During the 2022 audit of PrairieStar Health Center, Inc. our auditors found two instances of the PRF calculation being calculated incorrectly. The two instances were 1) having miscellaneous revenue adjustments in the actual calculation but not in the budget section of the lost revenue calculation and 2) not being able to directly identify if the capital project was completed before the period of availability for period two which is December 31, 2021. This has resulted in a finding in the current year financial statements audit. Management has evaluated the finding and reviewed whether any funds need to be repaid and evaluated its controls around future provider relief reporting cycles. It has been determined that even with the two errors identified lost revenues would have been sufficient to obligate the entire award. Therefore, we have determined no repayment is necessary. If allowed in future provider relief reporting periods, PrairieStar will correct the misreporting. In addition, management will ensure adequate time to review the provider relief reporting prior to the submission deadline in order to catch these oversights. Shandi Stallman, Chief Financial Officer, is the party that has overall responsibility for this corrective action. The anticipated completion date is expected to be March 2023.

FINDING 2022-002 ? R2T4 Calculation Program Name: Federal Pell Grant ALN and Program Expenditures: 84.063 ($729,843) Award Number: P063P213629 Federal Award Year: July 1, 2021 to June 30, 2022 Questioned Costs: $1,988 Condition Found: The R2T4 calculation was completed incorrectly for three of the five students in our R2T4 testing sample. The Federal Pell Grant funds disbursed were not adjusted for module courses that the students did not begin. In addition, the incorrect semester start date was used for two of the three students. Corrective Action Plan: Management agrees with the auditors? finding and their recommendation. The Financial Aid Director recalculated the R2T4s for the students in question. The Financial Aid Director determined that $1,988 of Federal Pell Grant funds should be returned for these students. On September 12, 2022 these funds were returned to the Department of Education. The remaining R2T4 calculations completed by the College were reviewed and there were no additional errors. The Financial Aid Director has improved R2T4 calculation procedures to ensure that the Federal Pell Grant is adjusted for module courses that a student does not begin attendance in before completing the R2T4 calculation. Anticipated Completion Date: The corrective action was completed on September 12, 2022. Contact Person (for both findings): Brian Rains, Director of Financial Aid 417-268-6045