Corrective Action Plans

Views of Responsible Officials and Planned Corrective Actions: The County agrees with the recommendation and has discussed additional review procedures with the subrecipients. In addition, the County created a Grants Division with increased staffing that can help provide monitoring throughout the year.

Program: AL 93.575 ? Child Care and Development Block Grant ? Period of Performance Corrective Action Plan: DHHS has already taken steps to prevent this from occurring again with NSP. DHHS also worked with the Office of Child Care (OCC), after last year?s finding, and corrected both the 2021 and 2022 findings. The use of funds to pay agency employee payroll has already been corrected. DHHS will use allowable obligation and liquidation schedules when contracting with other state entities and paying state employees. Contact: Nicole Vint; Rebecca Kempkes Anticipated Completion Date: 12/12/2022

Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Community Mental Health Services CFDA # 93.958 Finding Summary: There was no formal documentation of review of wage rates for eight employees selected for testing. There was no formal documented review for the calculation of indirect costs submitted for reimbursement for four months selected for testing. There was no formal documented review for seven reimbursements requests selected for testing. Washburn Center has designed internal controls over these areas; however, the controls were not formally documented. Responsible Individuals: Mohamed Omar, MBA, MS, Chief Administrative Officer Corrective Action Plan: Management will review the current active review process and implement a formal documentation of the review including the appropriate level of management sign off and date of review on the supporting documentation. Anticipated Completion Date: December 2023

View of Responsible Officials The Department does not concur. The Department notes extensions are in place related to COVID-19 and the Tydings Amendment through the Department of Education mitigating the condition noted. The Department will confer with the US DE to clarify the extensions in place and resolve any disparities identified within the finding. Anticipated Completion Date: Completed as of the date of this report Contact Person: Lindsey Labonville, Melissa White Rejoinder Based on the supporting documentation provided by the Department, it did not appear that the expenses identified within the condition found were charged to the correct period of performance during the liquidation period. Subsequently management adjusted the CAN the expenses related to which would correct the condition found.

Quarterly Reporting The State concurs in part with the condition and recommendation. A unique challenge with ERA reporting has been changes in the U.S. Treasury portal for that program, which have impacted the State?s ability to download and provide copies of past reports that have been submitted. In addition, this issue in the reporting portal has been inconsistent, as some previously submitted reports were made accessible by Treasury, while others were not, which resulted in the State being able to access some requisite materials but not others. The State did not have documented procedures to ?pull down? copies of reports it had submitted to Treasury because the State has otherwise been able to rely on access to its previously submitted reports within reporting portals in order to enable the testing required during audit for the relevant periods. Meaning, in the State?s experience with COVID-19 related federal funds reporting, it has been able to access and download past reports for purposes of audit. However, also noted above is that the Treasury portal was recently revised and updated to allow for accessing previously submitted ERA reports that were not otherwise available (the communication from Treasury acknowledging this change was provided by the State). However, the reporting portal change did not take place in time for the State?s auditors to reasonably conduct the necessary testing. The State did provide the data and materials it reported to Treasury for the relevant periods, but auditors were unable to test and validate that data because the State could not access and provide a copy of what was actually uploaded into the portal. Nevertheless, to avoid any such potential issues in the future, the State has already implemented a procedure that involves downloading copies of reports as soon as they are submitted and taking screenshots of portions of the portal where perceived necessary to support what the State has submitted to Treasury. This updated procedure will be memorialized in the program?s transaction processing memo during its next update. Monthly Reporting The State concurs in part but has already implemented related corrective action in line with the recommendation above. The State would also like to note that as part of the ERA reallocation process U.S. Treasury has relied on both quarterly and monthly reporting, and that the State has continued to engage in thorough monitoring of its subrecipient and receives regular reports from that subrecipient, including weekly, biweekly, and quarterly data, which also includes quality control reports. This is inclusive of the monthly reports that were required by U.S. Treasury at one time but no longer are. The State reviews and then discusses reports received at standing, calendared, weekly meetings with the subrecipient and often engages in e-mail correspondence concerning those reports, especially if any questions concerning the data provided arise. However, the State has acknowledged that its documentation of those weekly conversations needed to be more formally memorialized. During the current fiscal year, the State began providing agendas and summaries of topics discussed during the weekly check-ins and will ensure that the program?s transaction processing memo adequately documents this requirement and procedure. The very nature of this program and U.S. Treasury?s facilitation of it has required the State and its subrecipient to stay in close contact, make regular decisions on strategies and policies within the program, and closely consider data relative to it. Anticipated Completion Date Quarterly reporting - Corrective action relative to acquisition of submitted federal reports has already been implemented and this revised procedure will be memorialized in the transaction processing memo for the program during its next update in Q1 2023. Monthly Repotting - Corrective action relative to documentation of weekly meetings was already complete as of the State?s response to this finding, and the State will ensure that the transaction processing memo for the program reflects these measures during its next update in Q1 2023. Contact Person Chase Hagaman, Lisa Cota-Robles, and Emily Larson

Program: COVID-19 Education Stabilization Fund ALN 84.425F Higher Education Emergency Relief Fund ? Institutional Portion Compliance Requirement: Cash Management Criteria: Pursuant to 2022 Compliance Supplement ESF Section 2 III Cash Management, the College is required to disburse funds within three days of draw from G5. Condition: The College had approval from the Department of Education to transfer allowable activities to other expenditures that were applicable under the grant guidelines and replace debt forgiveness outside the period of performance. This caused cash management to become out of compliance with the three days to apply expenditures from the date of drawdown. Context: The College originally applied funds to debt forgiveness in which the parameters of the three days to apply funds did apply. The debt forgiveness was not approved by the Department of Education for items before March 13, 2020. The Department of Education gave written approval to the College to reclass invoices that were applicable under the grant guidelines. This produced the draws being over three days from drawdown for majority of the items. Cause: On September 23, 2022, the College was asked to contact the Department of Education for guidance on debt forgiveness or obtain a waiver. The College?s request for a waiver was denied on November 29, 2022. The Department of Education gave written approval to the College to apply invoices that are within the guidelines of the grant as grant expenditures instead of the original debt forgiveness. Transferring allowable activities resulted in noncompliance with the criteria of expending funds within three days of draw. Effect: The College could be asked to return funding if draws are viewed as out of compliance after the reclassification. Questioned Cost: None Repeat Finding: No Recommendation: The College needs to ensure they understand high-risk grant requirements by reviewing the compliance supplement, the Department of Education?s website and making contact with the Department on questions of concern. Views of Responsible Officials: The College requested a reclassification of expenditures for the grant year. The request was approved by the Department of Education. The College will request any clarification on items from the Department when in question to ensure they understand the requirements of the grant. No further action is required.

Program: COVID-19 Education Stabilization Fund ALN 84.425F Higher Education Emergency Relief Fund ? Institutional Portion Compliance Requirement: Period of Performance Condition: The quarterly reports reflect $4.6 million in expenditures for debt forgiveness that was for institutional debt before March 13, 2020. These expenditures were not in compliance with the period of performance. Criteria: Pursuant to 2022 Compliance Supplement ESF Section 2 III Reporting, the College is to file quarterly reports to reflect expenditures of that quarter by purpose for expenditure within the period of performance. Cause: The College was not aware of the grant?s period of performance. On September 23, 2022, the College was asked to contact the Department of Education for guidance and clarification on debt forgiveness being outside the period of performance for $4.6 million of $6.5 million in debt forgiveness expenditures or obtain a waiver allowing expenditures prior to March 13, 2020. The College?s request for a waiver was denied on November 29, 2022. However, the Department of Education gave written approval to the College to apply invoices for expenditures that are within the grant guidelines and period of performance to replace the disallowed portion of the debt forgiveness that was before March 13, 2020. As the approval was obtained prior to presentation to the Board of Regents for approval, the reclassified expenditures were considered in the compliance testwork and were within the grant guidelines. Amended reports reflecting expenditures by the updated purpose need to be filed with the Department of Education. Effect: The College could be asked to return funding if expenditures are viewed as out of compliance with the period of performance. Context: The College originally applied funds to debt forgiveness in which $1.9 million was within the period of performance and $4.6 million that was outside the period of performance. The debt forgiveness waiver was not approved by the Department of Education for items before March 13, 2020, due to the Department of Education viewing these as recruiting expenditures. The Department of Education gave written approval to the College to amend reports with expenditures that were applicable under the grant guidelines. The quarterly reports reflected only debt forgiveness and have not been amended to reflect accurate expenditures for the period of performance. Questioned Cost: None due to the Department of Education?s approval to file amended reports and exchange disallowed costs with allowable expenditures. Repeat Finding: No Recommendation: The College needs to ensure they understand high-risk grant requirements by reviewing the compliance supplement, the Department of Education?s website and making contact with the Department on questions of concern in a timely fashion. Views of Responsible Officials: The College requested an exchange of expenditures in order to ensure only allowable costs were utilized. The Department of Education granted this exchange and approved filing amended reports. The College will amend the quarterly reports to properly reflect the approved allowed expenditures as per the email from the Department of Education. Staff will contact the Department on any questions they have going forward on questioned expenditures or allowed costs.

Finding 2022-006 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster CFDA # 10.766 Finding Summary: Included in the population of the Hospital?s program expenditures included amounts prior to the period of performance. There is a potential that expenses claimed under the major federal program are not during the period of performance. Responsible Individuals: Ashley Jaramillo, Chief Financial Officer Corrective Action Plan: Amounts prior to funding were paid for by the hospital. Anticipated Completion Date: Completed

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have complete and accurate information for the P & E report. In addition to the policy and procedure, an added person will assist with these reports by creating the reports through our financial software and reviewing before giving the reports to the Auditor who will prepare the P & E reports and then the Commissioner?s will review before the Auditor submits the report to the Treasury. The Bartholomew County Auditor?s Office is continually designing and implementing a proper system of internal controls so that any errors are detected and corrective measures are made as needed, Anticipated Completion Date: December 31, 2023

FINDING 2022-004 COMMENT: Under Uniform Guidance requirements, the County may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity. Each individual project under this program has a specified work deadline, which may be extended at the discretion of FEMA. RESPONSE: The County has requested an extension related to the FEMA work, but as of the date of the report, the extension has not been approved. Effective June 26, 2023, Rett Daniels, Deputy County Administrator, and Sarah Sun, Budget Director, will continue to seek and obtain the proper extensions needed for the FEMA project in question.

2022-002 Missing Personnel Files (Material Weakness) New Finding This Year Recommendation: Recommend adhering to adopted policies regarding the retention of personnel files. Action Taken: Due to the absence of the HR Generalist who was involved in a motorcycle accident in the midst of putting together all personnel files as recommended by the BIA records review, there were documents that were not filed immediately. We have created a checklist to ensure all files are complete and all documents filed in a timely manner. In 2020 when the building was undergoing renovation many of the personnel files were placed in storage and upon arrival of the new management team we had to recover and replace many missing documents. Thus creating a checklist to ensure each personnel file is complete.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-002 Internal Control Over Compliance With Special Tests and Provisions Finding Summary 47 CFR ? 54.1711 requires that the District only seek support for eligible equipment provided to students and school staff who would otherwise lack connected devices sufficient to engage in remote learning. During our audit, we noted the District did not have sufficient controls in place within its Emergency Connectivity Fund Program to assure compliance with federal special tests and provisions requirements. We noted that the District requested federal reimbursement for purchased technology devices prior to those devices being used or deployed, and thus not yet meeting the definition of eligible equipment for which the District could seek reimbursement. Corrective Action Plan Actions Planned ? The finding resulted from a timing issue caused by unfamiliarity with a new federal program. The District subsequently deployed all devices for which it was reimbursed to students in accordance with the unmet needs defined and approved in its award applications. The District understands the applicable guidance and will ensure that future reimbursement requests under the Emergency Connectivity Fund Program will not be made until after the equipment has been placed in service. Official Responsible ? Director of Finance and Operations, Christopher Kampa. Planned Completion Date ? March 31, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Director of Finance and Operations, Christopher Kampa, will assure appropriate internal controls are in place to verify future compliance with special tests and provisions requirements for the Emergency Connectivity Fund Program.

Finding # 2022-002 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: Expenses were charged for services outside of the contract period Recommendation: Procedures should be in place to ensure invoices are accrued and charged to the proper period when services/goods were performed or received. Corrective Action: Expenses will be reviewed during month end close to ensure proper recording. Management will provide training to program personnel. Anticipated Completion Date: June 30, 2023

Corrective Action Plan Finding 2022-001 Assistance Listing #93.461 Internal Control over Compliance? Activities Allowed or Unallowed and Eligibility, Due to the evolving nature of the COVID-19 pandemic, and the rapid pace in which programs were implemented, documentation of controls related to the reporting of COVID-19 uninsured patients was not maintained. However, controls were in place and proper submission of claims was accurate. As part of the prior year audit finding, NorthShore implemented a process as of January 2022 to document internal controls related to the quality review of claims to ensure patients meet the eligibility requirements. HRSA reviewed the documentation and determined that the finding had been satisfactorily resolved. Although the program has now ended, NorthShore will ensure the internal controls are documented should the HRSA program be reinstated. Responsible Official: John Skeans, Senior Vice President, Patient Financial Services.

COVID-19 Coronavirus State and Local Fiscal Recovery of Funds Federal Financial Assistance Listing 21.027 Period of Performance Significant Deficiency in Internal Control over Compliance Finding Summary: During the course of the audit engagement, it was noted that the City included one 2023 expenditure in the 2022 reported schedule of expenditures of federal awards. Responsible Individuals: Wyatt Papenfuss, Finance Manager Corrective Action Plan: The City will take steps to ensure that all federal expenditures are in the correct period under Uniform Guidance. Anticipated Completion Date: December 31, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Elizabeth J Billue Contact Phone Number: 574-583-1515 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: All future reporting of the COVID-19 Coronavirus State and Local Fiscal Recovery Funds will be reviewed for accuracy by a second Auditor staff member prior to submission. The report will be signed/dated by both the preparer and the reviewer. To prevent future errors in reporting of these grant funds, the preparer will have an Auditor?s Deputy review the reports for accuracy and completion prior to submission. All grant receipts and adjustments to grant related receipts and disbursements completed in the Auditor?s Office are now reviewed for accuracy and initial/dated by a second Auditor Office staff member. In addition, a note will be made within our financial system records and all available supporting documentation will be attached/scanned as part of the permanent record of adjustments to receipts and disbursements. A new electronic storage system is under consideration for ease of access to adjustment documentation. Anticipated Completion Date: 4/30/24

Name of Auditee: City of Niagara Falls, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2022 CAP Prepared by: Daniel Morello, City Controller Phone: (716) 286-4346 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2022-002 Management's Response The City is in agreement with this audit finding. Due in part to delays in finalizing both the 2021-2022 annual action plan and the 2022-2023 annual action plan, the City was delayed in being able to utilize those funds until approval was provided by HUD. The City continues to direct funds to projects that have the ability to be completed in a timely manner in order to be consistent with the CDBG regulation related to timeliness. The City is aware of the timeliness requirements and will continue to select projects that better allow the City to operate in accordance with these regulations. Estimated Completion Date - Next HUD verification date of May 1, 2024

Finding 2022-004 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Agency Name: U.S. Department of Health and Human Services Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services CFDA: 93.829 Finding Summary: During our testing, there was no documentation of review and approval of employee timecards for a portion of the sample selected. A nonstatistical sample of 60 expenditures submitted for reimbursement were selected for testing. Of these 60, 3 did not show evidence of proper review and approval prior to payment. Responsible Individuals: Michael Luedtke, Chief Financial Officer Corrective Action Plan: Management agrees with the finding. The Organization will enhance internal control policies to ensure all employee timecards are reviewed and approved prior to payment to ensure that all payments are necessary and correct. Anticipated Completion Date: May 15, 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: Mary K. Kaczka, Assistant Director, Community Development Contact Phone Number: 574-322-4472 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will take the following steps to address the period of performance weakness that have been identified: Staff involved with posting or reviewing of claims in both the city ledger and IDIS will be trained on the requirements of 2 CFR 200.343(b) regarding allowable costs during the period of performance. Changes to the claims process has been implemented in which CDBG staff includes the grant number and program year on the face of the invoice or claim sheet in addition to general ledger account number. Invoices are processed for claim packets by department office service staff and reviewed for accuracy and completeness by management. This change in process will assist in reconciliation between the City Ledger and IDIS. Anticipated Completion Date: August 31, 2023

The Board entered into multi-year contracts to garner additional savings for the district during the contractual period. The Board has developed allocation schedules to ensure a more appropriate matching of expense to the financial period. The Board may continue to enter into multi-year agreements for contractual savings but will expense only the portion of the contract in the period of performance.

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (CHIP) Assistance Listing Number: 93.767 Award Number and Year: 2205DE5021 (10/1/2021 ? 9/30/2023) Compliance Requirement: Period of Performance Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DMMA will review reported expenditures based on the date of the federal draw to ensure that the expenditures occured within the period reported. Name(s) of the contact person(s) responsible for corrective action: Unkyong Goldie Planned completion date for corrective action plan: September 30, 2023

Corrective Action Plan Finding 2022-001 Internal Control Deficiency Allowed/Allowable Costs At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups were assisted by outside consultants to stay updated on the reporting requirements as the continued to evolve. As part of the Uniform Guidance audit, OU Health provided documentation of the FEMA review process that explained how eligible costs were identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of personnel costs as reported as FEMA federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist will be retained with the existing report. Responsible Official: Michael Milligan, Vice President of Accounting Anticipated Completion Date: March 31, 2023

Identifying Number: 2022-009 Finding: Period of Performance: payroll costs Corrective Actions Taken or Planned: UCAN agrees with this finding and is committed to strengthening internal controls to ensure that amounts are properly recorded and reported. UCAN has already taken steps to insure that items are billed in the period incurred and only items that fall into the grant period are billed. We believe that significant turnover in the finance department led to this deficiency, so we are actively documenting procedures and cross-training employees, so we always have coverage. All vouchers will also go through a review process before they are sent to the funder. This is a repeat finding, with the original corrective action plan to be completed before June 30, 2023. We do believe that corrective actions that have been taken have resolved this issue. Contact person is Kimberly Parish, Chief Financial Officer and she can be reached at kim.parish@ucanchicago.org.

August 26, 2022 Legislative Audit Advisory Council P.O. Box 94397 Baton Rouge, LA 70804-9397 RE: Jennings American Legion Hospital, Inc. FYE 11/30/2021 Financial Statement Audit Management Corrective Action Plan Dear Council Members: Management has taken the following action is response to the finding of our auditors, Lester, Miller & Wells, CPAs for the fiscal year ended November 30, 2021. Finding 2021-001 ? Medicare and Medicaid Cost Report Receivables Position(s) of Agency Personnel taking correction action: Chief Executive Officer Corrective Action: Management has considered the recommendation and concluded that the implementation cost is greater than the benefit derived from preparing interim cost reports. It is more efficient and cost effective for external cost report preparers to prepare the cost reports at year-end. Finding 2021-002 ? Recognition of Insurance Proceeds Position(s) of Agency Personnel taking correction action: Chief Financial Officer Corrective Action: Management will recognize insurance proceeds as a gain (loss) and ensure assets being replaced or repaired are recorded at cost. If you should require additional information please call (337) 616-7030. Sincerely, Dana D. Williams Chief Executive Officer

FINDINGS ? FEDERAL AWARD PROGRAM AUDIT SIGNIFICANT DEFICIENCY 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: YWCA should establish written policies and procedures to provide for timely and appropriate review and approval for period of performance. Action Taken: We concur with the recommendation and have developed the following plan. YWCA Madison, Inc., in compliance with guidance set forth in the Uniform Guidance 2 CFR section 200.303, will develop written policies and procedures on what, when, and who is responsible for review and approval for period of performance for YWC Madison funding. Additionally, YWCA Madison, Inc. will create a grant tracking checklist with key details for the funding including the performance period, total funding amount, allowable costs, the program or department funding is to be used for, etc. The checklist will also include an approval section for YWCA Madison finance team members to complete indicating their review of costs charged to the funding source at the beginning and the end of the performance period. The monitoring checklist will be updated to add a review of any new grant tracking checklists for the month as part of its internal controls checklist. The monitoring checklist will be reviewed monthly by the CEO and the review will be documented.