Corrective Action Plans

Corrective Action Plan Finding 2023-003 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA); Assistance Listing No. 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to comply with the terms and conditions of the award and the reporting requirements. However, management did not retain documentation evidencing the performance of these controls. Corrective Action: 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 Provider Relief Fund 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 contract labor costs as reported 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: Bernard Githinji, AVP Corporate Controller Anticipated Completion Date: April 30, 2024

Corrective Action Plan Finding 2023-001 Internal Control Deficiency Activities Allowed or Unallowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of the Treasury; Assistance Listing No. 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLRF) Condition: Per discussion with management, OU Medicine, Inc. has processes and internal controls in place to ensure expenses submitted to the CSLFRF program were allowable expenses per the grant agreement These internal controls include ensuring completeness and accuracy of the expenses to ensure the expenses comply with the terms and conditions of the award. However, management did not consistently retain documentation evidencing the performance of these controls. Corrective Action: As part of the Uniform Guidance audit, OU Health provides documentation to explain how eligible costs are/will be 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 costs as reported as 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 and all correspondence will be retained with the report and within the Audit Folder. Responsible Official: Bernard Githinji, AVP – Corporate Controller Anticipated Completion Date: April 30, 2024

The final report for the grant H126A210056 has already been submitted to the RSA. No changes can be made to the RSA report at this point. A reconciliation process has been introduced which will eliminate period of performance (POP) violations for the current/future grants. Currently, OVR is using this method to ensure correction of POP violations for the current VR grants (if any). Adjusting entries to correct the POP violation in SAP will be posted by 04/15/2024 subject to the approval of OB-OCO to open the closed internal orders of the grant. Anticipated Completion Date: 04/15/2024 Contact Name: Zulqarnain Nasir, Chief Financial Officer, OVR

Program: AL 93.575 – Child Care and Development Block Grant – Period of Performance Corrective Action Plan: This finding was a result of staff turnover. The Agency completed a journal entry to move payroll costs to the correct grant year. Contact: Ann Murphy Anticipated Completion Date: Complete

Finding 2023-002 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Information of the federal program: Federal Grantor: United States Department of Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that internal controls were not working effectively regarding review of the calculated limitations and allocations. Ascension has reserved the questioned costs and has communicated with the State on their desired method of repayment. For future grants, Ascension Living will implement controls for appropriate review and approval and to have a secondary review to validate calculations. St. Agnes Healthcare, Inc., Maryland - This finding pertains to retroactive grants where expenses were incurred in previous periods but were subsequently eligible for grant reimbursement. Management is working on creating a report to identify timecards lacking manager approval for exclusion as allowable grant expenses. Grant Accounting is incorporating Time and Effort tracking features a separate approval control to mitigate the issue of timecards lacking manager approval. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024, and July 01, 2024

Finding Summary: In connection with the audit procedures performed, it was noted that there was one expenditure amount that was incurred prior to the period of performance. Responsible Individuals: Christa Beauchat, Chief Financial Officer Corrective Action Plan: Management is revising its processes to ensure that an adequate review of the period of performance is occurring over the expenditures of each federal award contract (verification that any expenditure charged to a federal award has actually been incurred during the federal award’s contract period). Anticipated Completion Date: Ongoing

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.

FINDING 2023-006 Finding Subject: Special Education Cluster (IDEA) – Activities Allowed or Unallowed, Period of Performance Summary of Finding: Material Weakness The Individuals with Disabilities Act (IDEA) Special Education – Grants to States program provides grant to states, and through them to Local Educational Agencies (i.e. the School Corporation), to assist them in providing special education and related services to eligible children with disabilities ages 3-21. IDEA’s Special Education – Preschool Grants program provides grants to states, and through them to LEAs to assist them in providing special education and related services to children with disabilities ages three to five and, at the state’s discretion, to twoyear- old children with disabilities who will turn three during the school year. The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. Activities Allowed or Unallowed: The School Corporation did not have internal controls in place over payroll disbursements charged to the special education grants. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Period of Performance: A payroll journal report was generated by the Payroll/Benefits Coordinator and reviewed and approved by the Chief Financial Officer or the Deputy Treasurer to ensure costs charged to the special education grants were within the period of performance. However, there was no documented evidence of the review. Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Quarterly grant meetings will be held between the CFO, Deputy Treasurer, and Grant writer. This will ensure compliance requirements continue to be met. The CFO now reviews the Org Charge report and signs off before the payroll batch being released to the bank. This report is generated by Payroll and Benefits. Also, this entire report is now included with board claims for board approval rather than a final summary sheet. Anticipated Completion Date: February 2024

Corrective Action Plan Federal Award Findings and Questioned Costs For the Fiscal Year Ended June 30, 2023 Finding 2023-001 – A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Federal Program: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Entity: Ohio Emergency Management Agency Summary of finding: UC Health did not retain supporting documentation over key aspects of its internal review and approval processes for overtime labor hours that were not directly approved by employee managers. For a portion of overtime labor costs reimbursed under the program, UC Health did not retain sufficient documentation to evidence execution of internal controls that support compliance with the terms and conditions (T&Cs) of specific projects. While management has processes in place to review overtime labor costs for compliance, evidence of all key aspects and conclusions of these reviews was not consistently retained. Planned corrective action: Management agrees with this finding and the need to update documentation policies and procedures to evidence review of compliance with program requirements. Anticipated completion date: September 30, 2024 Responsible contact person: Michael Wiedeman, Vice President and Controller

Responsible Contact Person(s): Angela Morse, Director of Benefit Programs Frank Smith, Associate Director of Benefit Programs Corrective Action Planned: DSS has requested the vendor's records. Once received, DSS will audit those records to provide reasonable assurance that the contractor administered the LIHWAP federal grant program in accordance with federal statutes, regulations, and the terms and conditions of the federal award before it closes the grant award. Estimated Completion Date: 6/30/2024

The Downey Adult School concurs with the finding and to prevent future occurrences, the school purchased a new student database management software system (Campus Café) that was implemented on August 1, 2023. The school also partnered with National Student Clearinghouse (NSCH). NSCH articulates with the new student database management software system (Campus Café). The new student database management software system together with National Student Clearinghouse will help to prevent human errors and omissions from occurring when reporting National Student Loan Data System (NSLDS) data. While the district purchased the new system in November of 2022, the school did not begin using the new system(s) until August of 2023 because the switch had to be implemented at the beginning of the fiscal year. Implementation is a several month process and all DAS employees have been receiving extensive training (ongoing) to be proficient and comfortable with the new system(s). We have ongoing weekly training for all DAS staff as we continue to fully implement the new student database management software system.

Management Response: Management will ensure an individual who does not perform the adjudication will review and document whether information was entered correctly and whether the adjudications are proper and documented prior to a member’s start date. Responsible Person: Lisa Moore, Executive Director Anticipated Remediation Date: Fiscal year ended August 31, 2024

Reporting – The College will review and update reporting procedures to ensure the correct academic start dates and enrollment dates are submitted to the Department of Education’s COD system. Anticipated Completion Date - January 31, 2024; Responsible Contact Person for Planned Corrective Action - Carissa Davis, Director of Financial Aid

Return of Title IV Funds - The College will review and update current written policies and procedures to ensure the correct amount of days are used for the academic term in the return of Title IV funds calculation. Anticipated Completion Date - January 31, 2024; Responsible Contact Person for Planned Corrective Action - Carissa Davis, Director of Financial Aid

Finding 2023-004: Capital Fund Grant Admin NHA Corrective Action: The Authority has all documentation on paper for all payment vouchers, statements that monies were drawn down correctly, invoices, and records of payments. The updated annual online budget forms were not completed in the required Capital Funds timeline regulations. Plans are underway to update the 2023 online budgets within the next month. Ongoing Capital Funds Education continues to be prioritized. Improvements in internal processes will be implemented as knowledge is accumulated. When these online budgets are updated with the information from the paper tracking documentation and submitted for approval to the regional office, it will be clear that the $206,189.50 in Questioned Costs in this finding were accurately distributed. In order to prevent this situation from occurring in the future, the Authority will follow the finding recommendation to provide the following reports at monthly board meetings beginning with the April 2024 board meeting.: • status of grants including grant award • obligation and expenditure deadlines • funds obligated • funds advance, and • funds expended

Criteria and Condition: 2 CFR 200.303 requires the non-federal entity to establlish and maintain effective internal controls over compliance with Federal statues, regulations, and the terms and conditions of the Federal award including proper tracking of grant expenditures or compliance. Certain internal controls were not in place to prevent costs from outside the period of performance from being charged to the grant. Action taken: In regard to 2023-003, Management will provide a 2nd review of project worksheets before submission. The designated FEMA Coordinator will be responsible for this corrective action and anticipates completion of corrective action before October 1, 2023.

Exempt employees will enter time into their timesheet every payroll and supervisors will approve the timesheet.

The City agrees with the finding. The Treasury Portal automatically fills in the amounts for revenue loss for 2022 with amounts reported in 2020. The Treasury portal has many flaws that would cause errors in reporting. In addition, the portal has changed every quarter, which makes it challenging to report accurately. The City will implement controls to ensure that a second review is completed prior to certification of the report. Additionally, the Grant Administrator will work with department staff responsible for reporting and ensure that each report's supporting documentation is complete and ties to underlying subrecipient reports, the general ledger and grantor reports. All supporting documentation, along with a copy of the submitted report, will be stored in a central location to ensure that they are available for subsequent reviews and audits. This will be completed by June 30, 2024.

A recalculation of the student financial aid was completed using the corrected spring semester start date. The corrected financial aid was credite to the student's account.

Corrective Action Plan 2023-002: The University concurs with the finding and has provided corrective action through correcting the identified errors and adding additional review of the R2T4 calculations. Anticipated Completion Date: June 2023 Contact Person: Reta George, Director of Student Financial Services

FINDING 2023-002 Finding Subject: Emergency Connectivity Fund – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance compliance requirements. The School Corporation completed reimbursement requests and submitted them online; however, there was no evidence of an oversight or review process to ensure that the reimbursement requests were for allowable activities, allowable costs, and within the period of performance. Contact Person Responsible for Corrective Action: Derek Coulombe, Director of Technology Contact Phone Number and Email Address: (317) 856-5265; dcoulombe@decaturproud.org Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will develop procedures to ensure disbursement requests are printed out and a representative from the Business Department documents review of them for allowable activity before final submission. Anticipated Completion Date: March 1, 2024

Finding Number: 2023‐004 Federal Program, Assistance Listing Number and Name: ALN 10.557, Department of Agriculture, Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Condition: Original Finding Description: The City did not have adequate controls in place to ensure obligations were liquidated (paid) within the required 60 days. Contact Person Responsible for Corrective Action: Terri Daniels (ODG), Regina Greear (ODFS), Denise Fair Razo (DHD) Anticipated Completion Date: June 2023 Planned Corrective Action: During the AFCAP process, the OCFO will work with the Health Department to implement additional controls to ensure all subrecipients and contractors submit invoices timely and that they are reviewed, approved and processed timely and accurately for payment prior to the 60 liquidation requirement period.

Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend the Organization put procedures in place to identify the performance period when charging invoices to grants, particularly during the start and end of the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional and recurring training will be provided to both program and accounting staff. Grant procedures will be updated to expand review and monitoring of expenditures at beginning and end of grant periods for all federal grants. This will include hiring of an additional oversight position over all federal grants. Name(s) of the contact person(s) responsible for corrective action: Drew Erickson, Controller Planned completion date for corrective action plan: 04/30/2024

Contact Person: Kasi Turner, Registrar Corrective Action: We manually reported a student as withdrawn on 2/17/2023. The status change came in as an error on the 3/16/2023 submission (the following month) and we manually updated the status and status start date for the student again. However, it looks like the student’s status reverted to Three-Quarter time on the final transmission on 5/1/2023. We will commit to closer monitoring of withdrawals submitted manually by our office on subsequent enrollment transmissions through the Clearinghouse. Anticipated Completion Date: December 15, 2023

Finding number 2023-001 – Special Tests and Provisions-Enrollment Reporting-Significant Deficiency Over Internal Controls Over Compliance Contact person responsible for corrective action: Sue Gosney, Chief Financial Officer, (213) 356-5330 Expected date of corrective action: The corrective action was implemented in December 2023. The school's management agrees with the finding and has implemented procedure whereby changes in enrollment status reported to the National Student Clearinghouse will be sample reviewed by the Registrar within NSLDS five business days following the reporting date to ensure the accuracy of the information. As an additional layer, the Financial Aid Manager will also calendar a review reminder. Permanent address changes will be reported on a six-week cycle after the add/drop period each term. Address changes will also be sample reviewed to ensure accuracy within NSLDS.