Corrective Action Plans

Finding Number: 2022-005 Condition: The schedule of expenditures of federal awards (SEFA) for the year ended June 30, 2022 includes expenditures incurred during the prior fiscal year. Planned Corrective Action: The Organization acknowledges this finding. Going forward the Organization will implement a review process of the Schedule of Expenditures of Federal Awards. Contact person responsible for corrective action: Bregeita Jefferson, President of FEED International Anticipated Completion Date: January 31, 2023

2022-003 Period of Performance USDOT Auditor?s Recommendation: PRCI management should develop and implement procedures and modify accounting structures to ensure compliance with period of performance requirements. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PRCI has worked with the awarding agency to ensure that all grants are extended to an appropriate period of performance. PRCI additionally has reviewed the contracts with its vendors to ensure that they are billing timely for the contractual obligations of the grant awards. PRCI staff will work with USDOT staff to rectify any current contracted agreements where this same finding may exist in the future but acceptance for any agreement changes would be required by both parties.

Audit Finding #2022-003 Reporting Name of Contact Person: Maryland Hutchinson, Fiscal Manager. Corrective Action: UCAP has implemented measures to ensure that there is no delay in financial reporting in the future. UCAP works directly with the grantors and contract administrators in order to ensure timely payment of all reimbursable grants and has implemented steps in order to ensure that costs won?t have to be recategorized in the future. Proposed Completion Date: This will be complete by 6/30/2023 and will be reflected in the upcoming year-end.

Condition: Invoices and payroll were charged for services performed prior to the approval dates by the pass-through agency. Corrective Action Planned: Town Accountant and School central office staff have worked together to correctly monitor award approval dates to ensure that goods and services charged to federal grants occur during the period of performance. Anticipated Completion Date: 2022-2023 school year Contact: Thad King, Superintendent of Schools

Condition: Final financial reports were not filed in a timely manner for a Special Education Cluster grant. Corrective Action Planned: To date all grants required to be closed out have been completed. Anticipated Completion Date: 2022-2023 school year Contact: Thad King, Superintendent of Schools

Finding 2022-001 ?Internal Control Over Allowable Activities/Costs and Period of Performance Status: Plan is being formulated. 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 look-back review plan will be for each nursing home beneficiary that received COVID-19 Funds to submit during the first month of the third quarter of 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 15 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 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, Acting Executive Director Completion Date: Adoption of the Look-Back Audit Procedures December 31, 2023

Corrective Action Plan: Okanogan Behavioral HealthCare (OBHC) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The monthly close checklist has been modified to include a payroll transaction process for the September close for this grant. This is the sole grant that requires a second grant closure process. Name of the contact person responsible for corrective action: Patty Branch, Finance Manager Planned completion date for corrective action plan: October 2022 for the September close and grant invoice submission.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Mary Brown Contact Phone Number: 765-472-3901 Ext. 1240 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: During the 2022, we were notified the reporting of the cumulative expenditures for ARPA Funding was inaccurately reported. We have already contacted US Department of Treasury to correct the prior and current year reporting and awaiting a response. We will change the process for reporting to attempt to correct the prior years reporting to ensure we are providing complete transparency for the expenditure of funds. In addition, we will implement the internal control to require the reviewing individual sign the report. Anticipated Completion Date: January 2024

The Accounting Office will require all program personnel to complete a checklist of all expenditures incurred close to the end of the fiscal year in order to identify any expenditures that need to be accrued. Personnel responsible for implementation: Nyame-Tease Prempeh Position of responsible personnel: Assistant Director of Accounting Date of Implementation: July 1, 2023

Finding 2022-001: Internal Control Deficiency over Activities Allowed/Allowable Costs and Period of Performance Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048, Special Programs for the Aging, Title IV, and Title II, Discretionary Projects Summary of Finding: Management did not have adequately designed internal controls in place over expenses charged to the federal program. Corrective Action Plan: Internal controls will be implemented to ensure expenditures are appropriately reviewed and approved prior to entering into the expenditure or requesting reimbursement from the federal program. Documentation will be maintained to support that expenditures were reviewed for appropriate period of performance. Management will ensure all duties are appropriately segregated. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: December 31, 2023

Finding: 2022-021 Department of Human Services Response/Corrective Action Plan: The Department of Health and Human Services agrees with the recommendation. The Department will run reports from AWARE quarterly to identify any payments made from the system that were charged to the incorrect period of performance. Contact Person: April Haring, Program Accountant for Vocational Rehabilitation Anticipated Completion Date: The Department began running the report in December 2022.

2022-002 ? CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? NONCOMPLIANCE WITH SUBRECIPIENT GRANT AGREEMENT REQUIREMENTS ? ALN 21.027 ? OTHER NONCOMPLIANCE Condition: Burleigh County did not communicate and document all of the elements as outlined in 2 CFR 200.332(a) for the subrecipients of the Coronavirus State and Local Fiscal Recovery Funds program. During testing, we noted the following elements were not included: ? subrecipient's unique entity identifier ? federal award identification number ? federal award date (see definition of Federal award date ? 200.1) of award to the recipient by the Federal agency ? subaward period of performance start and end date ? name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity ? Assistance Listings number and Title ? identification of whether the award is Research and Development ? indirect cost rate for the Federal award (including if the de minimis rate is charged) per ?200.414 ? a requirement that the subrecipient permit the pass-through entity and auditors to have access to the subrecipient's records and financial statements as necessary for the pass-through entity to meet the requirements of this part, and appropriate terms and conditions concerning closeout of the subaward Corrective Action Plan: We agree with the recommendation. Burleigh County has implemented new policies and procedures in 2023 regarding subrecipient monitoring. Anticipated Completion Date: FY 2023

Federal Award Findings and Questioned Costs for the Year Ended June 30, 2022 Finding No. 2021-001 (Activities Allowed or Unallowed; Allowable Costs and Eligibility ? Significant Deficiency in Internal Control Over Compliance ? Uninsured Program) Information on the federal programs: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No. ? 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 07/01/2021 ? 06/30/2022 Views of responsible officials and planned corrective actions: Management will implement procedures to ensure the retention of documentation to support the application of internal controls over the process of identifying eligible patients and submitting claims for reimbursement under the COVID-19 Uninsured Program. Responsible Officials: Robert Thornton, Vice President of Finance, UF Health Shands Completion Date: July 31, 2022

Corrective Action Plan Finding 2022-001 Provider Relief Fund (Assistance Listing #93.498) Activities Allowed or Unallowed and Allowable Costs At the beginning of the pandemic, Eisenhower Medical Center created a COVID-19 response team to evaluate the requirements for the COVID-19 funding received and ensure the funds were only used for allowable purposes. The response team continuously monitored the FAQs and other guidance on the reporting requirements as they continued to evolve as additional funds were received. As part of the Uniform Guidance audit, Eisenhower Medical Center provided documentation of the Provider Relief Fund review process, including response team meeting agendas, email correspondence, as well as management sign-off on the lost revenue calculations and expenses submitted as part of the Provider Relief Fund Period 2 report. Through the audit testing, we were asked to provide copies of approval documents for some of the supply requisitions for expenses reported as part of the Provider Relief Fund period 2 report. The documents in question were paper approval forms for some of the supplies purchased in July through December of 2020. Historically these documents were only retained for two years and thus they were not available for the audit procedures. In November 2021, we implemented a new automated supply requisition process that is integrated with our financial software (Workday). This new implementation will help to correct this issue in the future with the ability to provide electronic documentation of date/time stamped approvals. In addition to the new requisition process we wanted to improve the process for documenting the review of the expenses and lost revenue to be reported in the Provider Relief Fund reports. To ensure our internal controls are documented to level necessary under current audit standards, Eisenhower has developed a review checklist to document the review and approval of supporting documentation of the revenue and expense information to be reported in the Provider Relief Fund reports. The checklist will be retained with our existing support of Provider Relief Fund federal expenditures. The new checklist had not been developed when the Provider Relief Fund Period 2 Report was submitted, and thus not used. The new checklist however, will be used for any future Provider Relief Fund Report submissions. Responsible Official: Melanie Long, VP Finance Anticipated Completion Date: March 31, 2023

Condition: During our testing, we noted the Loan Fund did not comply with the period of performance requirements. We noted during out testing over allowable costs that 3 of the 45 tested payroll disbursements were for a pay period before the start of the period of performance. Recommendation: We recommend that the Loan Fund reviews the period of performance for grants when applying expenditures to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management accepts this finding and has made efforts to review and update our policies and procedures to prevent future noncompliance with federal cost principals and period of performance requirements. Name(s) of the contact person(s) responsible for corrective action: Conchie Searle, CFO Planned completion date for corrective action plan: May 2023

Report will be filed as required.

Finding 2022-004 Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 View of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The American Rescue Plan was completely new in 2022 and the reporting was not documented correctly per the State and Federal guidelines. We have since received some instruction on the proper filing procedures and will put those guidelines into our Internal Control Policy. Anticipated Completion Date: October 1, 2023

Finding 2022-002 Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 View of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We are working putting Internal Controls in place specific to grants like the Covid-19 Coronavirus State and Local Fiscal Recovery Funds grant. We will put a checklist together, including review and approval of disbursement by the governing body, that has to be met before the claim or the project can be processed. Anticipated Completion Date: October 1, 2023

Finding 2022-002 U.S Department of State Professional and Cultural Exchange Programs - Citizen Exchanges ? Assistance Listing No. 19.415 Recommendation: We recommend American Institute For Foreign Study Foundation, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to awards in the proper period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review more closely to ensure costs are charged to awards within the period of performance. They note that all costs being charged to awards are grant related regardless of the period and that they consistently do not use all approved grant awards. Name of the contact person responsible for corrective action: James Mahoney, CFO Planned completion date for corrective action plan: September 15, 2023 If the U.S. Department of State has questions regarding this plan, please call James Mahoney at 203-399-5143.

Information of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Uninsured Program) Ascension Ministry Market: Various Pass-Through Award Numbers: Various Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials: The Uninsured Program administered by HHS stopped accepting claims due to lack of funding. All claims for testing or treatment had a deadline of March 22, 2022; thus, no further action plan is needed. Any patient accounts billed in error have been refunded to HRSA. Responsible Official: Andrew Gwin, Senior Director, Regional Lead, Revenue Cycle Anticipated completion date: N/A

Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Tennessee Department of Health Ascension Ministry Market: Tennessee Pass-Through Award Number: 34352-93122, 34352-90022, 34352-69822 Pass-Through Award Period: 07/06/2021?Ongoing Pass-Through Grantor: Michigan Health & Hospital Association Ascension Ministry Market: Michigan Pass-Through Award Number: Not applicable Pass-Through Award Period: 12/01/2021?09/30/2023 Pass-Through Grantor: Kansas Department of Health & Environment Ascension Ministry Market: Kansas Pass-Through Award Number: Not applicable Pass-Through Award Period: 09/01/2021?02/28/2022 Views of responsible officials: Ascension will reinforce internal controls over review and approval of time cards and retention of documentation evidencing the approval of expenses. The use of the average labor contract rate was a conservative approach as Ascension?s actual average labor rate was higher than the average $150 per hour expensed to the grant. Ascension will reevaluate the methodology and appropriateness of use of an average contractor labor rate for contract labor reimbursement. Responsible Official: Jennifer Huettl, Accounting Manager, Grants & Research Finance Anticipated completion date: June 30, 2023

Finding # 2022-004 Title of Finding Period of Performance Contact Person Jewell Aguilar Anticipated Completion Date 06/30/2023 Corrective Action planned to be taken: The Commissions requests to amend the statements to reflect that this premium pay was for work performed for the period of March 2021 through December 2021 instead of March 2020 through December 2020 as previously stated. The amount paid would have calculated the same as it was it same employees that worked in 2021 that had worked in 2020, therefore, the only change to the description would be the date of performance. In the future, regulations will more thoroughly reviewed for accuracy.

Finding 2022-002: Internal Control over Compliance with Period of Performance and Noncompliance of Period of Performance and Reporting Condition: The period of performance compliance requirement related to total expenditures and close of financial products was not met. As of September 30, 2022, the Agency expended approximately 50% of the CDFI RRP Assistance of which approximately 36% was in closed financial products. Additionally, the Agency did not provide a narrative explanation of the failure. Management Response: We acknowledge this finding. Corrective Action Plan: Management had prepared the budgeted expenditures below for the CDFI-RRP Award. Shared Equity Resources $ 1,300,000 Housing Resiliency Fund $ 100,000 Income Assistance $ 125,000 Mortgage Assistance $ 27,325 Admin Fee $ 273,940 Total Grant $ 1,826,265 Management has hired staff in Period 1 and provided marketing and training to fully execute the above $1.3MM expenditures related to the Shared Equity Resources portion of the award. THF was in the process of expending the final resources available from a corporate grant to support the Housing Resiliency Fund in Period 1 before utilizing the CDFI-RRP Award resources for this purpose. Management has been tracking the progress on the above budgeted uses and currently has utilized 96% of the grant resources as of June 30, 2023. Management will utilize 100% of the resources by the end of the second period of performance and be in compliance of utilizing 100% of the award by the end of Period of Performance 2. Tracking of utilization to date is below: [see report for table] This corrective action plan will be 100% completed by 09/30/23.

FINDING 2022-006 Contact Person Responsible for Corrective Action: Laura Boldery, CFO/Corporation Treasurer Contact Phone Number: 812-866-6253 or Cell: 812-801-9070 Contact Email: laurab@swjcs.us Views of Responsible O?cial: We concur with this audit finding. Description of Corrective Action Plan: Action taken in an e?ort to remedy finding 2022-006 includes, but is not limited to, the following: ? We will review or internal controls again and try to implement a process to ensure it is being monitored and completed. ? We will have all invoices monitored before submission. Revenue will be monitored and checked with invoices when received. Anticipated Completion Date: February 1, 2023

SRC agrees that the proper eForms were not completed in two of the transactions DCAA selected for testing. However, as noted in DCAA?s audit report, there were mitigating controls and documentation showing the project managers were aware of the transfer of materials and were tracking it manually. SRC does agree that the proper eForms should have been used and will provide training to responsible employees to ensure compliance with MAT-P-540. Contact Person Responsible for Corrective Action: John Simms, Director, Facilities Completion Date: All corrective action will be implemented by September 30, 2023.