Corrective Action Plans

Management concurs that the subscription period was from June 28, 2022 through June 27, 2023 and the benefits of the subscription service purchased under the award were received outside the grant?s period of performance. However, benefits were in support of Year 3 of the Coronavirus Recovery Project, which was granted by MBDA in January 2022 to start July 1, 2022. In order to have coverage from the start of the project, the subscription was purchased to ensure no break in service during to MBE during Year 3. In the future, as a part of our grant financial process, we will seek written approval from our program manager. Name of the contact person responsible for corrective action: Sharon Pinder, President, (301)593-5860. Planned completion date for corrective action plan: December 31, 2023.

Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Continuum of Care Program CFDA #14.267 Finding Summary: The Organization claimed a portion of expenses that benefited the period outside of the period of performance which was November 1, 2021 to October 31, 2023. During our testing, there was no documentation of review and approval of expenses for a portion of the sample selected. Responsible Individuals: Caroline Hood, President & CEO Paul Puerzer, Chief Financial Officer Jessica Johnson, VP of Assets & Operations 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: 12/31/2023

2022-002 Journal Entry and Cash Disbursement Review and Approval: A General Ledger is run monthly and stored and shared on BPC?s Google Workspace Drive. The Executive Director and Director of Development review monthly. Documentation for journal entries is maintained by the Accounting Manager. The Executive Director or designee formally reviews the general ledger and journal entries monthly. The Executive Director and Director of Development retain administrative access to the QuickBooks account as an ongoing control measure. Corrective action plan documented in BPC?s organization?s operational financial guidelines that was completed September of 2022.

Finding 2022-003 Internal Control Deficiency and Non-compliance over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: The Hospital?s reporting submissions did not follow the published HRSA guidance related to the reporting of lost revenue. Internal controls over the method used to report lost revenues in the HRSA and ARP reports were not precise enough to identify the submissions were not compliant with HRSA reporting guidance. Corrective Action Plan: Management will ensure internal controls are in place to identify the submissions are compliant with HRSA reporting guidelines. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023

Finding 2022-002 Internal Control Deficiency over Allowable Activities Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: Management did not retain evidence of controls surrounding the compliance with the terms and conditions of the award. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023

Finding 2022-001 Internal Control Deficiency over Reporting Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Award Period of Performance: January 1, 2020 ? December 31, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to ensure lost revenues submitted for the Provider Relief Fund were allowable under the terms and conditions of the award, as reported in the HRSA filings. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2023

Action Plan: We will work with our departments to ensure that controls for grants are documented with written procedures. These procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, re-performable manner with the name of the responsible individuals, the specific control(s) they performed over compliance for the grant, and the date(s) the controls were performed. Contact Names Responsible for the plan - Marcia Saulo Anticipated completion date of the plan - September 20, 2024

Action Plan: We will work with our departments to ensure that controls for grants are documented with written procedures. These procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, re-performable manner with the name of the responsible individuals, the specific control(s) they performed over compliance for the grant, and the date(s) the controls were performed. Contact Names Responsible for the plan - Marcia Saulo Anticipated completion date of the plan - September 20, 2024

CFDA No. and Name: 10.691 Good Neighbor Authority Responsible Persons: Siri Mullaney, Finance Director Anticipated completion date: June 30, 2023 Corrective Action: Concur. In fiscal year 2023, the Flood Control District was moved from the Public Works Department and formed into a stand-alone department, allowing for the hire of new staff dedicated to the management of federal awards. This increase in oversight will provide the capacity to accurately account for federal awards and comply with requirements such as adherence to the award start and end dates and the receipt of pre-approval by the federal agency for pre-award costs. The County will continue to provide technical assistance and resources to departments managing federal awards.

Department of the Treasury ? CDFI Fund Grant Vantage West Credit Union respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Doeren Mayhew 305 West Big Beaver Rd., Ste. 200 Troy, MI 48084 Audit period: January 1, 2022 ? December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF TREASURY CDFI Program ? CFDA No. 21.024 Significant Deficiency: See Finding 2022-001. Recommendation: Complete established procedures to identify and track eligible loans deployed during the RRP grant performance period and reconcile the totals to the underlying loan data. Action Taken: Vantage west will enhance its reporting to our third party CDFI reporting consultant to clarify and fully define borrower data points, in support of improving the accuracy of financial products reported annually on the Performance Reports to the CDFI Fund.

Finding Reference Number: 2022-004 Description of Finding: Per the Coronavirus State and Local Fiscal Recovery Funds Compliance and Reporting Guidance (as approved and documented under OMB PRA number ? OMB #1505-0271), quarterly Project and Expenditure Reports are due to the Treasury by the last day of the month following the end of the period covered, and the funds may be used to cover eligible costs incurred between March 3, 2021 and December 31, 2024. Statement of Concurrence of Non-compliance: The City works in good faith to report in a timely manner on all grants as required. There was an issue with the login information and password that was not responded to until after the reporting date. The City was under the impression using the interim final rule that costs associated as of the beginning of the pandemic were applicable costs. As such, we agree with this finding. Corrective Action: The City has since reported on time, testing login information prior to the due date to ensure that there are no issues with login or password. We will be reviewing all costs associated during the applicable time frame and utilizing other related costs left off reporting and resubmitting to the US Treasury.

Finding Reference Number: 2022-001 Description of Finding: Per the Coronavirus State and Local Fiscal Recovery Funds Compliance and Reporting Guidance (as approved and documented under OMB PRA number ? OMB #1505-0271), quarterly Project and Expenditure Reports are due to the Treasury by the last day of the month following the end of the period covered, and the funds may be used to cover eligible costs incurred between March 3, 2021 and December 31, 2024. Statement of Concurrence of Non-compliance: The City works in good faith to report in a timely manner on all grants as required. There was an issue with the login information and password that was not responded to until after the reporting date. The City was under the impression using the interim final rule that costs associated as of the beginning of the pandemic were applicable costs. As such, we agree with this finding. Corrective Action: The City has since reported on time, testing login information prior to the due date to ensure that there are no issues with login or password. We will be reviewing all costs associated during the applicable time frame and utilizing other related costs left off reporting and resubmitting to the US Treasury.

2022-002 Crime Victim Services- Assistance Listing No. 16.575 Recommendation: The Organization should implement internal controls to ensure that there is review and approval of monthly payroll accruals by someone who does not prepare the accrual calculation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Payroll accruals are currently reviewed and approved by a contracted accountant. This task will transition to financial staff by the end of the fiscal year 2023. Name(s) of the contact person(s) responsible for corrective action: Yulanda Williams

Finding 2022-004 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. There were no material cost issues in the overall report. There was a categorization error. This was discussed in Finding 2022-003. 2. The Revenue Loss expenditures were all valid personnel costs. Over 80% of the costs are police & fire. Other various city departments comprise the balance of the expenditure. We concur with the finding. Corrective Action: A. An additional layer of review has been initiated. The Director of Development is familiar with the requirements of the SLFRF guidance and will review and sign off on future reports. Anticipated Completion Date: 30 June 2022

Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status of Audit Finding: At the time of the audit, CCR had not received funds for three months of work as a subgrantee on the large federal grant that is the subject of this plan. The grantor was awaiting the federal contract extension and funds, and so did not have the funds to release. CCR received communication from the grantor that the extension and funds would be available soon, so we prepared a check for a vendor. Then, there was an extensive additional delay in receiving the funds, and CCR did not send the check because the contract had not yet been signed and funds could not be dispersed. The expense had been approved by the grantor and the work was underway during the delay in mailing the check. Corrective Action: As of June 2022, stricter internal controls have been implemented to ensure that any reimbursements listed on a grant invoice have been sent out to the vendor before submitting the report. A more formal review process has been implemented: CCR?s Executive Director will review and approve monthly grant reports via email. She will also review and approve supporting documentation for reach grant report. Approval (sent via email) will be kept with in a digital file with the reporting documentation. An additional internal control has been implemented to ensure that expenditures submitted for reimbursement are within the period of performance for the grant agreement. The Executive Director will monitor the grant expenses against the grant agreement, paying specific attention to the invoices at the end of the grant period, in order to ensure that the invoice is dated prior to the end of the grant agreement or most current amendment.

Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Organization?s documentation. In addition, there was no indication that a review was performed of the information submitted for one of the four months tested, which resulted in the reimbursement amount from the pass-through entity being more than the support maintained by the Organization for three of the 12 months and no documentation of the review for one of the months. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: Schedule meetings with 3rd party vendor to identify the significant rounding errors occurring. Develop an agreement on rounding procedures to be used by both parties ensuring reconciliation. Anticipated Completion Date: 12/31/23 ? Note- this system of reimbursement terminated on 3/31/23

Finding 2022-015 U.S. Department of Health and Human Services AL No. 93.568 Total Low-Income Home Energy Assistance Significant Deficiency over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: The Office of Home and Energy Programs (OHEP) bureau of The Mayors Office of Children and Family Success (MOCFS) agency has implemented a plan to locate needed files from previous and current fiscal years. The agency has implemented a scanning and uploading Standard Operating Procedure (SOP) that requires each case file to be digitally attached to its application and supporting documents. This will remedy this finding in its totality. Contact Person: OHEP Director ? Rigel Moore Completion Date: March 10, 2023

Finding 2022-018 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to the correct grant period within the general ledger. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday, and accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-016 U.S. Department of Health and Human Services AL No. 93.767 Children?s Health Insurance Program (CHIP) Material Weakness Over Compliance and Internal Control over Period of Performance Repeat Finding: Yes Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to a grant. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-024 U.S. Department of Health and Human Services AL No. 93.977 Totally Sexually Transmitted Diseases (STD) Prevention and Control Grants Significant Deficiency in Compliance and Internal Control over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to the correct grant period within the general ledger. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-023 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Significant Deficiency in Compliance and Internal Control Over Reporting Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to maintain compliance with reporting requirements. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on 440 Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-022 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness over Period of Performance Repeat Finding: Yes Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to a grant. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finance and the Office of Highway Safety will work together to create policies and procedures to ensure compliance with Period of Performance. Anticipated Completion Date: September 30, 2023 Contact Person: Loren Doyle, Acting Chief Operating Officer / Chief Financial Officer Department of Transportation loren.doyle@dot.ri.gov

FINDING 2022-004 Contact Person Responsible for Corrective Action: Cheryl Alcorn, County Auditor Contact Phone Number: 574-753-7700 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Auditor and Commissioner will work together to ensure Project and Expenditure Amounts are properly reported to the Department of Treasury. The corrective plan of action will include the guidance of financial advisors to ensure reporting to be complete and accurate. Anticipated Completion Date: Corrective action plan will start immediately.

CHRISTUS Health Corrective Action Plan Year Ended June 30, 2022 Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. We plan to review our processes related to the retention of expense documentation to improve audit evidence. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: September 2023 with the filing of the 5th portal filing.