Corrective Action Plans

December 1, 2022 U.S. Department of Education 400 Maryland Avenue SW Washington, DC 20202 Re: Corrective Action Plan Pacific School of Religion (PSR) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 through June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding 2022-001 Enrollment Reporting Criteria: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of an enrollment report from the Secretary, institutions must update all information included in the report and return the report to the Secretary: (i) in the manner and format prescribed by the Secretary: and (ii) within the timeframe prescribed by the Secretary. Unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, an institution must notify the Secretary within 30 days after the date the institution discovers that: (i) a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the institution, and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least half-time basis for the period for which the loan was intended; or (ii) a student who is enrolled at the institution and who received a loan under Title IV of the Act has changed his or her permanent address. Recommendation: The School should revise its procedures to ensure accurate enrollment information is sent to NSLDS with the required timeframe for all students. Corrective Action Plan: Procedural changes implemented by the school during the Spring 2022 semester that allow for more frequent and timely enrollment reporting will correct this type of enrollment reporting error going forward. In addition, school administration will update procedures to verify status start dates for any enrollment changes specifically match the student?s enrollment in the student information system. Sincerely, Natasha Lee Vice President for Finance and Administration

FINDING 2022-005 Subject: Special Education Cluster ? Period of Performance Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the equipment requirements of the Period of Performance compliance requirement. Context: The School Corporation was a member of a joint service cooperative (Cooperative). The Cooperative operated the special education programs on behalf of the School Corporation and managed the special education grant funds. Because the grant agreements were between the Indiana Department of Education and the School Corporation, the School Corporation was ultimately responsible for compliance with the grant agreement and the Period of Performance compliance requirement. During fiscal year 2021, the School Corporation paid membership fees to the Cooperative out of federal Special Education funds. These membership fees made up approximately 48% of the total federal expenditures reimbursed during fiscal year 2021. The Cooperative accounted for state, local, and federal funds in a single fund. The fund did not separately account for each of the funding sources. This made it difficult to identify which expenditures were from federal funds, or to identify expenditures by federal program, award number, or years. Therefore, we could not test compliance with the period of performance requirements for approximately 48% of the expenditures. The School Corporation did not have adequate procedures in place to ensure that the Cooperative complied with the period of performance requirements. The Cooperative did not have adequate procedures in place to ensure that costs were charged to the programs only during the period of performance, or that all obligations were liquidated within 90 days of the end of the period of performance. The lack of internal controls and noncompliance were systemic issues, which occurred specifically during fiscal year 2021. No reportable findings were noted for fiscal year 2022. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Members of the cooperative are no longer paying their cooperative member fees with federal funds. This was resolved effective 7/1/2021. Responsible Party and Timeline for Completion: Zach Dennis, CFO, 7/1/2021

FINDING 2022-003 Subject: Staffing for Adequate Fire and Emergency Response (SAFER) Contact Person Responsible for Corrective Action: Dustin Dillard Contact Phone Number: 812-331-1906 Views of Responsible Official: We understand and agree with the importance of internal controls and segregation of duties at the District and we believe our policies, procedures, individual job descriptions and management oversight fulfill these necessary requirements, we intend to comply with the suggestions made by the auditing staff. Description of Corrective Action Plan: The SAFER Reimbursement Request spreadsheets are prepared by two administrative personnel who perform checks and balances on calculations, payroll reports, time-keeping reports and employee roster changes before submitting the information to the Fire Chief for review and submission. The District now requires both Administrative personnel to sign and date a cover sheet upon completion of the compilation. The Financial Administrative Assistant will reconcile the data entered into the FEMA portal by the Chief by initialing a printed copy of the dated request. Anticipated Completion Date: To be implemented with all future reimbursement requests following this date 8-23-23 More information about this finding is available in the Supplemental Report.

Finding Number: 2022-001 Condition Found: The Organization was found to have a significant deficiency in internal controls over compliance and compliance related to period of performance and cash management. Individual(s) Responsible for Corrective Action: Wanda Matthews, CFO and Ellen Krajewski, CEO. Corrective Action Planned: In order to comply with the U.S. Code of Federal Regulations (CFR), 45 CFR 75.309(a), and 45 CFR 75.305(b)(l), and ensure that the timing and amount of advance payments are as close as is administratively feasible to the actual disbursements by the organization for direct program or project costs and the proportionate share of any allowable indirect costs, the following process has been established for internal quality control: ? Drawdowns for salary expenses will be completed bi-weekly one week after the second week payroll. Drawdowns for other expenses will be completed at the end of every month for expenses that are documented as paid. This will help to ensure that grant funds expended prior to completing a drawdown in the PMS system. ? The request for disbursement from PMS will be submitted to the CEO with all corresponding backup that includes an earnings summary, documented and approved work hours report, expanded general ledger for other than salary expenses, the statement of revenue and expenditures for each grant, the worksheets that are completed for grant expenditure tracking, and a review checklist for completion by the CEO that includes the following requirements: o Are expenses related to the current budget period? o Is the drawdown amount in line with the expenses? o Is the drawdown amount for expenses that have been paid? o Are the expenses eligible for this grant? o Does the General Ledger and PMS system balances match? o Does supporting documentation provided support the expenses included in drawdown request? o At the end of the month, the statement of revenue and expenditures will be run for each grant. An adjusting entry will be completed to recognize grant revenue based on the verified expenses for each grant and recorded in the adjusting entry journal. o The adjusting entry journal is presented to the CEO for approval along with all supporting documentation for review and approval. Anticipated Completion Date: The process was started immediately upon notification of the finding. An updated Policy and Procedure will be submitted to the Board of Directors at the October 24, 2022 meeting.

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

Finding No. 2022-001 ? Activities Allowed or Unallowed; Allowable Costs; and Reporting Identification of the federal programs: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution 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: Although not in place the entire period of performance, effective March 31, 2022, the Financial and Data Analytics Director began conducting spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting and retains evidence of this testing.

Finding No. 2022-002 ? Activities Allowed or Unallowed; Allowable Costs and Eligibility ? Significant Deficiency in Internal Control Over Compliance Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Program) Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 07/01/2021?06/30/2022 Views of responsible officials: December 31, 2022, the Company completed its evaluation of additional EPIC automated processes and opportunities to add documentation to evidence HRSA claim reviews. Additional opportunities to add documentation in EPIC were not identified. Testing and treatment claims under the above federal program are no longer accepted after March 22, 2022 and vaccine claims are no longer accepted after April 5, 2022. Should the program return, the Company would support either internal claim compliance spot testing, with evidence of this testing retained, or an EPIC system software audit of the automated processes.

Condition: We noted that the District reported expenditures to ISBE on the June 30, 2022 expenditure report when they were not incurred and paid for until July 2022 for the Education Stabilization Fund. Recommendation: We recommend that expenditures incurred by the District be reported in the proper period in the reports to ISBE. Management Response: The District will ensure that expenditures are reported in the proper period in the reports to ISBE. Anticipated Date of Completion: June 30, 2023

Condition: We noted that expenditures incurred for the Federal Special Education Cluster were not reported in the proper periods on the expenditure reports submitted to ISBE. Recommendation: We recommend that the expenditures incurred by the District be reported in the proper quarter in the reports to ISBE. Management Response: The District will ensure that expenditures are reported in the proper quarter in future expenditure reports. Anticipated Date of Completion: June 30, 2023

2022-006: Internal Control Over Compliance and Compliance with Period of Performance Management is emphasizing prompt period closing to ensure that know Items are recorded in the wrong period. New layers of internal control have been added to ensure detailed review of accounting transactions. The ERM department is in the process of hiring an international compliance director, whose team will work as the second set of eyes (internal audit function) to ensure compliance. Individual(s) Responsible for Corrective Action Plans: Simon Peter Kabogoza, Controller, Heartland Alliance International skabogoza@heartlandalliance.org Anticipated Completion Date: 12/2023 Anticipated Completion Date:

Finding 2022-005: Internal Control Over Compliance and Compliance with Period of Performance Management through the local offices has already developed a policy to ensure that the period of performance is adhered too. Management is in the process of hiring another international compliance officer in both US and Iraq to particularly focus on grants performance requirements and sub-recipient grants management. Management through its Enterprise risk management is planning to schedule trainings for various departments concerning period of performance. Individual(s) Responsible for Corrective Action Plans: Simon Peter Kabogoza, Controller, Heartland Alliance International skabogoza@heartlandalliance.org Anticipated Completion Date: 12/2023

Contracts charged for expenses outside of the period of performance have been credited for ineligible expenses. Share's Director of Finance, Christopher Brox will provide training to accounting staff responsible for expense entry, expense review and approval, and invoicing by June 30, 2023 that include the following topics: - Allowability of expenses based on both contract criteria and the period of performance. - key identifiers that could flag an exception in allowability based on period of performance, and how to catch this in the review of expenses. - General ledger transactions that require further review for period of performance allowability during monthly review of expenses prior to preparing invoices. This training will highlight this being a specific area of focus for review during periods when a contract terms and a new contract starts. This training will happen with all new accounting staff responsible for expense entry and review and will be incorporated as refresher trainings if contract and grant administrator expense reviews identify this as being a continued issue by staff performing expense data entry.

The South Carolina Department of Social Services respectfully submits the following corrective action plan for the year ended June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAM AUDIT U. S. Department of Health and Human Services 2022-017 CCDF Cluster - Assistance Listing: 93.575 and 93.596 Recommendation: We recommend that the Department review and update internal controls to ensure all expenditures charged to federal awards are incurred within the grant's period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional controls have been implemented to ensure the Department?s Grants Accounting and Reporting manager and staff review and research all transactions posted in the liquidation period of a given grant year to ensure they include only those legally obligated as of the obligation date. The transactions incorrectly posted to the 2020 Discretionary Grant have now been correctly moved to the 2021 Discretionary Grant and are being replaced with qualified voucher expenditures previously moved from the 2020 Discretionary grant to the 2020 Mandatory Grant. Name(s) of the contact person(s) responsible for corrective action: Reshma Parikh, Grants Accounting and Reporting Manager Planned completion date for corrective action plan: June 30, 2023

Condition: Expenditure reports were not filed accurately by claiming unallowable expenses. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that expenditure reports are reviewed are allowable expenses and that all expenses are after the grant start date before submitting the reports. Management Response: Management will take the necessary steps to file all quarterly expenditure reports accurately in the future. Anticipated Date of Completion: June 30, 2023.

The County accepts the recommendation and will correct the 2022 and 2023 reports to indicate actual expenditures have been incurred for the relevant CSLFRF funds.

DEPARTMENT OF TREASURY 2022-002 COVID-19 Coronavirus Relief Funds ? Assistance Listing No. 21.019 Recommendation: We recommend the Town strengthen its internal controls over compliance to ensure allowable costs charged to federal programs are incurred during approved performance periods. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Understood. Name(s) of the contact person(s) responsible for corrective action: Randi Arruda Planned completion date for corrective action plan: Deadlines will be adhered to.

FINDING 2022-003 Contact Person Responsible for Corrective Action: George ann Ewald, Director of Finance & HR Contact Phone Number: (574) 277-4452 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Assistant Fire Chief will prepare an Excel? spreadsheet which will contain blank cells for all allowable reimbursement costs associated with each firefighter position covered by the 2019 Staffing for Adequate Fire and Emergency Response (SAFER) federal grant. The Director of Finance & HR will complete the blank spreadsheet by entering the corresponding data inside each of the cells for all covered positions. The Director of Finance and HR will attach supporting documentation (payroll history report & ledger line-item transactions) to indicate the costs were accurate, allowable, and within the period of performance. The Fire Chief will review and authorize the completed spreadsheet. The Fire Chief will then direct the Assistant Fire Chief to complete the reimbursement request via the FEMA GO website, which will include uploading the completed spreadsheet and supporting documentation. Once the reimbursement request has been submitted, the Assistant Fire Chief will print the completed reimbursement request documents and obtain signatures from each of the following individuals: 1. Prepared By: (NAME), Director of Finance & HR 2. Reviewed & Approved By: (NAME), Fire Chief 3. Submitted By: (NAME), Assistant Fire Chief Anticipated Completion Date: ? Implementation: June 2023

This is a repeat finding that was only first reported to Met Council at the end of the fiscal year covered by this audit. As such, the finding could not possibly have been corrected until fiscal year 2023. The policies to ensure the accuracy of our payroll and accounts payable processes were immediately adopted after the receipt of the fiscal year 2021 audit recommendation at the end of the 2022 fiscal year. As a result, our recommended course of action, as stated below, remains unchanged from the prior year: Payroll Review Electronic timesheets are completed and submitted by employees through the payroll system. All timesheets must be approved electronically by an employee's supervisor. The Senior Human Resources Manager, Benefits, reviews and signs the preprocessing payroll register prior to submission. Once approved the Payroll/Human Resources Administrator submits the payroll to the payroll administrator for processing. The Payroll/Human Resources Administrator sends the signed preprocessing register by email to the Managing Director of Human Resources, the Controller, and the Senior Budget Director listing all the exceptions for the current payroll. The Fiscal Project Manager then, through the payroll administrator, will generate a salary summary that includes a listing of the prior payroll and the current payroll indicating any differences. The fiscal project manager then sends the last page of the processed payroll register along with the salary summary to the Managing Director of Human Resources and the Controller for their review and signature approval. The payroll journal entry is generated by the Fiscal Project Manager and uploaded into the accounting software for review and approval by the Controller. Accounts Payable ("AP") Review The AP Accountant saves a PDF of each invoice (whether received electronically or on paper) and sends an email together with the invoice to the respective program director for approval. The program directors approve and code the invoices by signature which they then email back to the AP team for processing. When an invoice is coded to be charged to a grant ? the invoice is also placed in a folder by date on the shared drive for the Budget Department to review and approve the grant coding on each invoice. Once the coding is initialed and dated by the Senior Director of Budgets and Grants, it is entered into our accounting software for AP processing.

Research and Development Cluster ? Assistance Listing No. 10.216 Recommendation: We recommend that the Corporation review their period of performance process to ensure that costs that are charged against the grants are within the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The budget office will review final reports with the OSP post award area to ensure final narratives, final financial reports and the final draw of funds are correct and fall within the grant performance period. Name of the contact person responsible for corrective action: Kim Duff, Executive Director Planned completion date for corrective action plan: March 2023

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