Corrective Action Plans

Views of responsible officials and planned corrective actions: The College has taken steps to charge the cost to the appropriate grant award number. The College will ensure that future costs are properly charged to the correct grant award number and that costs are within the appropriate period of performance. In addition, finance and program staff will be trained on period of performance requirements, as well as other aspects of grant management. Contact Person: Rodalyn Gerardo, Vice President for Finance & Administration Expected Completion Date: September 30, 2023

2022-003 Small Business Administration Financial Assistance Listing #59.075 COVID-19 Shuttered Venue Operators Grant Program Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Material Weakness in Internal Control over Compliance Condition: While the Organization had policies and procedures in place over the review and approval of expenditures, during the testing of expenditures there were certain items that lacked the documentation of such review and approval. The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. The review and approval process was a collaborative process that took place in face to face meetings without documentation retained. Management?s Response and Corrective Action Plan: The Museum Deputy Directory/COO reviewed all grant expenditures in detail for accuracy and approved them before submission to the SBA, and written documentation of the review and approval of the submitted expenditures was maintained. However, written documentation of the approval of certain expenditures at the time they were actually incurred was not maintained, even though there were consistent, contemporaneous oral communications between the Deputy Director/COO, the Controller and the Payroll Administrator regarding those expenditures. As of January 2023, the CFO has implemented procedures whereby written documentation of approval of those expenditures is maintained. Responsible Individual: Robin Klung, CFO Anticipated Completion Date: January 2023

Responsible Official: Matt Zook, Finance Director Views of responsible officials: Management understands the requirement for secondary review and approval both at the source level (transactions generated by departments) and the and approval and submission of grant reports) and will actively implement and execute these steps into the internal control policy. Management will meet with the public works department to evaluate the software used to track force account equipment and ensure that Supervisor review and sign off will be conducted either through the software program or physically on paper. Management will also meet with the parks department to review their process for tracking force equipment charges. They use a paper tracking system, so we will ensure that they include a supervisor review and sign off process on staff tracking sheets. Management will also create a review process within the finance department specifically for the calculation and submission of grant reporting. Management agrees to comply with this within 90 days of the filing date of the financial statements no later than March 19, 2023.

2022-005 Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Sam Kimball Title: Corporate Controller Phone Number: 202-296-9165 Estimated Completion Date: December 2023 Corrective Action: During 2023, the Foundation is implementing a new ERP system with an anticipated go-live date of October 1, 2023. This new system will allow for better structure around the period-end accrual process and allow the Foundation to more clearly and effectively accrue for costs in the period of performance. Additionally, the Foundation will hold informal training sessions to remind staff of the importance of recording expenditures in the appropriate period and the policies around year-end accruals for costs that have not yet been invoiced.

Corrective Action Plan Finding 2022-001 ? Reporting Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: Assistance Listing 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Federal Award Numbers: N/A Federal Award Period of Performance: July 1, 2020 ? December 31, 2020 A material weakness was issued related to reporting for the Provider Relief Funds (PRF) that represented the major program subject to the Uniform Guidance (UG) audit. This included a compliance finding with no questioned costs. Community Foundation of Northwest Indiana, Inc. and Subsidiaries (CFNI) did not maintain written documentation of the detailed review and approval process of the underlying lost revenue calculations or the approval and sign-off process for the portal submission. CFNI Finance has developed a policy and checklist to maintain written documentation of the review and approval process required under current audit standards to improve internal controls going forward. Due to the timing of the prior year UG audit, the implementation of the new policy could not impact the current UG audit, resulting in the same finding. This has been corrected for future audits with the policy being effective October 2022. In the compliance finding, management failed to catch a change in formula to a large excel file returned from an external resource. This resulted in underreporting lost revenues for one entity. The finding affirms the need for an official policy identified in the reporting deficiency, which CFNI has fully corrected, and management will improve the review process and communication over changes to files sent and received from both internal and external resources. CFNI will correct the reporting error in the next reporting submission for period 4. Responsible Official: Pamela Pokropinski, Director Accounting & Financial Systems Status of finding: Fully corrected.

Finding 2022-003 Federal Agency Name: National Endowment for the Arts Program Name: Promotion of the Arts Partnership Agreement CFDA # 45.025 Finding Summary: The Organization has a process for allocating employee wages based on hours worked, however, retroactive pay adjustments, bonus allocation for one employee, and one pay period for one employee did not follow this process. The controls in place did not operate as designed and failed to detect errors in the allocation of employee pay to the grants. Responsible Individuals: Anne Romens, Vice President and Emily Anderson, Chief Administrative Officer Corrective Action Plan: Arts Midwest uses Paylocity, a third-party payroll provider, for employee time tracking and payroll processing. Salary and benefit allocations to departments and grants are based on labor distribution reports generated by Paylocity. The Finance Team will review and verify report parameters and details to ensure they are accurate before the payroll costs are imported into the accounting system. In addition, the finance and operations teams will verify any one-time pay adjustments are correctly calculated and allocated based on related period of hours worked. With the start of a new Chief Financial Officer, this will be a priority for the first quarter of 2023. Estimated Completion Date: March 31, 2023

Finding 2022-001 ? Activities Allowed or Unallowed and Eligibility 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 and the COVID-19 Coverage Assistance Fund Federal Award Numbers: Various Federal Award Period of Performance: 09/01/2021?04/05/2022 Views of responsible officials and planned corrective actions: Management made the adjustments to the report script to ensure all uninsured COVID-19 patient accounts eligible for reimbursement by HRSA are captured for management review and includes accounts with a zero balance and/or have a closed status. The corrective action plan was implemented and in place by December 31, 2021 shortly after the 8/31/2020 Uniform Guidance audit was completed on November 29, 2021. The adjustments will ensure that claims completed after December 31, 2021 are captured. Responsible Official: Michael Mullen, Vice President Revenue Cycle Completion date: December 31, 2021.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor review all claims and sign off that the work has been done. Anticipated Completion Date: May 15, 2023

Recommendation: Established a control procedure that reconciles the grant funds utilized as reflected in the accounting records to that being reported on the Use of Awards Report. Action Taken: Management agrees with the finding and will establish the recommended control procedure. The Use of Award report was corrected during the course of the audit.

Finding 2022-005 Personnel Responsible For Corrective Action: Cheryl Vannoy, Deputy Superintendent, Accountability, Data & Technology Services Anticipated Completion Date: June 30, 2023 Corrective Action Plan: The Information Technology Department will schedule a call with the ECF consultant, the Financial Management Office, and the Fiscal Control Office by July 15, 2023 to discuss all necessary paperwork that will be submitted to the Financial Management and Fiscal Control Offices 30 days prior to the final submission deadline to ensure that all payment requests can be submitted in the allotted time period, and give the Finance Offices understanding of what the reimbursement amount will be. The ECF consultant will copy the Chief Financial Officer, Finance Director, Grants Manager, and Fiscal Control Director on his/her submission.

Corrective Action Plan Contact Person: Randy Cates rcates@yesomaha.org 402.345-6704 FINDING 2022-004: Allowability Regarding Allowability?The process we have put in place includes the following: ? All invoices and fund receipts will be reviewed by the Director of Operations and/or CFO for authenticity and accuracy. ? All approved fund receipts and invoices will be coded by the CFO. ? All coded invoices will be forwarded to our CPA firm. ? Our CPA firm will: o Scan all invoices and create a file for which the Director of Operations, CFO, and Executive Director will also have access. o Input all invoices into our Accounting Software ? CFO will review all Receipts and Expenses monthly with Executive Director Reasonable completion date: Process is place as of July 7, 2023 Responsible Party: Randy Cates, CFO

Finding 2022-002 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Pass-Through Grantor: Not applicable Pass-Through Award Number: Not applicable Pass-Through Award Period: 1/1/2020-12/31/2022 (Periods 3 and 4) Summary of finding: Management?s internal controls over the review and interpretation of instructions related to the input of lost revenue into the HRSA PRF portal were not sufficient to ensure the lost revenue recorded in the General Distribution portal ?Total Lost Revenues for the Period of Availability (January 1, 2020 to December 31, 2022)? line did not include the lost revenues that had been transferred from the Parent to subsidiaries and recorded in the portal for the subsidiaries Targeted Distributions. Corrective Action Plan: When populating the Period 4 HRSA PRF portal for Spectrum Health System, Corewell Health West management was aware that the inputs were not considering the System lost revenue attributed to the affiliates appropriately. In order to communicate to the users of the portal and other auditors, Management included an excel tracking worksheet which was uploaded on the HRSA PRF portal showing the total lost revenue used as an organization and the remaining balance left to be used. When populating the Period 5 filing, due September 30, 2023, Corewell Health West Management will correctly input the lost revenue in the Parent submission in order to reflect the lost revenue used by the individual subsidiaries. Individual responsible for the corrective action: Cindy Brink, Director, System Accounting & Reporting Timing of the Corrective Action Period 5 HRSA PRF portal filing, due September 30, 2023.

FINDING 2022-003 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will ensure that internal controls that are currently in place will be modified in order to be effective in preventing, detecting and correcting errors. This will include making sure the county auditor and designated county commissioner are aware of all reporting deadlines and reporting periods covered. Once the county auditor enters expenditure and obligation information, the designated county commissioner will review the data and submit the necessary report(s). Anticipated Completion Date: This will be completed by September 30, 2023, allowing the county auditor to update the designated county commissioner in the Department of the Treasury?s system and inform him of all upcoming report deadlines. This will ensure the effectiveness of existing internal controls.

Finding 2022-005 Identification of the Federal Program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing: Various ? Research & Development (R&D) Cluster Pass-Through Grantor: Various Pass-Through Award Number: Various Pass-Through Award Period: 1/1/2022-12/31/2022 Summary of finding: Management does not track expenses by budget period for Corewell East federal Research and Development (R&D) grants and is therefore unable to support that expenses are recorded in the appropriate period of performance. Corrective action plan: The hierarchy and functionality of the prior Corporate financial management system (prior to July 1, 2023) did not support separate budget periods during a single award project period. This was managed manually by the CHE Sponsored Programs Administration via a customized internal report. Effective July 1, 2023, the institution transitioned Corewell Health East onto Workday, the common financial management system already used by Corewell Health West. The Workday financial management system includes a separate grant module that has the capability to establish defined budget periods under a single award. CHE successfully transitioned to Workday beginning July 1, 2023. With the functionality now enabled by Workday, we do not anticipate any barriers to maintaining defined budget periods within an award funding cycle to assure that expenses are recorded in the appropriate period of performance. Individuals responsible for corrective action: Giacomo DeChellis, Sr. Director, Research Operations, Corewell Health East Timing of corrective action: July 1, 2023 and going forward.

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, 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 grants in the proper period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All expenditures will be reviewed and recorded in the proper period of performance. The correction was put into place during the audit and all expenditures have been reviewed during entry and at the point of signature from the Finance Director. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 4/24/2023

Identifying Number: 2022-002 Finding: The following discrepancies and inconsistencies were identified: administrative procedures and requirements of the grantor were not followed; there were no proper review or approval of required reporting prior to submission. Contact person responsible for corrective action: Kevyn Harmon, Senior Director of Finance & Administration Corrective Action: All personnel involved with the Title programs undergo training on the all the processes and requirements to administer the programs, and management will perform proper review of all claims for reimbursement. In additional, an annual update on the procedures and the requirements to ensure propriety and accuracy. Proposed Completion Date: EPIC Academy will complete implementation of the above procedures by November 30, 2022.

Finding 2022-002 ? Considered a significant deficiency in internal control over compliance/immaterial non-compliance Federal Grant ? ALN 93.958 Condition ? During testing it was noted that FICA costs were overcharged by $14,047. Corrective Action ? HealthWest will review its methods for determining allocations of fringe benefits to their grants. Review and, any necessary, updates to daily procedures and processes are occurring. All finance staff and any HealthWest staff assigned to grants will be required to obtain grants specific training annually. Finally, monthly monitoring of all expenses will be reviewed. Contract Person ? Brandy Carlson, Chief Financial Officer Anticipated Completion Date ? June 30, 2023

Finding 2022-002 - Internal control deficiency and noncompliance over calculation of indirect costs The grants management team will be trained on the correct indirect cost calculation and requirements. Review of indirect calculation will be included in the Fund Transfer Request (FTR) review meetings. Contact person: Administrative Director, Grants ? Erasmo ?Tony? Cortez. Expected Completion Date: October 2023.

FINDING 2022-005 Contact Person: Donald Lopp, Director of Operations and Planning Contact Phone Number: (812) 948.4110 Views of Responsible Official: Corrective Action As Director of Operations and Planning, the American Rescue Plan quarterly reports are submitted through the office. During the audit, it appears eight of the ten audit items had the correct cumulative expenditure but those figures were not also applied to the current quarter expenditures. The US Treasury portal will not allow for the submission of the quarterly report unless the cumulative obligations and expenditures match. Description of Corrective Action Plan: Prior to submission, quarterly reports will be printed and reviewed by secondary staff in Office to review submission correctness. Anticipated Completion Date: This method will be instituted at the July 2023 quarterly report submission.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with health and safety requirements for the Child Care and Development Fund program. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $412 Status: Corrective action in progress Corrective Action: The Department is strongly committed to ensuring the health, safety, and well-being of all children in care. The Department concurs with the finding and has taken the following actions: ? In September 2020, in response to the COVID-19 pandemic, the Department obtained grantor?s approval to revise the Child Care and Development Fund (CCDF) State Plan to waive the annual unannounced monitoring requirement and allowing for virtual monitoring, through September 30, 2021, but some providers were unable to participate in the virtual process resulting in monitoring visits not being conducted during state fiscal year 2022. ? In the fall of 2022, to address staff turnover issues, the Department began recruiting new staff and providing training on child care licensing rules and regulations. This included adding a new position in November 2022 to assist supervisors with onboarding and training new staff hired during the audit period. ? The Department implemented a data driven, phased in approach, to return staff to in-person field work after the COVID-19 pandemic: o In July 2022, began authorizing staff, subject to pandemic related restrictions, to visit providers on-site to provide assistance with meeting health and safety requirements. o In the spring of 2023, prioritized monitoring visits to return to compliance with CCDF health and safety requirements. ? Established an overpayment for the questioned costs and referred to the Office of Financial Recovery for collection. ? For license-exempt family, friend, and neighbor (FFN) providers, the Department: o Requested approval from the Office of Child Care for a hybrid monitoring approach (in-person and virtual visits). o Dedicated staff resources to update WA Compass to include all health and safety requirements for FFNs and address data format issues. The Department will continue to strengthen internal controls as follows: For licensed providers: ? Continue to implement return to in-person field work by reducing pandemic level requirements. ? Prioritize new staff training to first focus on monitoring visits and health and safety requirements. ? Continue to track and monitor health and safety requirements with available tools until all WA Compass system development is completed. ? Create an in-training licensing position to assist staff recruitment efforts and add additional lead worker positions to assist supervisors with training and caseload management. ? Conduct a root cause analysis to determine other underlying causes for missed monitoring visits and untimely follow-ups, and how to address them. ? Examine ways to secure resources to add additional full-time staff to support caseload needs. For FFN providers: ? Continue to track and monitor FFN health and safety requirements with available tools until all WA Compass system development is completed. The conditions noted in this finding were previously reported in findings 2021-039, 2020-042, 2019-039, 2018-035, 2017-025, 2016-022 and 2015-024. Completion Date: Estimated July 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with period of performance requirements for the Child Care and Development Fund. Questioned Costs: Assistance Listing # 93.575 93.575 COVID-19 93.596 Amount $0 Status: Corrective action in progress Corrective Action: The Child Care and Development Fund (CCDF) program was previously managed by the Department of Social and Health Services and the Department of Early Learning. Since the program transitioned in 2019, the Department has been making efforts to strengthen internal controls over payments to child care providers and other CCDF grant requirements. The Department implemented grant-level management of all federal funds, including the CCDF grant. The Department allocated the CCDF grant to eligible clients and allowable activities in compliance with 45 CFR 98.67. For the fiscal year 2021 program audit, the State Auditor?s Office (SAO) issued a finding with $32 questioned costs for non-compliance with the CCDF eligibility requirement. No other findings, management letters, or exit items were reported in this compliance area or the cost allocation of funds based on eligibility. Given that eligibility or cost allocation has not been an area of concern, and transfers were processed between CCDF source of funds with the same eligibility criteria, the Department is assured that CCDF funding was spent appropriately within federal regulations. The Department is committed to improving internal controls. The Department does not currently have the resources to develop and maintain the business process redesign, as well as the information technology initiatives necessary to meet the level of assurance recommended by SAO. In response to prior year?s audit recommendations, the Department has submitted a budget request to the Legislature in the 2023-2025 biennial budget for additional resources to process adjustments to include transaction-level data. As part of the audit resolution process, the Department of Health and Human Services (HHS), which oversees the CCDF program at the federal level, reviews all SAO findings and issues management decision letters. The letters will reflect the grantor?s determination of whether an audit finding is sustained, the reasons for the decision, and the required actions by the auditee. When a management decision is issued for the fiscal year 2021 finding, the Department will work with HHS and follow the audit resolution process. The conditions noted in this finding were previously reported in finding 2021-037 and 2020-041. Completion Date: Estimated December 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

FINDING 2022-002 Contact Person Responsible for Corrective Action: Debra G. Walker Contact Phone Number: 765-529-2800 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: We have corrected and added the $47,363 to the expenditure report. Anticipated Completion Date: Corrected on the March 2023 expenditure report.

Views of Responsible Officials and Corrective Action Planned: The Seminary hired a third-party financial aid servicer, Financial Aid Services, LLC (?FAS?) who will do the enrollment reporting as part of their contract. The FAS contract was signed May 2022 for the upcoming fiscal year 2022 to 2023. This contract was approved by the Administrative Council in May 2022. The Seminary?s current part-time financial aid coordinator sent out the April 2022 enrollment roster which included student status changes on October 17, 2022.

Finding: The Department of Health did not have adequate internal controls to ensure payments to providers were allowable, met cost principles, and were within the period of performance for the Special Supplemental Nutrition Program for Women, Infants, and Children. Questioned Costs: Assistance Listing # 10.557 10.557 COVID-19 Amount $0 Status: Corrective action not taken Corrective Action: The Department disagrees with the auditor?s assessment of a significant deficiency in internal controls over the consolidated contract provider payment process for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Department has established processes in place to ensure payments are allowable, meet cost principles, and comply with period of performance requirements for the WIC program. These include: ? Perform annual review and approval of detailed subrecipient budgets. ? Compare invoice amounts to budgeted amounts for reasonableness before payment approval. ? Provide subrecipients regular technical assistance and training on applicable policies related to fiscal and programmatic processes. ? Conduct biennial program and fiscal monitoring visits to subrecipients as part of the Department?s monitoring procedures. In addition, the WIC program has monitoring controls in place and evidence of review at the program level. The quality assurance program staff maintain a detailed payment log that documents review and approval and details any amounts that need to be withheld until issues with invoice support are resolved. These reviews are to be completed within the 10-day period before payment is released. Similar conditions noted in this finding were previously reported in finding 2021-004. Completion Date: Not applicable Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure payments to providers for the Block Grants for Prevention and Treatment of Substance Abuse program were allowable and met period of performance requirements. Questioned Costs: Assistance Listing # 93.959 93.959 COVID-19 Amount $19,959,714 Status: Corrective action in progress Corrective Action: The Authority partially concurs with the audit recommendations. The Authority concurs that expenditures for indirect charges were applied to the award, through the Authority?s cost allocation system, for activities that occurred after the period of performance. The Authority will develop written procedures to review allocation bases at the end of a grant period. The Authority does not concur with the audit exceptions related to two accruals recorded in the accounting system before the period of performance. As noted by the auditors, no payments were made on these accruals. The period of performance of the grant extends beyond the end of the state?s fiscal year. Invoices for the program continue to be received after fiscal year end and the cut-off date for reporting on the Schedule of Expenditures of Federal Awards. Staff review payments for grant allowability based on service month when invoices are received. The Authority does not concur with the questioned costs related to the year-end accruals and will verify with the grantor that questioned costs do not need to be repaid. The year-end accruals were solely recorded as estimates and were not used to make any program payments or draw funds from the grantor. While the year-end accruals may include some amounts beyond the state fiscal year, questioning the year-end accruals in their entirety is an overstatement of any potential error that was made. The Authority will update procedures for calculating year-end accruals to: ? Maintain all supporting documentation used to calculate the year-end accrual transactions. ? Maintain a workbook to calculate estimated expenditures to be accrued for the fiscal year. The conditions noted in this finding were previously reported in findings 2021-057 and 2020-059. Completion Date: Estimated September 2023 Agency Contact: William Sogge, CPA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov