Corrective Action Plans

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.

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