Corrective Action Plans

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-002 Internal Control Over Compliance With Special Tests and Provisions Finding Summary 47 CFR ? 54.1711 requires that the District only seek support for eligible equipment provided to students and school staff who would otherwise lack connected devices sufficient to engage in remote learning. During our audit, we noted the District did not have sufficient controls in place within its Emergency Connectivity Fund Program to assure compliance with federal special tests and provisions requirements. We noted that the District requested federal reimbursement for purchased technology devices prior to those devices being used or deployed, and thus not yet meeting the definition of eligible equipment for which the District could seek reimbursement. Corrective Action Plan Actions Planned ? The finding resulted from a timing issue caused by unfamiliarity with a new federal program. The District subsequently deployed all devices for which it was reimbursed to students in accordance with the unmet needs defined and approved in its award applications. The District understands the applicable guidance and will ensure that future reimbursement requests under the Emergency Connectivity Fund Program will not be made until after the equipment has been placed in service. Official Responsible ? Director of Finance and Operations, Christopher Kampa. Planned Completion Date ? March 31, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Director of Finance and Operations, Christopher Kampa, will assure appropriate internal controls are in place to verify future compliance with special tests and provisions requirements for the Emergency Connectivity Fund Program.

Finding # 2022-002 Immaterial Noncompliance U.S. Department of Labor 17.249 WIOA Youth Activities Finding: Expenses were charged for services outside of the contract period Recommendation: Procedures should be in place to ensure invoices are accrued and charged to the proper period when services/goods were performed or received. Corrective Action: Expenses will be reviewed during month end close to ensure proper recording. Management will provide training to program personnel. Anticipated Completion Date: June 30, 2023

Corrective Action Plan Finding 2022-001 Assistance Listing #93.461 Internal Control over Compliance? Activities Allowed or Unallowed and Eligibility, Due to the evolving nature of the COVID-19 pandemic, and the rapid pace in which programs were implemented, documentation of controls related to the reporting of COVID-19 uninsured patients was not maintained. However, controls were in place and proper submission of claims was accurate. As part of the prior year audit finding, NorthShore implemented a process as of January 2022 to document internal controls related to the quality review of claims to ensure patients meet the eligibility requirements. HRSA reviewed the documentation and determined that the finding had been satisfactorily resolved. Although the program has now ended, NorthShore will ensure the internal controls are documented should the HRSA program be reinstated. Responsible Official: John Skeans, Senior Vice President, Patient Financial Services.

COVID-19 Coronavirus State and Local Fiscal Recovery of Funds Federal Financial Assistance Listing 21.027 Period of Performance Significant Deficiency in Internal Control over Compliance Finding Summary: During the course of the audit engagement, it was noted that the City included one 2023 expenditure in the 2022 reported schedule of expenditures of federal awards. Responsible Individuals: Wyatt Papenfuss, Finance Manager Corrective Action Plan: The City will take steps to ensure that all federal expenditures are in the correct period under Uniform Guidance. Anticipated Completion Date: December 31, 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Elizabeth J Billue Contact Phone Number: 574-583-1515 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: All future reporting of the COVID-19 Coronavirus State and Local Fiscal Recovery Funds will be reviewed for accuracy by a second Auditor staff member prior to submission. The report will be signed/dated by both the preparer and the reviewer. To prevent future errors in reporting of these grant funds, the preparer will have an Auditor?s Deputy review the reports for accuracy and completion prior to submission. All grant receipts and adjustments to grant related receipts and disbursements completed in the Auditor?s Office are now reviewed for accuracy and initial/dated by a second Auditor Office staff member. In addition, a note will be made within our financial system records and all available supporting documentation will be attached/scanned as part of the permanent record of adjustments to receipts and disbursements. A new electronic storage system is under consideration for ease of access to adjustment documentation. Anticipated Completion Date: 4/30/24

Name of Auditee: City of Niagara Falls, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2022 CAP Prepared by: Daniel Morello, City Controller Phone: (716) 286-4346 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2022-002 Management's Response The City is in agreement with this audit finding. Due in part to delays in finalizing both the 2021-2022 annual action plan and the 2022-2023 annual action plan, the City was delayed in being able to utilize those funds until approval was provided by HUD. The City continues to direct funds to projects that have the ability to be completed in a timely manner in order to be consistent with the CDBG regulation related to timeliness. The City is aware of the timeliness requirements and will continue to select projects that better allow the City to operate in accordance with these regulations. Estimated Completion Date - Next HUD verification date of May 1, 2024

Finding 2022-004 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Agency Name: U.S. Department of Health and Human Services Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services CFDA: 93.829 Finding Summary: During our testing, there was no documentation of review and approval of employee timecards for a portion of the sample selected. A nonstatistical sample of 60 expenditures submitted for reimbursement were selected for testing. Of these 60, 3 did not show evidence of proper review and approval prior to payment. Responsible Individuals: Michael Luedtke, Chief Financial Officer Corrective Action Plan: Management agrees with the finding. The Organization will enhance internal control policies to ensure all employee timecards are reviewed and approved prior to payment to ensure that all payments are necessary and correct. Anticipated Completion Date: May 15, 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: Mary K. Kaczka, Assistant Director, Community Development Contact Phone Number: 574-322-4472 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will take the following steps to address the period of performance weakness that have been identified: Staff involved with posting or reviewing of claims in both the city ledger and IDIS will be trained on the requirements of 2 CFR 200.343(b) regarding allowable costs during the period of performance. Changes to the claims process has been implemented in which CDBG staff includes the grant number and program year on the face of the invoice or claim sheet in addition to general ledger account number. Invoices are processed for claim packets by department office service staff and reviewed for accuracy and completeness by management. This change in process will assist in reconciliation between the City Ledger and IDIS. Anticipated Completion Date: August 31, 2023

The Board entered into multi-year contracts to garner additional savings for the district during the contractual period. The Board has developed allocation schedules to ensure a more appropriate matching of expense to the financial period. The Board may continue to enter into multi-year agreements for contractual savings but will expense only the portion of the contract in the period of performance.

Reference Number: 2022-018 Prior Year Finding: 2021-014 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Medicaid and Medical Assistance Federal Program: Children?s Health Insurance Program (CHIP) Assistance Listing Number: 93.767 Award Number and Year: 2205DE5021 (10/1/2021 ? 9/30/2023) Compliance Requirement: Period of Performance Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DMMA will review reported expenditures based on the date of the federal draw to ensure that the expenditures occured within the period reported. Name(s) of the contact person(s) responsible for corrective action: Unkyong Goldie Planned completion date for corrective action plan: September 30, 2023

Corrective Action Plan Finding 2022-001 Internal Control Deficiency Allowed/Allowable Costs At the beginning of the pandemic, OU Health created working groups to evaluate the requirements for COVID-19 funding received and ensure the funds were only used for allowable purposes. The working groups were assisted by outside consultants to stay updated on the reporting requirements as the continued to evolve. As part of the Uniform Guidance audit, OU Health provided documentation of the FEMA review process that explained how eligible costs were identified and submitted. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will develop a checklist to document the review and approval of supporting documentation of personnel costs as reported as FEMA federal expenditures. The supporting documentation will be reviewed by management to ensure expenses charged to the federal program are allowable and have not been reimbursed under another federal program. The checklist will be retained with the existing report. Responsible Official: Michael Milligan, Vice President of Accounting Anticipated Completion Date: March 31, 2023

Identifying Number: 2022-009 Finding: Period of Performance: payroll costs Corrective Actions Taken or Planned: UCAN agrees with this finding and is committed to strengthening internal controls to ensure that amounts are properly recorded and reported. UCAN has already taken steps to insure that items are billed in the period incurred and only items that fall into the grant period are billed. We believe that significant turnover in the finance department led to this deficiency, so we are actively documenting procedures and cross-training employees, so we always have coverage. All vouchers will also go through a review process before they are sent to the funder. This is a repeat finding, with the original corrective action plan to be completed before June 30, 2023. We do believe that corrective actions that have been taken have resolved this issue. Contact person is Kimberly Parish, Chief Financial Officer and she can be reached at kim.parish@ucanchicago.org.

August 26, 2022 Legislative Audit Advisory Council P.O. Box 94397 Baton Rouge, LA 70804-9397 RE: Jennings American Legion Hospital, Inc. FYE 11/30/2021 Financial Statement Audit Management Corrective Action Plan Dear Council Members: Management has taken the following action is response to the finding of our auditors, Lester, Miller & Wells, CPAs for the fiscal year ended November 30, 2021. Finding 2021-001 ? Medicare and Medicaid Cost Report Receivables Position(s) of Agency Personnel taking correction action: Chief Executive Officer Corrective Action: Management has considered the recommendation and concluded that the implementation cost is greater than the benefit derived from preparing interim cost reports. It is more efficient and cost effective for external cost report preparers to prepare the cost reports at year-end. Finding 2021-002 ? Recognition of Insurance Proceeds Position(s) of Agency Personnel taking correction action: Chief Financial Officer Corrective Action: Management will recognize insurance proceeds as a gain (loss) and ensure assets being replaced or repaired are recorded at cost. If you should require additional information please call (337) 616-7030. Sincerely, Dana D. Williams Chief Executive Officer

FINDINGS ? FEDERAL AWARD PROGRAM AUDIT SIGNIFICANT DEFICIENCY 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: YWCA should establish written policies and procedures to provide for timely and appropriate review and approval for period of performance. Action Taken: We concur with the recommendation and have developed the following plan. YWCA Madison, Inc., in compliance with guidance set forth in the Uniform Guidance 2 CFR section 200.303, will develop written policies and procedures on what, when, and who is responsible for review and approval for period of performance for YWC Madison funding. Additionally, YWCA Madison, Inc. will create a grant tracking checklist with key details for the funding including the performance period, total funding amount, allowable costs, the program or department funding is to be used for, etc. The checklist will also include an approval section for YWCA Madison finance team members to complete indicating their review of costs charged to the funding source at the beginning and the end of the performance period. The monitoring checklist will be updated to add a review of any new grant tracking checklists for the month as part of its internal controls checklist. The monitoring checklist will be reviewed monthly by the CEO and the review will be documented.

Housing Choice Voucher Program ? Assistance Listing No. 14.871 We recommend that the City review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA staff will review its current procedures for completing rent reasonableness requirements. As noted above, they will pursue options available under their contract with McCright, data feeds that could work within their existing software, and any other options in use at peer agencies to determine the best specific path forward to ensuring compliance with rent reasonableness requirements. PHA Supervisory Staff have also requested more detailed information on the audit results to help them further analyze the specific rent reasonableness cases where documentation and performance errors were made which led to this finding. This will help supervisory staff conduct a more thorough review and consider additional procedural changes. Also, as noted above the Finance Department suggests the PHA engage its software vendor or a peer agency to review functionality in the software to determine whether additional features could be employed in the software to prevent a HAP payment on a unit where rent reasonableness has not been completed yet. Name(s) of the contact person(s) responsible for corrective action: Steve Schaer Planned completion date for corrective action plan: 3/31/2024

KCHD will implement internal controls to review outstanding items and ongoing projects monthly, particularly those charged to grants, for proper reporting to ensure compliance with the terms of the award. Specifically, the Business Manager and Administrator will identify any hidden issues that could violate Uniform Guidance reporting requirements. The Health Department expects to have this procedure in effect no later than July 1, 2023. Additionally, the KCHD plans to obtain adequate resources to assist the financial and grant reporting function to ensure compliance.

2022-001: Reporting Corrective Action: Due to ever-evolving processes, LCCC did not fully comprehend all reporting nuances for the HEER program. The Comptroller and Director of Sponsored Awards will continue to perform in-depth reviews of all reporting guidance and requirements to ensure accurate reporting. Anticipated Completion Date: June 30, 2023 Contact Persons: Nola Rocha, Comptroller and Jennifer McCartney, Director of Sponsored Awards and Compliance

Finding 2022-003: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Plan to Correct: If we are to receive federal funding of this kind in the future we will insure the validity of any expense chosen after verifying against the standards set by the fund guidelines before expenditures are made or any reporting is completed. Internal staff will also review work papers in detail to double check data integrity to ensure reporting is accurate. We will work with our CPA firm or other appropriate consultant if we have any questions surrounding expenses chosen. Responsible Party: Denise Doucette, CFO/VP Estimated Completion: Ongoing.

2022-006 Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Chris Holmes Title: Controller Phone Number: 202-235-1938 Estimated Completion Date ? done Corrective Action The results of the 2022 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on the allowability of trailing costs and the unallowability of newly incurred costs. From 2023, PSI will resume delivering in person training to its global finance and program staff.

Reference Number: 2022-003 Description: Lack of Written Procedures for Federal Awards Corrective Action Plan: The Society will develop written procedures for federal awards received. Anticipated Corrective Action Plan Completion Date: ongoing Contact Information: For additional information regarding this finding, please contact Larry Gaffey, General manager at 262-723-3228.

Identifying Number: 2022-001 Finding: The Center did not file a FFATA sub-award report for sub-grants greater than or equal to $30,000. The Center did not have a policy and procedures in place to ensure compliance with the FFATA reporting requirement. Corrective Actions Taken or Planned: On June 28, 2023, the Vice President of Finance of the Center filed the FFATA sub-award report for sub-grants greater than or equal to $30,000.

Corrective Action Plan: The Department will continue its work to ensure the data provided to the USED and other entities is timely and accurate. This includes communication to subrecipients through CCIP notes, reminder emails, reporting dashboard information and guidance documents on the time period for reporting and expectations. Going forward, the Department will also include a training webinar and open office hours. In addition, the Department will revise its process for annual reporting ESSER expenditures to the USED to ensure the Department?s survey to collect ESSER expenditure data from subrecipients has a validation/error test against OAKS payments for a given reporting period. If the data does not align with the expenditure data in OAKS, the subrecipient will have to undergo data correction to ensure accurate reporting. Data correction will vary depending on the organization and any previous expenditures reported to USED. Anticipated Completion Date for Corrective Action: July 2023 Contact Person Responsible for Corrective Action: Corey Fronk, Director of Audits and Risk Management, Ohio Department of Education 25 South Front Street, 7th floor, Columbus, Ohio, 43215 Phone Number: 614-644-7812, E-Mail Address: Corey.Fronk@education.ohio.gov

Contact Person - Jeremy Tammi, Superintendent. Corrective Action Plan - The District will implement procedures to ensure the budget and expenditures are reported in the correct year. Completion Date - December 31, 2022.

Finding 2022-001 Federal Agency Name: Department of Homeland Security, State of Idaho Office of Emergency Management Program Name: Disaster Grants ? Public Assistance CFDA # 97.036 Finding Summary: Administrative labor costs were claimed for reimbursement that fell outside the period of performance of the federal award in two instances. In addition, one instance in which the Cooperative submitted a material cost for reimbursement that was not used in the project. Responsible Individuals: Reed Christensen Corrective Action Plan: Management revised its procedures to ensure a review of labor hours submitted in the future for FEMA-reimbursed projects in order to ensure the labor hours submitted fall more precisely within the Federally specified timeframe of the disaster declaration. As it concerns material cost reimbursements, in the future the work order will be reviewed and reconciled to the ?pick list? quantities. This has also been added to our FEMA-related work procedure. Anticipated Completion Date: March 30, 2023

2022 ? 008 Reporting (Significant Deficiency and Noncompliance) Management Response: The City agrees with the finding. The City will implement controls to ensure compliance with federal financial management regulations. The City recognizes that it needs to improve its procedures for preparing quarterly report for Treasury funds. Going forward, the Family and Community Services Department will work with the Grants Section to develop and implement standardized procedures for identifying and documenting expenditures, and for reviewing quarterly reports prior to submission. Timeline and Responsible Position: June 2023 ? City Controller/DFAS Deputy Director and Director of Family & Community Services