Corrective Action Plans

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 Management agrees with this finding and performed a review of claims submitted to the HRSA COVID 19 Uninsured Program identifying payments for ineligible services and refunded the entire overpayment amount. In March 2022, HRSA announced the discontinuance of the HRSA COVID 19 Uninsured Program, and therefore, remediation of internal controls is no longer applicable. Paula Yarbrough, VUMC Director ? Grants and Contracts, will be responsible for implementation by fiscal year-end 2023.

Corrective Action: The Grants Accounting team has internally enforced a two-way check on all claims. Claims are reviewed by peer first, then either a Supervisor or Manager of Grants accounting. This two-way review of all claims will ensure that claims are made for invoices during the period of performance. Grants Accountants are also being required to take Financial Management courses online yearly to remain fiscally responsible in their positions. A part of being fiscally responsible is knowing Periods of Performances for grants. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: January 2024

Corrective Action: Management will update written procedures and train the Grants Accounting team regarding period of performance to ensure all requests are made within the proper period based on the period of performance. The procedures and training will include grant period close, cost allowability, requirements for documentation, and review of charges prior to requests. In addition, Grants Accounting has initiated monthly meetings with Government Agencies to closely monitor grant spenddown, address any processing issues, and ensure proper cut-off. These meetings will be instrumental in tracking progress and oversight in our grant management process. Name of Responsible Individual(s): Jason Brenier, CFO Anticipated Completion Date: January 2024

Recommendation: We recommend the Organization implement a process to evaluate if expenses are eligible for reimbursement during the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As mentioned above with the implementation of our new accounting software in March 2023, it allows for expenses and payments to be allocated to each grant as intended and drawn down specifically to that grant. In doing this, it allows for constant and consistent tracking for live to date tracking and allows for revenue and expenses to be reviewed and reported at any point in time. In allowing for constant tracking of this information it allows us to send out monthly and/or quarterly invoices for reimbursement from our grantors. Name(s) of the contact person(s) responsible for corrective action: Sally Worley, Executive Director, Kasey Bunce, Finance Director, Chastity Schonhorst Finance Coordinator, Alisha Bower, Senior Operations Director, Sarah Carlson, Senior Program & Member Engagement Director, and Christine Zrostlik, Marketing & Communications Director. Planned completion date for corrective action plan: This has already been implemented as of March, 2023.

Findings and Questioned Costs Relating to Federal Awards: Insufficient Controls Related to the Application of Indirect Costs Rates Management will enhance procedures related to indirect costs rates matters, including accounting and review process. A Standard Operating Procedure will be developed to address key tasks, responsible parties, and oversight activities. Management expects this SOP to be completed and implemented on or before June 2024.

Views of Responsible Officials and Planned Corrective Actions: 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.

The Corrective action plan will be to follow the period of performance going forward in order to not have this reoccur again in the future. The County management will review all grant documents to make sure they are in Compliance with the requirements. Van Wert County adopted the Standard Allowance for revenue loss up to $10 million for the ARPA funds. Lost revenue dates will be reviewed in the future to ensure supporting documents are also in Compliance with the grant requirements.

The Town of Clinton/School Department will follow grants closeout procedures, consequently, the district will monitor closely all grants spending throughout each grant cycle. For both state-administered and direct grants, regardless of the period of availability, the District must liquidate all obligations incurred under the award not later than 90 days after the end of the funding period unless an extension is authorized. These procedures have been updated in the Financial Procedures Manual (pages 226-230 under Section G - Timely Obligation of Funds)

U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s internal controls were not designed to properly ensure a review over program expenditures occurred that expenses being incurred and the basis for ultimate reimbursement were incurred within the grant award’s period of performance. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will implement controls that address whether expenses incurred have a basis for reimbursement and are incurred within the period of performance. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: March 2024

While our Human Resources Specialist position was filled in May 2021, we are still working to have sufficient HR and accounting staffing to meet our significant growth. Additional positions of Human Resources Manager and Controller will help reduce/eliminate these types of errors in the future.

CONDITION: The ROE did not submit or timely submit the required reports to the Illinois State Board of Education. PLAN: New ROE management is providing close oversight for the timely submission of grant expenditure and performance reports. The Regional Superintendent has created a shared calendar of submission due dates with the Business Manager and Program Directors. Reminders are sent out via email in advance of the due dates, and then management reviews the grant report submissions in IWAS for accuracy and completion before approving and submitting to ISBE. ANTICIPATED DATE OF COMPLETION: This plan was initiated during the new Regional Superintendent’s appointment to office in October 2022 and has been fully implemented since January 2023. CONTACT PERSON: Ms. Jill Reedy, Regional Superintendent

Recommendation: The Organization should follow its cash disbursements policy to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Action Taken: EWP has reviewed its current cash disbursement policy and re-implemented procedures to maintain invoices and have them approved by the appropriate levels of management prior to the issuance of checks. Agency leadership staff have been reviewing allowable and unallowable costs to ensure accurate administration of awards. Responsible Person and Anticipated Completion Date: Executive Director, October 2023.

Finding Numbers 2022-002 and 2022-003 Planned Corrective Action: To date, management has already started additional training with the team responsible for grants and any communications between them and HRSA. The accounting department has also been advised to insist on more written documentation prior to assigning expenses to grants. Anticipated Completion Date: November 30, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

Finding No.: 2022-006 Federal Agency: U.S. Department of Education AL Program: 84.181 Special Education – Grants for Infants and Families Area: Period of Performance Questioned Costs: $0 Views of Auditee and Corrective Actions: GDOE agrees with the finding. In GDOE’s Munis system, if the Human Resources (HR) pay records are not accurately updated, GDOE payroll will reflect dated pay tables until such time HR makes the appropriate updates based on the project leads request to update accounts to current grant year. GDOE corrected the improperly charged payroll expenditures to the proper grant year via the journal voucher process. Plan of action and completion date: The GDOE Business Office will perform a monthly review of all transactions to ensure charges are recorded in the appropriate grant year. Additionally, Grant Project Managers and Program Coordinators will timely communicate to the Human Resources and Business Office any changes to accounts charged for federally funded payroll expenditures. Plan to monitor and responsible officials: GDOE Comptroller (vacant), will assign an accountant to monitor the expenditures of federal grants and the corresponding periods of performance and liquidation periods. Grant Project Managers, Federal Compliance review team will be responsible for timely communicating any changes in grant year funding to HR.

Finding No.: 2022-004 Federal Agency: U.S. Department of Education AL Program: 84.027 Special Education – Grants to States Area: Period of Performance Questioned Costs: $1,835 Views of Auditee and Corrective Actions: GDOE agrees with the finding. During the period of performance in question, the TPFA issued check no. 2012949 to a vendor in February 2022, within the liquidation period. However, the TPFA indicated that the vendor lost the check and the TPFA re-issued payment to the vendor on January 29, 2023. The untimely reissuance of the check resulted in the transaction occurring one day after the liquidation period expired. Plan of action and completion date: As of April 2023, the TPFA has not been issuing checks to vendors, as the responsibility was returned to the GDOE to process all fiscal transactions within the GDOE Munis. The Business Office will closely monitor grant liquidation dates and payments to vendors. SOPs will be reviewed to update the procedures for monitoring grant period of performance. Plan to monitor and responsible officials: The Deputy of Finance and Administrative Services, Joann Camacho, as well as the GDOE Comptroller (vacant), will assign an accountant to monitor the expenditures of federal grants and the corresponding periods of performance and liquidation periods.

• Condition: During our testing of reimbursement requests, we identified an invoice that included expenses outside the period of performance for a grant in the federal program. • Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the account is being invoiced for the correct expenses during the proper timeframe • Planned Corrective Action: During the newly established monthly meetings that will take place, MHA and Accounting Rep will review the expenses being submitted for reimbursement together to ensure no invoices are submitted outside the grant period.

The County plan has been implemented.

Findinq No.:2022-012 Period of Performance Responding Agency: Department of Public Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The extension was granted by the Department of lnterior.

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

Timesheets are reviewed by project managers before they are submitted to payroll processing. Additionally, a reconciliation of actual to budgeted hours will be performed on a monthly basis. Documentation of the timesheet reviews will be maintained electronically. Staff time for federal grants will be supported by a completed timesheet signed by a project manager. The National Alliance Against Disparities in Patient Health does acknowledge that an additional level of review is justified as our grant volume continues to expand. The verification of work performed on a monthly basis will ensure accuracy. Project managers will meet weekly with the executive team to address any transitional issues. Evidence of this allocation review will be maintained electronically for future inspection and/or presentation to grantors or others with a need to know.

Action taken in response to finding: County department personnel changes have been implemented which address this deficiency. New department personnel have been properly trained by County Auditor staff as well as State grantor personnel to ensure correct grant reporting. Department supervising staff will monitor grant reporting documentation. All manual adjusting entries will be requested through the County Auditor’s office to ensure proper supporting documentation is provided. Name(s) of the contact person(s) responsible for corrective action: Dave MacDonna, Community Resources Director. Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: October 2, 2023

U.S. Small Business Administration Eugene O’Neill Memorial Theater Center, Inc. respectfully submits the following corrective action plan for the year ended August 31, 2022. Audit period: August 31, 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 PROGRAMS AUDITS U.S. Small Business Administration 2022-001 Shuttered Venue Operators Grant – Assistance Listing No. 59.075 Recommendation: We recommend Eugene O’Neill Memorial Theater Center, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are recorded within the financial statements as grant revenue 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 recorded within the financial statements as grant revenue in the proper period.. They also note that costs charged to awards are all award related and within the full award period. Name of the contact person responsible for corrective action: William Kuklinski, Controller and Tiffani Gavin, Executive Director Planned completion date for corrective action plan: October 2, 2023 If the U.S. Small Business Administration has questions regarding this plan, please call William Kuklinski or Tiffani Gavin at (860) 443-5378.

2022-004: Reporting - Timely Submission of Financial Reports – Material Weakness in Internal control over Financial Reporting and Noncompliance  The City recently hired a Finance Director and is working to fill the Controller position. Being fully staffed will assist in the timely completion of the City’s audit.  Anticipated completion: December 2023

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Definitive guidance clarifying this requirement was not released until August 2021, after the close of the reporting period. As a result, the Organization applied the best available interpretation at the time of close. To prevent similar issues, the Organization will incorporate ongoing monitoring of updated directives, strengthen pre submission technical reviews, and consult with external advisors to validate compliance with period of availability rules prior to future filings.