Corrective Action Plans

2022-002 Crime Victim Services- Assistance Listing No. 16.575 Recommendation: The Organization should implement internal controls to ensure that there is review and approval of monthly payroll accruals by someone who does not prepare the accrual calculation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Payroll accruals are currently reviewed and approved by a contracted accountant. This task will transition to financial staff by the end of the fiscal year 2023. Name(s) of the contact person(s) responsible for corrective action: Yulanda Williams

Finding 2022-004 Contact Person: Peter Gray Contact Phone: 765-775-5150 Views of Responsible Official: 1. There were no material cost issues in the overall report. There was a categorization error. This was discussed in Finding 2022-003. 2. The Revenue Loss expenditures were all valid personnel costs. Over 80% of the costs are police & fire. Other various city departments comprise the balance of the expenditure. We concur with the finding. Corrective Action: A. An additional layer of review has been initiated. The Director of Development is familiar with the requirements of the SLFRF guidance and will review and sign off on future reports. Anticipated Completion Date: 30 June 2022

Finding 2022 ? 001 Fiscal year in which the finding occurred: 2022 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: Chicago Bar Foundation Contact Person(s) Responsible for Corrective Action: Whitney Trumble and Cassandra Lively Contact Phone Number: 312-922-6464 Status of Audit Finding: At the time of the audit, CCR had not received funds for three months of work as a subgrantee on the large federal grant that is the subject of this plan. The grantor was awaiting the federal contract extension and funds, and so did not have the funds to release. CCR received communication from the grantor that the extension and funds would be available soon, so we prepared a check for a vendor. Then, there was an extensive additional delay in receiving the funds, and CCR did not send the check because the contract had not yet been signed and funds could not be dispersed. The expense had been approved by the grantor and the work was underway during the delay in mailing the check. Corrective Action: As of June 2022, stricter internal controls have been implemented to ensure that any reimbursements listed on a grant invoice have been sent out to the vendor before submitting the report. A more formal review process has been implemented: CCR?s Executive Director will review and approve monthly grant reports via email. She will also review and approve supporting documentation for reach grant report. Approval (sent via email) will be kept with in a digital file with the reporting documentation. An additional internal control has been implemented to ensure that expenditures submitted for reimbursement are within the period of performance for the grant agreement. The Executive Director will monitor the grant expenses against the grant agreement, paying specific attention to the invoices at the end of the grant period, in order to ensure that the invoice is dated prior to the end of the grant agreement or most current amendment.

Finding 2022-002 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified three months in which the reimbursement amount received from the pass-through entity was more than the Organization?s documentation. In addition, there was no indication that a review was performed of the information submitted for one of the four months tested, which resulted in the reimbursement amount from the pass-through entity being more than the support maintained by the Organization for three of the 12 months and no documentation of the review for one of the months. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: Schedule meetings with 3rd party vendor to identify the significant rounding errors occurring. Develop an agreement on rounding procedures to be used by both parties ensuring reconciliation. Anticipated Completion Date: 12/31/23 ? Note- this system of reimbursement terminated on 3/31/23

Finding 2022-015 U.S. Department of Health and Human Services AL No. 93.568 Total Low-Income Home Energy Assistance Significant Deficiency over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: The Office of Home and Energy Programs (OHEP) bureau of The Mayors Office of Children and Family Success (MOCFS) agency has implemented a plan to locate needed files from previous and current fiscal years. The agency has implemented a scanning and uploading Standard Operating Procedure (SOP) that requires each case file to be digitally attached to its application and supporting documents. This will remedy this finding in its totality. Contact Person: OHEP Director ? Rigel Moore Completion Date: March 10, 2023

Finding 2022-018 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to the correct grant period within the general ledger. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday, and accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-016 U.S. Department of Health and Human Services AL No. 93.767 Children?s Health Insurance Program (CHIP) Material Weakness Over Compliance and Internal Control over Period of Performance Repeat Finding: Yes Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to a grant. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-024 U.S. Department of Health and Human Services AL No. 93.977 Totally Sexually Transmitted Diseases (STD) Prevention and Control Grants Significant Deficiency in Compliance and Internal Control over Period of Performance Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to the correct grant period within the general ledger. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-023 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Significant Deficiency in Compliance and Internal Control Over Reporting Repeat Finding: No Auditee?s Corrective Action Plan: BCHD will implement controls to maintain compliance with reporting requirements. BCHD will continue to work with the Department of Finance to ensure parameters for generating reports are the same and there is an agreed upon reconciliation when the parameters for reporting are not the same. Policies and procedures will be updated to ensure what is reported on 440 Reports are reconciled to general ledger details in addition to ensuring all submitted reports have proper approvals documented. Accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finding 2022-022 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness over Period of Performance Repeat Finding: Yes Auditee?s Corrective Action Plan: BCHD will implement controls to allow only costs within the period of performance to be charged to a grant. BCHD will ensure that if there are any exceptions that allow for costs to be charged outside the period of performance, the proper supporting documents will be kept. Baltimore City's new financial system, Workday, allows for all supporting documentation to be kept electronically in one system. Policies and procedures for internal controls will be updated to incorporate processes in Workday and the accounting staff will be trained appropriately. Contact Person: Chief Financial Officer ? Unyime Ekpa Completion Date: December 2023

Finance and the Office of Highway Safety will work together to create policies and procedures to ensure compliance with Period of Performance. Anticipated Completion Date: September 30, 2023 Contact Person: Loren Doyle, Acting Chief Operating Officer / Chief Financial Officer Department of Transportation loren.doyle@dot.ri.gov

FINDING 2022-004 Contact Person Responsible for Corrective Action: Cheryl Alcorn, County Auditor Contact Phone Number: 574-753-7700 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Auditor and Commissioner will work together to ensure Project and Expenditure Amounts are properly reported to the Department of Treasury. The corrective plan of action will include the guidance of financial advisors to ensure reporting to be complete and accurate. Anticipated Completion Date: Corrective action plan will start immediately.

CHRISTUS Health Corrective Action Plan Year Ended June 30, 2022 Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. We plan to review our processes related to the retention of expense documentation to improve audit evidence. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: September 2023 with the filing of the 5th portal filing.

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.